Few studies have evaluated structured, long-term, family-based, weight management programs in children. This study’s purpose was to determine if completion of such a program resulted in reduced body mass index (BMI) z-scores and improved lifestyle habits. An observational study overtime from 2008-2010 was conducted with 89overweight/obese children. Subjects were divided into two groups, compliers (completed ≥ 7 intervention classes) and non-compliers (completed <7 intervention>classes.) The LiVe program, a 12-month structured, multi-component, family-based program, served as the study intervention. Anthropometric measurements and a written survey on lifestyle habits were used to obtain changes over 12 months in anthropometric, nutrition, activity, and behavior habits for subjects. Descriptive statistics, chi square, analysis of co-variance, and a mixed modellogistic regression were used to determine anthropometric and lifestyle habits changeover time as well as differences between age, gender, and compliance groups. Nodemographic differences were seen between compliance groups. Compliers had asignificant decrease in BMI z-score (-0.1903 p=.0004) and BMI percentile (-2.02p=.0235) over time. Compliers had a higher probability of meeting vegetable intake (pre 0.31%, post 55.67%; p=<.0001), and physical activity guidelines (pre 13.58%, post 56.58%; p=.0032) post intervention. Males were more likely than females to meet the physical activity guideline (p=.0007). Both compliers and non-compliers had a higher probability of meeting fruit (p=.0015) and sugar-sweetened beverage intake guidelines (p=.0337) at 12 months. No significant differences in age and gender were seen for changes in anthropometric or lifestyle habits except as noted above. Long-term, family-based, structured weight management programs are effectivein reducing BMI z-scores and improving lifestyle habits in children. Continueddevelopment and evaluation of these programs is warranted to address childhood obesity treatment methods.

Indiana University-Purdue University Indianapolis (IUPUI) / Communities and States are increasingly targeting the consumption of sugar sweetened beverages (SSBs), especially soda, in their efforts to curb childhood obesity. However, the empirical evidence based on which policy makers design the relevant policies is not causally interpretable. In the present study, we suggest a modeling framework that can be used for making causal estimation and inference in the context of childhood obesity. This modeling framework is built upon the two-stage residual inclusion (2SRI) instrumental variables method and have two levels – level one models children’s lifestyle choices and level two models children’s energy balance which is assumed to be dependent on their lifestyle behaviors. We start with a simplified version of the model that includes only one policy, one lifestyle, one energy balance, and one observable control variable. We then extend this simple version to be a general one that accommodates multiple policy and lifestyle variables. The two versions of the model are 1) first estimated via the nonlinear least square (NLS) method (henceforth NLS-based 2SRI); and 2) then estimated via the maximum likelihood estimation (MLE) method (henceforth MLE-based 2SRI). Using simulated data, we show that 1) our proposed 2SRI method outperforms the conventional method that ignores the inherent nonlinearity [the linear instrumental variables (LIV) method] or the potential endogeneity [the nonlinear regression (NR) method] in obtaining the relevant estimators; and 2) the MLE-based 2SRI provides more efficient estimators (also consistent) compared to the NLS-based one. Real data analysis is conducted to illustrate the implementation of 2SRI method in practice using both NLS and MLE methods. However, due to data limitation, we are not able to draw any inference regarding the impacts of lifestyle, specifically SSB consumption, on childhood obesity. We are in the process of getting better data and, after doing so, we will replicate and extend the analyses conducted here. These analyses, we believe, will produce causally interpretable evidence of the effects of SSB consumption and other lifestyle choices on childhood obesity. The empirical analyses presented in this dissertation should, therefore, be viewed as an illustration of our newly proposed framework for causal estimation and inference.

Implementation of an Evidence-Based Childhood Obesity Toolkit in a Rural Pediatric Clinic in Cookeville, TN: A Quality Improvement Project Dawn G. Johnson, MSN, APRN, FNP-BC Tennessee Technological University Nursing 6802 – DNP Project Development Dr. Victoria Pope & Dr. Candice Short March 23, 2022 Author Note Dawn G. Johnson https://orcid.org/0000-0002-7090-8036 College of Nursing, Tennessee Technological University There are no conflicts of interest to disclose. Correspondence concerning this manuscript should be addressed to Dawn G. Johnson, Tennessee Technological University, 248 Haven Lane, Algood, TN 38506 Email: djohnson@tntech.edu Abstract Purpose: The purpose of this quality improvement project is to increase the early identification of overweight or obese children in the primary care setting and provide education through the implementation of an evidence-based childhood obesity toolkit. Aims: This project aims to implement the Healthy Care for Healthy Kids Physical Activity and Nutrition Survey Management Plan to educate patients and parents about childhood obesity. The Healthy Care for Healthy Kids Physical Activity and Nutrition Survey Management Plan is an evidence-based questionnaire and action plan used by healthcare providers in the prevention and treatment of childhood obesity. Processes: Nurses will provide the toolkit to children ages 5-18 who present to the clinic for well-child examinations and have a BMI classified as overweight or obese. Providers will then review the screening toolkit with the patient and family and make a corrective plan of action. The screening tool will then be signed by the patient, caregiver, and provider and placed in the child’s electronic medical record. Results: To be determined after project implementation is complete. Results are anticipated to be that more overweight and obese children are identified by the clinic and proper education is provided to the patient and family. Limitations: The study is limited to one location and only available to the providers who perform well-child examinations. Conclusions: Implementation of an evidence-based childhood obesity toolkit in the pediatric setting with increase the early identification of overweight and obese children. Keywords: childhood obesity, pediatric obesity, toolkit, obesity, overweight

Childhood obesity (CO) is a significant public health issue in the United States, including the immigrant populations. Obese children and adolescents are at increased risk for multiple preventable comorbidities that affect their physical health and psychological well-being. The perception exists that the immigrant child population may possess protection against CO, but this group also experienced an increased prevalence of CO. Acculturation, or the adaptation to American culture and lifestyles, has been shown to be associated with the increased obesity rate among immigrant children and adolescents. Understanding the association between acculturation factors and CO is necessary to effectively combat obesity among children and adolescents in immigrant populations. The purpose of this literature review is to analyze the association of acculturation factors on the prevalence of CO among U.S. immigrant children and adolescents. Only articles that examined CO and at least one aspect of acculturation were included in this review. Twelve articles meeting the criteria were retrieved from CINAHL, Medline, PsychInfo, Academic Search Premier, and ERIC. The review identified the following acculturation factors to be associated with CO: parental immigration factors, child immigration factors, country of birth, generational status and primary home language, parental level of acculturation, and CO related lifestyle practices. There is modest evidence to suggest that a combination of acculturation factors is associated with increasing CO rate in immigrant populations. This review enhances the knowledge and awareness of public and pediatric healthcare professionals to develop targeted interventions that promote healthy weight in immigrant children and adolescents at increased risk for obesity.

The prevalence and severity of childhood overweight has climbed dramatically in the past three decades and is recognized as a serious public health concern that requires urgent action. The home environment has been identified as a key influence on the diet and physical activity of children. Furthermore, low-income families experience obesity at higher rates and current interventions have not been translated from research to practice settings. Therefore, there is a need to evaluate the potential for evidence-based obesity treatment strategies to be translated into community or clinical delivery settings that reach broadly into the population of low-income families. In addition, while the home environment has successfully been targeted to treat childhood obesity, there is a paucity of measurement tools available to provide a comprehensive assessment of the home physical and social environment as it pertains to physical activity and dietary intake. This dissertation includes: (1) a mixed-methods study to determine the feasibility and effectiveness of a childhood obesity treatment intervention based on a partnership with a Health Care Organization and delivered through Cooperative Extension, (2) a systematic review of home environmental measures related to physical activity and dietary intake, and (3) a home environment measure development and validation study. Smart Choices for Healthy Families (SC) was developed through a research-practice partnership that included a local healthcare provider (Carilion Clinic), Virginia Cooperative Extension (VCE), and an interdisciplinary research team. The aim of this study was to assess the reach, implementation, and effectiveness of SC to reduce the BMI z-scores of overweight and obese children from low-income families. The resultant intervention, based on an evidence-based social-ecological model, included brief physician counseling and referral, six-biweekly group sessions taught by VCE lay leaders, and six automated telephone counseling calls on alternate weeks. Twenty-six of 264 eligible children (50% boys; mean age=10.5 years) were recruited and 78% completed baseline and 3-month assessments. Over the 6 class sessions, there was an average 65% attendance rate and an average 58% completion rate for the automated telephone calls. Results revealed a significant reduction in children's BMI z-score (p<0.01), an increase in lean muscle mass (p<0.001) and weight (p<0.05), and an increase in Health Related Quality of Life (HRQL; p<0.0001). The participating group had a higher income (p<0.05) and also participated in fewer food assistance programs (p<0.05). Despite this small difference, Smart Choices reached a sample that was representative of the larger target population and was effective in reducing BMI z-score, increasing lean muscle mass, and improving HRQL of low-income obese children. A systematic review was conducted of the measures of the home environment in order to collect and synthesize the current body of literature. It was found that some authors choose to use non-validated measures and that there is an inconsistent use of measures across the field, making comparisons between studies difficult and conclusions regarding parental influence on childhood obesity difficult to discern. The psychometric properties that were reported on these studies are reported in this review. Through the systematic review of literature a number of measures were identified that assessed different aspects of the home environment. These measures were compiled and combined to generate a comprehensive tool to assess the physical and social aspects of the home environment that could influence eating and physical activity. This measure plus a social-ecological framework for the measure were provided to experts in the field who provided information on potential areas that had been overlooked and advice on additions or contractions of items and scales. The modified measure, the Comprehensive Home Environment Survey (CHES), was then tested for reliability and validity in a low-income audience. Parent-child dyads (n=132; Children 47% girls, age range 5 to 17; Parent 82% mothers; mean age=36) were recruited through a pediatric clinic in Roanoke, Virginia, that serves a primarily low-income audience (i.e., 95% eligible for Medicaid). Each of these parents completed the assessment tool and additional surveys to assess concurrent and predictive validity. Height and weight was assessed in each child, and children between the ages of 9 and 17 also completed nutrition and physical activity self-report surveys. Test-retest reliability was assessed in 43 parents who complete the survey a second time one-to-two-weeks following the initial assessment. Inter-rater reliability was assessed in 36 cases by having a spouse or second care-giver complete the assessment tool. Internal consistency, test-retest, inter-rater reliability, and predictive validity all showed promising results. Across the scales internal consistency was adequate to high with Cronbach's Alphas ranging from 0.67-0.92, test-retest reliability was high with Pearson Correlations ranging from 0.73-0.97 and inter-rater reliability was higher with Pearson Correlations ranging from 0.42-0.92. Finally, the CHES displayed predictive validity with subscale scores predicting outcome behaviors (e.g., parents who modeling more physical activity had children who were more active). This dissertation demonstrated that the home environment is a key factor in the treatment of childhood obesity and provides avenues for both intervention and measurement in this field of study. / Ph. D.

Background: Efficacious pediatric weight management (PWM) programs have existed for over two decades, but there is limited evidence that these programs have been translated into regular practice. There is even less evidence that they have reached communities experiencing health disparities where access to care is limited. The purpose of this project was to use a community-engaged approach to select an evidence-based PWM program that could be delivered with the available resources in a community that is experiencing health disparities. Methods: The project was developed by the Partnership for Obesity Planning and Sustainability Community Advisory Board (POPS-CAB) in the Dan River Region of southwest Virginia. The POPS-CAB included representatives from a local pediatric health care center, the Danville/Pittsylvania Health Department, Danville Parks and Recreation, the Boys and Girls Club, and the Fralin Center for Translational Obesity Research (n=15). Three PWM programs were identified that met the criteria of demonstrating short and longer-term efficacy, across multiple studies and diverse populations, in reducing childhood obesity for children between the ages of 8 to 12 years across multiple studies. The programs included the Traffic Light Diet, Bright Bodies, and Golan and colleagues' Home Environmental Change Model. All three programs included a high frequency of in-person sessions delivered over a 6-month period, but one included an adapted version that delivered the content via interactive technology and could be delivered with far fewer resources (Family Connections adapted from the Home Environmental Change Model). A mixed-methods approach was used to determine program selection. This approach included individual POPS-CAB member rating of each program, followed by small group discussions, a collective quantitative rating, and, once all programs were reviewed a rank ordering of programs across characteristics. Finally, a large group discussion was conducted to come to agreement on the selection of one program for future local adaptation and implementation. All small and large group discussions were audio recorded and transcribed verbatim to identify themes that influenced the program selection decision. The quantitative results were averaged across individuals and across the groups. Qualitative results were reduced to meaning units, and then grouped into categories, and lastly, themes. Results: Individual ratings across Bright Bodies, Family Connections, and Traffic Light were 3.9 (0.3), 3.6 (0.5), and 3.4 (0.4), respectively. The ratings differed slightly between community and academic partners demonstrated by a higher rating for Bright Bodies by community members and a higher rating for Family Connections by academic members. After small group discussions the average group ratings across the programs was 3.8 (0.4) for Bright Bodies, 3.5 (0.6) for Family Connections, and 3.4 (0.6) for Traffic Light. Finally, the rank order of programs for potential implementation was Bright Bodies, Family Connections, and Traffic Light. Qualitative information for each program was broken down into four main themes of discussion, (1) the importance for the chosen program to have a balance of nutrition and physical activity, (2) negative perceptions of calorie counting, (3) a desire to target both the parent and the child, as well as (4) the need for practicality and usability the target settings. During the final large group discussion, the above themes suggest that the primary reasons that Bright Bodies was selected included the availability of nutrition information, structured physical activity sessions, presence of a usable workbook, as well as the balance of parent and child involvement. Conclusion: Key considerations in program selection were related more to the program content, delivery channel, and available resources for replication rather than simply selecting a program that was less resource intensive. / Master of Science

The effectiveness of an eight-week nutrition and physical activity intervention at a summer camp to prevent obesity, and promote healthy eating habits and physical activity among children in Kuwait was studied. Two summer camps were recruited for intervention and comparison groups. Convenient sampling was used (N= 79). Pre-test/post-test assessment were used for the participants in the intervention and comparison groups. Modified Healthy Habits Survey (HHS) was used to measure children’s knowledge, behavior and attitude about nutrition, screen time and physical activities, BMI-for age percentile were collected. Statistical analysis included independent t-test, paired t-test, chi-squared test, McNemar's test, and multiple regression. Results indicated that there was a significant increase in nutrition knowledge score (Pp= 0.013, p = 0.007, p = 0.002, and p = 0.012, respectively). There was no significant decrease in the number of servings of unhealthy foods for french-fries and chips, fruit flavored drinks or soft drinks. The only significant decrease in the unhealthy food intake was seen in the number of servings of sweets and candies. Thirty-three-point-three percent of participants in the intervention group decreased their consumption of sweets and candies to 1 time or less per day (P=0.001). There was a significant increase in the intervention group in both physical activity and screen time knowledge (Pp

Background: Obesity’s rapid growth and its serious consequences for public health, is assessed as one of the most serious public health challenges. In Sweden, the number of children with child obesity has duplicated in 15 years. Statistics reveals that approximately 4 to 5% of all children in Sweden suffer of obesity. As families and individuals themselves choose their diet, they need knowledge to make healthy choices for themselves and for their children. Parents are the primary source for communicating health information to their children and adolescents. Hence, there is a demand to improve the targeted information to parents. The risk of a child becoming overweight reduces the sooner parents embrace healthy habits. Purpose: The aim was to examine the experts' experiences and perceptions of how parents get and receive information about children's health with a focus on child obesity. Method: The study design was explorative with a qualitative approach. Ten interviews were conducted and used for qualitative content analysis, and basis for the presented results. Results: The analysis resulted in ten subcategories and four categories presented below. 1. To study the environment around the entire family, 2. That there is a interest by all to promote children’s health, 3. To personalize information, 4. What the information should discuss. The main result of this study reveals that expert´s perceived parents today are getting good information through actors like child health center (BVC) and the school, hence the parents interpreted as positive to information regarding their children's health. However, it stated that the experts' experienced barriers in the treatment of child obesity and lack of information about child obesity. These barriers highlighted to depend on both genetics and environment while lack emphasized to base on ignorance and prejudices from parents and other stakeholders. Conclusion: The experts perceived that parents were positive towards information about children's health, but sometimes less positive towards information regarding child obesity. In contrary, the experts conveyed that there were gaps in the information of child obesity from BVC, due to a lack of knowledge and prejudice of the BVC: s staff. The biggest barrier to treatment and prevention against child obesity mediated as the environment. Society needs to make changes by suggestion to remove extra prices on candy, and instead both offer and send out information about healthier options. Suggested strategies was to organize group meetings to help parents manage information about child obesity. Stakeholders like BVC and school could take healthlitteracy into count when providing information. / Bakgrund: Fetmans snabba ökning och dess allvarliga konsekvenser för folkhälsan, bedöms som en av de allvarligaste folkhälsoutmaningarna. I Sverige har antalet barn med barnobesitas fördubblats på 15 år. Statistik visar att ungefär 4 till 5 % av barn i Sverige lider av obesitas. Eftersom familjer och individer själva väljer sin kost behöver de kunskap att göra hälsosamma val till sig själva och sina barn. Föräldrar är den primära källan för att vidarebefordra hälsorelaterad information till sina barn. Med hänsyn till detta behöver den riktade informationen till föräldrar utvecklas. Risken att ett barn blir överviktig minskar ju tidigare föräldrar anammar hälsosamma vanor. Syfte: Att undersöka experters erfarenheter och upplevelser av hur föräldrar får och tar emot information om barns hälsa med fokus på barnobesitas. Metod: Studiens design var explorativ med en kvalitativ ansats. Tio intervjuer genomfördes och med en kvalitativ innehållsanalys som grund, kunde resultat presenteras. Resultat: Analysen resulterade i tio subkategorier och fyra kategorier som presenteras nedan. 1. Att se över miljön runt hela familjen, 2. Att det finns ett intresse hos alla att främja barns hälsa, 3. Att individanpassa informationen, 4. Vad informationen ska avhandla. Huvudresultatet av föreliggande studie var att experterna uppfattade att föräldrar idag får bra information via aktörer som barnavårdscentralen (BVC) och skolan, samt att föräldrarna upplevdes som positiva till information gällande deras barns hälsa. Dock framkom att experterna upplevde barriärer vid behandling av barnobesitas och brister vid information som handlade om barnobesitas. Dessa barriärer ansågs bero på både arv och miljö. Dessutom ansågs bristerna grundas i okunskap och fördomar hos föräldrar och andra aktörer. Slutsats: Experterna upplevde att föräldrarna var positiva till information gällande barns hälsa, men ibland mindre positiva till information om barnobesitas. Intervjuade parter förmedlade att det fanns brister i informationen om barnobesitas från BVC, beroende på brist på kunskap samt fördomar hos BVC:s personal. Den största barriären för behandling och förebyggande insatser mot barnobesitas ansågs vara miljön. Samhället behöver göra förändringar genom att förslagsvis ta bort extrapriser på godis, och istället både erbjuda och sända ut information om hälsosammare alternativ. Förslag på strategier var att anordna gruppträffar för att hjälpa föräldrar att hantera information om barnobesitas. Aktörer som BVC och skolan behöver ta hänsyn till hälsolitteracitet när de ger information.

Prevalence of overweight and obesity has increased in adult and child populations during the last two to three decades in both developed and developing countries. Childhood obesity is common in the United Kingdom and has become a major public health issue. There is a growing body of evidence to suggest that the development of overweight and obesity in children has its roots in early life, with evidence of increasing weight over time in pre-school children. The study explored the early development of overweight in infants in Halton, an area of Northwest England. It was a mixed methods study comprising a quantitative analysis of routinely collected infant weight data and a longitudinal qualitative study of the process of weaning. Phase one - patterns of weight in Halton infants: The retrospective quantitative study utilised birthweight, and weight and length/height at eight weeks, eight months and 40 months of age from Halton infants born between 1994 and 2006 (16,328 singleton births). Analysis of these data provided further evidence of the early development of overweight, and highlighted patterns of infant overweight at eight months of age not previously reported. Phase two - longitudinal qualitative study of the process of weaning: Given the findings of phase one, factors that may influence early weight gain were considered. Therefore, the second phase focussed upon weaning, which has been little researched in terms of the way in which mothers manage the process. The aim was to explore weaning as a social process, focussing on the experience, knowledge, perceptions and actions of mothers as they weaned, in order to consider whether this could shed light on infant growth and development in general and the early development of overweight in particular. A grounded theory approach was utilised. Twenty one women were recruited and interviewed antenatally and then up to three times after their babies were born. A total of 67 interviews took place. A grounded theory, or ‘plausible account’, of the weaning process was developed. The centrality of the baby, and the way in which mothers talk about following the lead of the baby as they wean was highlighted, along with the ways in which this focus may falter or shift because of the complexity of influences on mothers’ lives. The primacy of embodied knowledge, that is the knowledge that mothers built up through the experience of feeding and weaning their infant, and the significance of being a mother in terms of being an ‘authority’ on feeding and weaning, were evident. In addition, the limitations of providing information, such as the feeding and weaning guidelines, without taking account of the individual mother, infant and their context was indicated. This is how some mistrust of the advice of health professionals, and possibly other ‘health messages’ emerged, as mothers did not see the advice as appropriate to them, their infant, or circumstances. Mothers did recognise babies as ‘bigger’ or ‘smaller’, but through valuing weight and weight gain were particularly aware of having small babies, which may have limited their capacity for recognising the significance of early signs of overweight in their infants. Final conclusions: Using mixed methods in this study allowed a broad picture of patterns of weight and overweight in Halton infants, and what some of the contributory factors to those patterns might be, to emerge, than if a single research method had been used. A number of implications for policy and practice: at an individual level in terms of the way in which women are supported to feed and wean their babies; and at a population level in terms of the monitoring of weight, were identified.

Objective: To assess the reliability of the Kids' Activity and Nutrition Questionnaire (KAN-Q) as part of a tiered process for developing Supplemental Nutrition Assistance Program-Education tools. Methods: The KAN-Q was administered at 2 time points to assess internal consistency using standardized values of Cronbach alpha and test-retest reliability using the intraclass correlation coefficient for continuous variables, Cohen's kappa (k) statistic for categorical variables, and the weighted k statistic for ordinal data. Results: Data were collected from 119 fourth graders. Cronbach a was adequate for behavior (.71) and knowledge (.72) scales and nutrition behavior (.78) and nutrition knowledge (.75) subscales. Test-retest reliability was generally acceptable, with intraclass correlation coefficients from 0.40 to 0.75 and k coefficients showing fair to substantial agreement (0.30 to 0.72). Conclusions and Implications: The KAN-Q is a practical and reliable questionnaire for school-based administration that aligns directly with Supplemental Nutrition Assistance Program-Education evaluation priorities.