Article one: Family Involvement in School-Based Health Promotion: Bringing Nutrition Information Home 
		
Section: RESEARCH BRIEF 
Family-school collaboration related to children's physical development has become increasingly important as childhood obesity rates continue to rise. The present study described the development and implementation of a literacy-based, family component of a school-based health education program and investigated its viability, acceptability, and effectiveness. Interactive children's books were the mechanism by which students, parents, and teachers received consistent messages at home and school regarding nutrition information. The home-school intervention served to bridge home and school cultures in an urban population. Preliminary process evaluation results indicated that the interactive children's books were feasible to implement in the school context. Parents, children, and teachers had positive perceptions of the books. Parents who received the books demonstrated increased knowledge of "5 a Day," which highlights the importance of eating fruits and vegetables. Although not statistically significant, after the first and second years of intervention, parents in the experimental group reported that their children were eating 0.54 and 0.36 additional servings of fruit and vegetables per day compared with children in the control group. The program did not seem to influence the availability and accessibility of fruits and vegetables at home.
To date, much of the focus of family-school collaboration in the educational literature is related to promoting children's academic and social development (e.g., Christenson, 2004). Home-school collaboration focused on promoting children's physical health has received less attention, yet may be just as important. The present study addresses this gap by focusing on home-school collaboration related to the promotion of healthy eating, an important topic for families and schools given that proper nutrition is important for cognitive and physical development (Nutrition-Cognition National Advisory Committee, 1998). This topic is relevant for school psychologists (Harrison, Cummings, Dawson, Short, Gorin, & Palomares, 2004; Ysseldyke et al., 2006), who can play important roles in the design, implementation, and evaluation of school-based health promotion programs (Power, DuPaul, Shapiro, & Kazak, 2003).
Given the current obesity epidemic (U.S. Department of Health and Human Services, 2001), it is now more important than ever for families and schools to collaborate in obesity prevention. Both home and school settings influence children's eating and physical activity, so consistent messages across these settings are important. This is particularly relevant for young children who rely on their caregivers and school to procure and prepare their food.
Because of the importance of children's healthy eating and the suitability of the school environment for nutrition education, many school-based nutrition education programs have been developed and evaluated. School-based programs frequently include family components. The authors conducted a systematic review of 58 school-based, nutrition education programs implemented in preschools and elementary schools.( n1) Thirty-eight programs (65.5%) mentioned the inclusion of a family component. Of the 38 programs that mentioned a family component, 8 (21.1%) included activities that were based at school or in the community only (e.g., family activity nights), 20 (52.6%) described activities that were based at home only (e.g., newsletters; homework), 8 (21.1%) described family activities that were based both at school and at home, and 2 (5.2%) were unclear. That many school-based nutrition programs send information home is important because parents frequently find it difficult to attend school events. Engaging, time-efficient, enjoyable activities that can be completed at home can meet the needs of large numbers of families. Two published studies incorporated home-based activities assigned for homework at the elementary school level. Gordon and Haynes (1982) developed a series of parent pamphlets that outlined information students learned in school over a 3-week period. Luepker, Perry, Murray, and Mullis (1988) designed family games and a 5-week correspondence course that was sent home in packets. Luepker et al. reported an 86% participation rate by families. These types of approaches are desirable to reach the maximum number of families. Although both approaches were evaluated in controlled studies, neither study reported the degree to which activities were implemented in the homes or parent- and child-reported acceptability. Information regarding the degree to which home-based activities are completed and found to be acceptable is important when considering issues of program feasibility and sustainability.

Article two: Family-based group treatment versus individual treatment
in the management of childhood obesity: randomized,
prospective clinical trial
Muazzez Garipağaoğlu & Yusuf Sahip &
Feyza Darendeliler & Öznur Akdikmen & Sibel Kopuz &
Necdet Sut
Received: 20 August 2008 / Accepted: 26 November 2008 / Published online: 16 December 2008
# Springer-Verlag 2008
Abstract
Introduction This study assessed the short- and long-term
effects of a 3-month family-based group treatment in
the management of childhood obesity versus individual
treatment.
Materials and methods Eighty obese children, aged between
6 and 14 years, and their parents were included in this
prospective controlled clinical study. Forty participants were
randomly assigned for group treatment and the other 40 for
individual treatment. A 3-month intervention program was
focused on implementing healthy eating behaviors. The
weight and height of the children were measured initially and
at each treatment session and at follow-up visits. Body mass
index was calculated and expressed as standard deviation
score.
Results and discussion At the end of 3-month treatment
program, there was a significant decline in BMI SDS in
both groups (p<0.001). After 1 year of follow-up period, there
was still a significant decrease in BMI SDS in the study group
(p<0.001), whereas the decrease in BMI SDS was not
maintained over the follow-up period in the standard group.
There was a significantly increased consumption of vegetable
and fruit and reduced consumption of carbonated drinks and
fruit juice in both groups (p<0.001).
Conclusion These findings demonstrate that the group
treatment is more successful than the individual treatment
in the management of childhood obesity.
Keywords Childhood obesity . Management .
Group treatment . Individual treatment . Risk factors
Introduction
Overweight and obesity have increased dramatically among
children and adolescents as well as in adults. Therefore, the
World Health Organization describes obesity as “most
neglected public health problem” and “a global epidemic”
[4]. It is estimated that 14 million school children in Europe
are overweight [11] and more than 30 million children and
adolescents around the world are obese [8]. In recent years, a
similar trend has been observed in our country as well [10].

Article Three: Family involvement in the treatment of childhood obesity:
the Copenhagen approach
H. N. Grønbæk & S. A. Madsen & K. F. Michaelsen
Received: 30 November 2008 / Accepted: 4 February 2009 / Published online: 21 February 2009
# Springer-Verlag 2009
Abstract
Introduction The objective of this study was to assess the
impacts of a family-based childhood obesity treatment on
anthropometry and predictors of dropout and successful
weight loss.
Materials and methods The 18-month treatment consisted
of a intensive period (IP) including physical exercise,
nutritional guidance, family psychotherapy, child group
sessions and a 1-year follow-up (FU).
Results One hundred children (10–12 years old, >140% of
median weight-for-height) participated. The 81 children
completing the IP decreased significantly from 2.9 to 2.6
body mass index (BMI) standard deviation score (SDS)
units (p<0.001). Furthermore, mean body fat percentage
decreased significantly from 33.7 to 31.9 during IP. The 49
children completing the FU had a further decrease of
0.2 BMI SDS units (p=0.003). Weight loss was less in
children from immigrant families. Drop-out was higher if
the mother had limited education and in immigrant
families.
Conclusions This treatment with a psychological approach
is feasible and results in significant weight loss during the
programme. Future research should focus on how to
improve the results of families with limited education and
immigrants with non-European origin.
Keywords Childhood obesity . Family-based interventions .
Outpatient . Sociodemographic predictors
Introduction
The development of obesity in Denmark follows the pattern
seen in the rest of the industrialised world. In particular,
childhood obesity is rapidly increasing. Over the past
50 years, the prevalence among children between 6 and
8 years of age increased from 0.04% to 5% in boys and from
0.2% to 4% in girls [33]. This unfavourable trend requires
actions that address general prevention and that develop
and evaluate community-based methods of treatment.
Treating childhood obesity is difficult. The recent
Cochrane review on treatment stated that there continue to
be few studies from which conclusions concerning effective
treatment methods could be drawn and that these reports
featured limited interventions [32, 40]. Most authors agree
that treatment of childhood obesity should be family-based,
includes a psychological intervention aimed at changing
lifestyles and should use methods to motivate families to
join and stay in the treatment programme [1, 8, 11, 13, 15,
23, 25, 32]. However, the published treatment programmes
have differed considerably with respect to levels of
intensity and duration of the intervention, extent of parental
involvement, and the degree to which nutrition and physical
training are incorporated. The focus of treatment has shifted
from solely dietary restriction to the introduction of healthy
habits and motivation for change [16, 32]. Flodmark et al.
[12] argued that treatment of childhood obesity must
function in a multidisciplinary setting, and has to take into
account both the physiological and psychological maturation
of the growing child. It has also been shown that the
effects of interventions in pre-adolescent children are more

Article Four: Prevalence of and risk factors for childhood
overweight and obesity
Paul |, Veugelers, Angela L. Fitzgerald
Abstract
Background: Increases in childhood overweight and obesity have
become an important public health problem in industrialized
nations. Preventive public health action is required, but more
research of risk factors is required before evidence-based initiatives
can be developed and targeted effectively. We investigated
the association between childhood overweight and obesity
and risk factors relating to dietary habits, actitivities,
[parents and schools.
Methods: In 2003 we surveyed grade 5 students and their parents
and school principals in Nova Scotia. We measured height
and weight and assessed dietary habits (using Harvard's
Youth/Adolescent Food Frequency Questionnaire), physical
and sedentary artivities, and parental and school-based risk
factors. We estimated neighbourhood income by averaging,
per school, the postal-code level means of household income
of residential addresses of children attending that school. We
used multilevel logistic regression to evaluate the significance
of these risk factors for overweight and obesity.
Results: On the basis of measurements taken of 4298 grade 5 students,
we estimated the provincial prevalence of overweight to
be 32.9% and of obesity to be 9.9%. Children who bought
lunch at school were at increased risk of ovepA'eight (fully adjusted
odds ratio [OR] 1.39, 95% confidence interval [CH
1.16-1.67), whereas those who ate supper together with their
family 3 or more times a week were at decreased risk (OR
0.68, 95% CI 0.52-0.88). Physical education classes 2 or more
times a week at school were associated with a decreased risk of
overweight (OR 0.61, 95% CI 0.43-0.87) and obesity (OR
0.54, 95% CI 0.33-0.88), Children in high-income neighbourhoods
were half as likely to be obese as their peers living in
low-income neighbourhoods (OR 0.50, 95% CI 0.36-0.70).
Interpretation: Parents and schools provide important opportunities
for public health initiatives for reducing childhood overweight
and obesity. Children and schools in low-income
neighbourhoods should receive priority in public health initiatives
to reduce future socioeconomic inequalities in health.
CM/^y2005;173(6):607-13
Increases in childhood overweight and obesity have become
a major public healtJi problem in industrialized
nations.'- In Canada, rates of overweight and obesity
among children have more than doubled in past decades,
with the most recent estimates indicating that about 30%
of children are overweight or obese.'"* The numerous psychosocial,
physical and economic consequences of overweight
and obesity are well-known. Childhood overweight
affects self-esteem and has negative consequences on cognitive
and social development."' Conditions such as type 2
diabetes mellitus, hypertension and bypercholesterolemia,
which were previously seen primarily in adults, are hecoining
more common among children as the prevalence of
obesity increases.' Because childhood overweight often persists
into adulthood, a rising numher of adults will be at increased
risk of these conditions as well as of cardiovascular
disease, osteoarthritis and certain tj'pes of cancer."" As a
whole, the obesity epidemic constitutes a substantial decrease
in quality of life and life expectancy and accounts for
billions of dollars in health care spending.'""
Insufficient physical activity and poor nutrition are
widely acknowledged as the primary mechanisms underlying
the rise in excess body weight.'' Recent studies have described
geographic and socioeconomic gradients and identified
aspects of children's lifestyle, including physical and
sedentary activities, as risk factors for overweight and obesity.
"^^" Most recently, Swinburn and colleagues identified
risk factors related to parents, family and school as potentially
significant and as requiring more evidence so that evidence-
based policy and program decision-making for the
prevention of excess weight can be developed.'' The need
for further research is underlined by the fact that a number
of schools and jurisdictions in Canada are already implementing
policies and programs without evidence of their
effectiveness.
In 2003, we conducted a comprehensive survey of risk
fectors for childhood overweight and obesity with grade 5
students and their parents and school principals in Nova
Scotia, a province with particular weight and health concerns
among both children and adults."-'-' Here, we evaluate
the prevalence of overweight and obesity and examine
the contribution of dietary habits, activities and sociodemographic
and school-based factors to weight problems
among children.
Methods
The 2003 Children's Lifestyle and School-performance Study
(CLASS) was a survey of grade 5 students in Nova Scotia on
health, nutrition and lifestyle factors. The procedures used in this
study are briefly described below and in more detail elsewhere.-"**^'
CMAJ • SEPT. 13, 2005; 173 (6) 607