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Cases used in case-based learning should be realistic, relatively difficult, engaging, and educational to maximize clinical knowledge and skills. Data are needed to support the effectiveness of existing and new techniques to ensure these case attributes. The purpose of this study was to explore dental students' perceptions of the wildcard technique in case-based learning. This novel technique aims to ensure key case attributes by adding new information to the analysis of a case that challenges the initial diagnosis and/or treatment plan.Constructivism (paradigm) and interpretative description (approach) informed the study design. Participants were 21 third- and fourth-year dental students who took part in an oral pathology seminar in which the wildcard was employed. Data were collected through individual, semi-structured interviews that were digitally recorded and transcribed verbatim. Inductive, manifest thematic analysis was used to analyze the data. Several verification strategies were implemented to ensure rigor throughout data analysis.Identified themes suggest that students perceived the wildcard as a new scenario that simulated clinical practice regarding settings, situations, conditions, and required skills. They also enjoyed the wildcard and found it effective in terms of knowledge acquisition, skills development, and engagement. Students valued and recommended wildcards that were challenging, authentic, and educational.Students positively valued the wildcard, which seems to ensure several case attributes. Learning and behavioral outcome evaluations are needed to further establish the effectiveness of the wildcard in case-based learning.

The behavioural sciences curriculum in dental education is often fragmented and its clinical relevance is not always apparent to learners. Curriculum integration is vital to understand behavioural subjects that are interrelated but frequently delivered as separate issues in dental programmes. In this commentary, we discuss behavioural change as a curricular theme that can integrate behavioural sciences in dental programmes. Specifically, we discuss behavioural change in the context of dental education guidelines and describe four general phases of behavioural change (defining the target behaviour, identifying the behavioural determinants, applying appropriate behavioural change techniques and evaluating the behavioural intervention) to make the case for content that can be covered within this curricular theme, including its sequencing. This commentary is part of ongoing efforts to improve the behavioural sciences curriculum in dental education in order to ensure that dental students develop the behavioural competencies required for entry-level general dentists.

Enrollment of international post-secondary students is increasing across Canadian campuses. International post-secondary students may experience challenges in accessing nutritious foods that meet their dietary needs and food preferences. These challenges can pose negative impacts on their health, well-being, and academic achievement. Our aim was to describe international post-secondary students’ perceptions of (1) challenges to attaining food security and (2) consequences of food insecurity on the university experience. We conducted individual semi-structured interviews with 11 international post-secondary students who had food insecurity, were enrolled at a public university in Canada, and who had requested emergency foodhampers from the on-campus food bank. Interviews were audio-recorded, transcribed verbatim, and analyzed using manifest, inductive content analysis. International post-secondary students reported several logistical issues related to obtaining sufficient food, including a lack of time, limited family support, modest food preparation skills, and low knowledge about supportive services and resources. Students also faced challenges in sourcing culturally appropriate foods, including issues related to food availability, accessibility, acceptability, and affordability. Further, they perceived food insecurity to negatively influence their academic performance through compromised concentration, reduced class and exam attendance, and adverse mpactson physical, mental, and social well-being. Some students reported extreme food deprivation, resulting in hunger. Our results revealed the negative impacts that food insecurity can have on international post-secondary students. Findings underscore the imperative to minimize the occurrence of food insecurity while studying in Canada by introducing and enhancing support systems on campus and in the community to enable food security., Les inscriptions d’étudiants internationaux augmentent sur les campus canadiens. Les étudiants internationaux de niveau postsecondaire peuvent vivre certaines difficultés pour accéder à des aliments nutritifs qui répondent à leurs besoins et préférences alimentaires. Ces défis peuvent avoir des effets négatifs sur leur santé, leur bien-être et leurs résultats scolaires. Notre objectif était de décrire les perceptions de ces étudiants en ce qui concerne (1) les défis pour atteindre la sécurité alimentaire et (2) les conséquences de l’insécurité alimentaire sur l’expérience universitaire. Nous avons mené des entrevues individuelles semi-structurées avec 11 étudiants internationaux de niveau postsecondaire qui souffraient d’insécurité alimentaire, qui étaient inscrits dans une université publique au Canada et qui avaient demandé des paniers alimentaires d’urgence à la banque alimentaire de leur campus. Les entretiens ont été enregistrés en audio, transcrits mot pour mot, et fait l’objet d’une analyse de contenu manifeste et nductive. Les étudiants internationaux de niveau postsecondaire ont signalé plusieurs problèmes logistiques liés à l’acquisition de nourriture, notamment un manque de temps, l’absence de soutien familial, des compétences culinaires faibles et une faible connaissance des services et des ressources de soutien.Les étudiants disent également avoir été confrontés à des défis pour se procurer des aliments culturellement appropriés, y compris des problèmes liés à la disponibilité, à l’accessibilité, à l’acceptabilité et au prix des aliments. De plus, ils disent percevoir une influence négative de l’insécurité alimentaire sur leurs résultats scolaires à cause d’une concentration moindre, d’une réduction de la fréquentation des cours et des examens et des effets néfastes sur le bien-être physique, mental et social qu’elle entraîne. Certains étudiants ont signalé une privation alimentaire extrême entraînant la faim. Nos résultats ont révélé les effets négatifs que l’insécurité alimentaire pouvait avoir sur les étudiants internationaux de niveau postsecondaire.Les résultats soulignent l’impératif de minimiser l’occurrence de l’insécurité alimentaire pendant les études au Canada en introduisant des systèmes de soutien sur les campus et dans la communauté pour permettre la sécurité alimentaire et en améliorant ceux qui existent.

BACKGROUND Stakeholders can provide valuable input to improve scheduling paediatric ambulatory clinic appointments, a complex process that requires effective planning and communication between parents, administrative staff and clinicians. The purpose of our study was to characterize recommendations from parents, administrative staff and clinicians to improve paediatric ambulatory appointment scheduling. METHODS Conducted between February 2018 and January 2019, this qualitative study was guided by qualitative description. Data collection was completed using focus groups with three stakeholder groups: parents, administrative staff and clinicians. Participants provided recommendations to optimize paediatric ambulatory appointment scheduling at the Stollery Children's Hospital in Edmonton, Alberta, Canada. Focus group data were transcribed verbatim and analysed using manifest inductive content analysis. RESULTS Forty-six participants (mean age: 42.7; 87% female) participated in 12 focus groups. Parents (n = 11), administrative staff (n = 22) and clinicians (n = 13) made recommendations that were organized into two categories: appointment triaging and arranging. Triaging recommendations were related to appointment availability (e.g. providing alternatives to cancelling clinics with short notice) and waitlist management (e.g. developing clear and consistent policies regarding information flow and communication between clinics and administrative staff). Appointment arranging recommendations referred to booking (e.g. directly involving parents in the booking process), reminders (e.g. using text message reminders) and attendance (e.g. providing parents with a single point of contact who can provide the correct information about late and cancellation policies). Recommendations were similar across stakeholder groups. CONCLUSION Our findings showed congruent recommendations across stakeholder groups to address challenges with scheduling ambulatory appointments, many of which have the potential to be modified. Experimental research and quality improvement initiatives are needed to determine the feasibility, acceptability and effectiveness of stakeholder recommendations to improve triaging and scheduling paediatric ambulatory appointments.

Motivational interviewing (MI) is an evidence-based counseling approach that can help individuals make positive behavioral and cognitive changes for managing obesity. We conducted a scoping review to summarize evidence on fidelity and key elements of MI-based interventions for managing adolescent obesity and examine the reporting of these interventions. Ten electronic databases and gray literature were searched systematically and included literature from January 1983 to February 2022, and 26 studies were included. Data on MI features, delivery context, training, and fidelity to treatment were summarized. Fidelity was assessed using an assessment grid with five domains-theory, training, implementation, treatment receipt, and treatment enactment. The last step of the review involved stakeholder consultation with clinician-scientists and researchers with experience in MI and managing adolescent obesity. Thirteen stakeholders were interviewed about our review findings on MI and treatment fidelity. Our analyses revealed that MI-based interventions for managing adolescent obesity had "low treatment fidelity"; no studies had "high treatment fidelity" across all five domains. Fidelity strategies adhered to the most was theory, and treatment enactment was the lowest. Stakeholders mentioned that "low treatment fidelity" may be due to increased time to complete fidelity assessments and increased cost associated with treatment fidelity. These findings have implications for planning, implementing, and evaluating MI-based interventions for managing adolescent obesity.

Introduction Obstructive sleep apnoea (OSA) is a sleep-breathing disorder that seems likely to have long-term negative social and health consequences in children and adolescents. There are no established standard management approaches when the first line of therapy, the tonsillectomy and adenoidectomy (T&A), is not indicated or fails to address paediatric OSA (residual paediatric OSA). This protocol describes a prospective cohort study that aims to assess the effectiveness of orthodontic interventions for managing residual paediatric OSA in patients with concomitant craniofacial issues. Methods and analysis Children aged 6–16 years who with an OSA diagnosis and did not benefit from previous T&A or qualified for T&A will be recruited. Orthodontic intervention(s), when adequately indicated (maxillary expansion, mandibular advancement or maxillary complex advancement with skeletal anchored headgear), and a control (orthodontic intervention declined) cohorts will be involved. A sample size of 70 participants (n=35 per cohort) is planned. Effectiveness data will be assessed through nocturnal polysomnography, a craniofacial index, sleep questionnaires and medical records. Additionally, the association of residual OSA and two comorbidities, obesity and asthma, will be investigated through assessing blood, urine and saliva metabolites. The changes on body mass index will also be investigated as a secondary outcome. Other additional outcomes, including association between residual paediatric OSA and periodic limbs movement, restless leg syndrome, insomnia, and the use of abiometric shirt to sleep monitoring purposes will also be considered. All participants will be followed up for 12 months after treatment allocation. The effectiveness of the intervention will be analysed by the assessment of sleep parameters, medical history (from medical chart reviews), questionnaire responses, craniofacial characteristics and metabolomic markers using an algorithm to be developed. Ethics and dissemination This study was approved by the Health Research Ethics Board-Health Panel, University of Alberta, Edmonton, Canada (Pro00084763). The findings will be shared with scientific and patient content-specific social network communities to maximise their impact on clinical practice and future research in the study topic. Trial registration number NCT03821831; Pre-results.

It is recommended that primary care-based physicians refer children with overweight and obesity to multidisciplinary paediatric obesity management, which can help to improve weight and health.To determine predictors of referral to multidisciplinary paediatric obesity management.This retrospective, population-level study included physicians who could refer 2-17 years old with a body mass index ≥85th percentile to one of three multidisciplinary paediatric obesity management clinics in Alberta, Canada. Physician demographic and procedural data were obtained from Practitioner Claims and Provider Registry maintained by Alberta Health from January 2014 to December 2017. Physician characteristics were compared based on whether they did or did not refer children for obesity management. Univariable and multivariable logistic regression models analysed associations between physician characteristics and referral making.Of the 3863 physicians (3468 family physicians, 395 paediatricians; 56% male; 49.3 ± 12.2 years old; 22.3 ± 12.6 years since graduation) practicing during the study period, 1358 (35.2%) referred at least one child for multidisciplinary paediatric obesity management. Multivariable regression revealed that female physicians (versus males) [odds ratio (OR): 1.68, 95% confidence interval (CI): 1.46-1.93; P0.0001], paediatricians (versus family physicians) (OR: 4.89, 95% CI: 3.85-6.21; P0.0001) and urban-based physicians (versus non-urban-based physicians) (OR: 2.17, 95% CI: 1.79-2.65; P0.0001) were more likely to refer children for multidisciplinary paediatric obesity management.Approximately one-third of family physicians and paediatricians referred children for multidisciplinary paediatric obesity management. Strategies are needed to improve referral practices for managing paediatric obesity, especially among male physicians, family physicians and non-urban-based physicians as they were less likely to refer children.Paediatric overweight and obesity impact one-third of children in Canada and the USA. It is recommended that physicians refer children with overweight and obesity to paediatric obesity management, which can help to improve their weight and health. While referral practices of US physicians have been well characterized, Canadian evidence remains limited. To address this gap, we examined predictors of referral making for paediatric obesity management. Our study included physicians (family physicians and paediatricians) who could refer 2–17 years old with overweight and obesity to three paediatric weight management clinics in Alberta, Canada between January 2014 and December 2017. Descriptive analyses and regression models were performed. Of the 3863 physicians practicing during the study period, 1358 (35.2%) referred at least one child for paediatric obesity management. Referring physicians were more likely to be female, paediatricians and practicing in urban-based clinics. Additional research is needed to explore physicians’ decisions to refer children for obesity management, which can inform interventions to enhance referral, and ultimately, improve the health and well-being of children with obesity.

This qualitative study aimed to explore the experiences of parents supporting their child with Autism Spectrum Disorder (ASD) and overweight or obesity (OW/OB), including their weight management support needs.Interview transcripts were analysed using inductive thematic analysis. Nine parents (The three themes developed were: (1) Our journey to obtain weight management support; (2) I need real-world solutions; and (3) The what, who and how of our weight management needs. Parents reported being proactive in seeking weight management support for their child but were disappointed with the services offered. Resources were not tailored to the child's complex nutrition and behavioural issues or their abilities and functioning. A multidisciplinary approach that integrated both disability and weight management expertise was desired, but not experienced. A range of formal and informal programs were recommended.This study provides a call to action for supports that ensure children with ASD and OW/OB receive integrated, individualised support to maximise their health and wellness.Implications for rehabilitationChildren with autism spectrum disorder (ASD) are at high risk of developing overweight or obesity.The weight management support needs of parents of children with ASD and overweight or obesity are not being met.Support must be tailored to the child's needs, which are often complex.Health services that integrate expertise in both disability and weight management are needed for children with ASD and their families.

ObjectiveScheduling ambulatory clinic appointments includes a complex set of factors and diverse stakeholders. Families, administrative staff and clinicians may have varied experiences with scheduling clinic appointments. The objective of our study was to understand stakeholders’ perceptions and experiences with scheduling pediatric ambulatory clinic appointments.DesignGuided methodologically by qualitative description, focus groups were conducted separately with three stakeholder groups and analyzed using qualitative content analysis.SettingThis qualitative study was completed at a children’s hospital in Alberta, Canada.ParticipantsParents, administrative professionals and clinicians who used the pediatric ambulatory scheduling system regularly to elicit perceptions and experiences about issues and areas where improvements could be made.ResultsAcross 12 focus groups, parents (n = 11), administrative professionals (n = 23) and clinicians (n = 13) discussed areas for improvement related to the pediatric ambulatory scheduling system. The perceived areas for improvement were grouped into three categories regarding levels of influence: (i) ‘intrapersonal’: knowledge, skills and behaviors (e.g. insufficient training of administrative professionals); (ii) ‘interpersonal’: communication processes (e.g. parents not receiving confirmation letters); and (iii) ‘institutional’: structures and processes (e.g. varying practices and processes across clinics).ConclusionsStakeholders provided a rich description of the interrelated factors and processes that influenced the scheduling of pediatric ambulatory clinic appointments. Multilevel, experimental interventions are needed to test whether the findings described herein can enhance the structure and function of pediatric ambulatory appointment scheduling.

Objective Although assessment is essential to accurately represent student learning, little is currently known about student and faculty perceptions of assessment in dental schools. Our study aimed to explore faculty and student views of didactic and clinical assessments in the School of Dentistry at the University of Alberta. Method Qualitative description informed the study design. Data were collected through focus groups and analysed inductively using manifest content analysis. Results Five focus groups were conducted with faculty (n = 34) and three with students (n = 19). Faculty and student views of assessment were related to improvements made (perceived positive changes), improvements needed (perceived limitations) and improvements recommended (recommendations to improve perceived limitations). Faculty and students reported that improvements made (eg adequacy of assessment to students' levels of training) varied across instructors, courses and learning environments. Both faculty and students perceived clinical assessments as less appropriate than didactic assessments. Faculty perceived limitations were mostly related to assessment appropriateness, especially assessment accuracy and comprehensiveness, whilst student perceived limitations included other issues related to appropriateness (eg misalignment with course objectives) as well as issues related to assessment volume, pace and scheduling. Similarly, faculty recommendations focused on enhancing the assessment of clinical competencies, whilst students' recommendations aimed to also improve assessment scheduling, volume and usage (eg for learning purposes). Conclusions Faculty and student views of assessment complemented one another. Our data show that assessment in dental education is multidimensional, so that multilevel strategies may be needed to improve this component of dental curricula.

Background: Health care providers (HCPs) report barriers to effective communication with adolescents with obesity when discussing lifestyle behavior change and may benefit from tailored health comm...

This study aimed to evaluate the oral health status of individuals with obsessive-compulsive disorder (OCD).Ninety-two participants, aged 18 years and older from which 46 had OCD symptoms, were included in this comparative cross-sectional study. Data on age, sex, smoking habit, educational level, and potential mediators including brushing frequency (BF) and brushing duration (BD) were collected. Clinical examinations determined outcome measures including decayed-missing-filled teeth (DMFT), presence of root caries (PoRC), gingival recession (GR), plaque index (PI), and papillary bleeding index (PBI). Pathway analysis was used for data analysis.Individuals with OCD had significantly lower DMFT (p.01), higher BF (p = .01), and lower PI (p = .01); however, there were no significant differences regarding BD, GR, PBI, and PoRC (p.05). While BD did not have a mediating role, BF mediated the effect of OCD on DMFT (B = -0.31, CI = -0.60 to -0.06) and PI (B = -0.15, CI = -0.36 to -0.03). Males had less PI (B = -1.03, CI = -1.81 to -0.24) and PBI (B = -1.14, CI = -2.09 to 0.20) than females. Except for OCD and sex, other predictors were not significant.Individuals with OCD had lower caries experience and similar gingival health compared to controls. Part of the impact of OCD was mediated through brushing habits.

Background: In Canada and the United States, most families referred for pediatric weight management services do not start treatment. Of families who initiate care, many discontinue before ...

OBJECTIVE To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Problem: Think-pair-share (TPS) is a teaching strategy that promotes active and collaborative learning; however, the effectiveness and applicability of this strategy in its original or altered form...

Background Clinical practice guidelines (CPGs) include evidence-based recommendations for managing obesity in adolescents. However, information on how health care providers (HCPs) implement these recommendations in day-to-day practice is limited. Our objectives were to explore how HCPs deliver weight management health services to adolescents with obesity and describe the extent to which their reported practices align with recent CPGs for managing pediatric obesity. Methods From July 2017 to January 2018, we conducted a qualitative study that used purposeful sampling to recruit HCPs with experience in adolescent weight management from multidisciplinary, pediatric weight management clinics in Edmonton and Ottawa, Canada. Data were collected using audio-recorded focus groups (4–6 participants/group; 60–90 min in length). We applied inductive, semantic thematic analysis and the congruent methodological approach to analyze our data, which included transcripts, field notes, and memos. Qualitative data were compared to recent CPGs for pediatric obesity that were published by the Endocrine Society in 2017. Of the 12 obesity ‘treatment-related’ recommendations, four were directly relevant to the current study. Results Data were collected through three focus groups with 16 HCPs (n = 10 Edmonton; n = 6 Ottawa; 94% female; 100% Caucasian), including dietitians, exercise specialists, nurses, pediatricians, psychologists, and social workers. We identified three main themes that we later compared with CPG recommendations, including: (i) discuss realistic expectations regarding weight management (e.g., shift focus from weight to health; explore family cohesiveness; foster delayed vs instant gratification), (ii) personalize weight management (e.g., address personal barriers to change; consider developmental readiness), and (iii) exhibit non-biased attitudes and practices (e.g., de-emphasize individual causes of obesity; avoid making assumptions about lifestyle behaviors based on weight). Based on these qualitative findings, HCPs applied all four CPG recommendations in their practices. Conclusions HCPs provided practical insights into what and how they delivered weight management for adolescents, which included operationalizing relevant CPG recommendations in their practices.

Objectives To characterize the children who were referred, determine the proportion of referred children who enrolled, and examine factors associated with enrollment in multidisciplinary clinical care for pediatric weight management. Study design This cross-sectional study included the population of children (2-17 years of age; body mass index of ≥85th percentile) referred to 1 of 3 hospital-based multidisciplinary weight management clinics in Alberta, Canada, from April 2013 to April 2016. Referral and enrollment data were obtained from Alberta Health Services databases. Bivariate and multivariable logistic regression models were used to determine the independent and combined effects of predictors of enrollment. Results Of the 2014 children (51.8% male; mean body mass index z-score: 3.42 ± 0.03) referred to multidisciplinary clinical care, 757 (37.6%) enrolled in care. Most referred children had severe obesity and were referred by physicians. Several factors independently predicted enrollment; however, in our most parsimonious multivariable model, only the time gap (OR, 0.94; 95% CI, 0.88-0.99; P = .03) between the attendance date of the orientation session and the booking date of initial appointment predicted enrollment for all children. Body mass index z-score (OR, 0.81; 95% CI, 0.67-0.98; P = .03) and time gap (OR, 0.92; 95% CI, 0.85-0.99; P = .02) predicted enrollment in children with severe obesity exclusively. Conclusions Fewer than 40% of referred children enrolled in multidisciplinary clinical care. Reducing the duration of enrollment and providing additional support for treatment initiation to children with severe obesity may enhance treatment uptake for pediatric weight management.

Objective To explore parents' recommendations to enhance enrollment in multidisciplinary clinical care for managing pediatric obesity. Study design Data for this interpretative description study were collected through individual, semistructured interviews that were audiorecorded, transcribed verbatim, and analyzed thematically. Parents (n = 79) were recruited from 4 multidisciplinary weight management clinics in Canada located in Edmonton, Hamilton, Montreal, and Vancouver. Results Most interviewed parents had children with obesity (body mass index ≥95th percentile; 84.2%), were female (87.3%), had postsecondary education (69.6%), and were white (75.9%). Parents' recommendations referred to enrollment opportunities, information about obesity services, motivation for treatment, and accessibility to obesity services. Specifically, parents recommended to increase referral options and follow-up contacts with families during the enrollment process, inform referring physicians and families about the availability and characteristics of obesity services, enhance families' motivation for treatment, prevent families from getting discouraged, make services more appealing to families, and address accessibility issues (eg, offering multiple options for appointment times, providing support for transportation). Conclusions Parents' recommendations support the need for family-centered approaches to enhance enrollment; however, their feasibility, acceptability, and effectiveness remain to be tested empirically.

Summary Objective To explore parents' reasons for discontinuing tertiary-level care for paediatric weight management. Methods Participants were parents of 10–17year olds (body mass index [BMI] ≥85th percentile) who were referred for paediatric weight management. Parents were recruited from three Canadian sites (Vancouver, BC; Edmonton, AB; Hamilton, ON) and were eligible if their children attended at least one clinical appointment and subsequently discontinued care. Data were collected using semi-structured individual interviews that were digitally recorded, transcribed, and analysed using an inductive manifest content analysis. Results Parents (n=29) of children [mean age: 14.7±1.8years; mean BMI percentile: 98.9±1.6; n=17 (58.6%) boys] were primarily female (n=26; 89.7%), Caucasian (n=22; 75.9%), and had a university degree (n=23; 79.3%). Reasons for discontinuing care were grouped into three categories: (i) family factors ( e.g. , perceived lack of progress, lack of family support, children's lack of motivation), (ii) logistical factors ( e.g. , monetary costs, distance, scheduling), and (iii) health services factors ( e.g. , unmet expectations of care, perceived limited menu of services, no perceived need for further support). Conclusions A range of multi-level factors influenced attrition from tertiary-level paediatric weight management. Our data suggest that experimental research is needed to examine whether addressing reasons for attrition can enhance families' retention in care and ultimately improve health outcomes for children living with obesity.

Traditional approaches to clinical education (CE) in dentistry have primarily focused on the needs and interests of students (student-centred), patients (patient-centred) or individuals receiving care (person-centred). Research has shown that giving priority to the interests of one stakeholder (eg students) may negatively affect the interests of others (eg patients, instructors and administrators). In this commentary, we discuss some limitations of traditional approaches to CE and suggest an eco-centred approach that assumes that the interests of all stakeholders must be considered when planning CE due to the interdependent relationships between stakeholders. A description of this new approach is provided, whilst research and innovation are encouraged to develop an ecologically informed system of CE.

Background Lifestyle modifications represent the first line of treatment in obesity management; however, many adolescents with obesity do not meet lifestyle recommendations. Given that adolescents are rarely consulted during health policy development and in the design of lifestyle interventions, their first-hand experiences, preferences, and priorities may not be represented. Accordingly, our purpose was to explore adolescents’ lifestyle treatment recommendations to inform policy and program decisions. Methods Conducted from July 2017 to January 2018, this study adhered to a qualitative, crosslanguage, patient-oriented design. We recruited 19 13–17-year-old adolescents (body mass index [BMI] ≥85th percentile) seeking multidisciplinary treatment for obesity in geographically and culturally diverse regions of Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews were audio-recorded, transcribed verbatim, managed using NVivo 11, and analyzed using quantitative and qualitative content analysis by two independent researchers. Results Adolescents’ recommendations were organized into five categories, each of which denotes health as a collective responsibility: (i) establish parental support within limits, (ii) improve accessibility and availability of ‘healthy foods’, (iii) limit deceptive practices in food marketing, (iv) improve accessibility and availability of varied physical activity opportunities, and (v) delay school start times. Respect for individual autonomy and decision-making capacity were identified as particularly important, however these were confronted with adolescents’ partial knowledge on nutrition and food literacy. Conclusions Adolescents’ recommendations highlighted multi-level, multi-component factors that influenced their ability to lead healthy lifestyles. Uptake of these recommendations by policy-makers and program developers may be of added value for lifestyle treatment targeting adolescents with obesity.

Objectives To pilot-test a mixed methods approach to evaluate tools and resources (TRs) that healthcare providers (HCPs) use for preventing childhood obesity in primary care, and report a preliminary descriptive assessment of commonly-used TRs. Methods This mixed methods study included individual, semi-structured interviews with purposefully-sampled HCPs in Alberta, Canada; interviews were digitally recorded and analyzed thematically (phase I). Two independent reviewers used three assessment checklists to evaluate commonly-used TRs (phase II). HCPs provided feedback on our coding scheme and checklist data (phase III). Results Three themes described how HCPs ( n =19) used TRs: purpose of use ( e.g ., clinical support), logistical factors ( e.g ., accessibility), and decision to use ( e.g ., suitability). The latter theme overlapped with constructs of suitability on the checklists. Overall, participants used 15 TRs, most of which scored ‘average' on the checklists. Conclusion Phases I and II provided unique insights on the evaluation of TRs used for preventing childhood obesity. Criteria on the checklists overlapped with HCPs' perceptions of TR suitability, but did not reflect logistical factors that influenced their use of TRs. Practice implications Developers of TRs should collaborate with HCPs to ensure that subjective and objective criteria are used to optimize TR suitability in the primary care setting.

Background Few children with obesity who are referred for weight management end up enroled in treatment. Factors enabling enrolment are poorly understood. Our purpose was to explore reasons for and facilitators of enrolment in paediatric weight management from the parental perspective. Methods Semi-structured interviews were conducted with parents of 10- to 17-year-olds who were referred to one of four Canadian weight management clinics and enroled in treatment. Interviews were audio-recorded and transcribed verbatim. Manifest/inductive content analysis was used to analyse the data, which included the frequency with which parents referred to reasons for and facilitators of enrolment. Results In total, 65 parents were interviewed. Most had a child with a BMI ≥95th percentile (n = 59; 91%), were mothers (n = 55; 85%) and had completed some post-secondary education (n = 43; 66%). Reasons for enrolment were related to concerns about the child, recommended care and expected benefits. Most common reasons included weight concern, weight loss expectation, lifestyle improvement, health concern and need for external support. Facilitators concerned the referral initiator, treatment motivation and barrier control. Most common facilitators included the absence of major barriers, parental control over the decision to enrol, referring physicians stressing the need for specialized care and parents' ability to overcome enrolment challenges. Conclusions Healthcare providers might optimize enrolment in paediatric weight management by being proactive in referring families, discussing the advantages of the recommended care to meet treatment expectations and providing support to overcome enrolment barriers.

Background Many adolescents with obesity do not meet recommendations for nutrition, physical and sedentary activities, and sleep habits, all of which can influence weight management. Objective To explore barriers and enablers that influenced the adoption of lifestyle behavior changes among adolescents receiving multidisciplinary clinical care for pediatric weight management. Methods In this multi-centre, qualitative description study, we used purposeful sampling to recruit 13-17 year olds (body mass index ≥85th percentile) enrolled in one of two pediatric weight management clinics in Edmonton and Ottawa, Canada. Adolescents participated in one-on-one, in-person, semi-structured interviews in English or French. Interviews lasted 30-60 minutes, were audio-recorded, transcribed verbatim, and managed using NVivo 11. Data were triangulated using transcripts, field notes, and memos and analyzed by two independent researchers using inductive, semantic thematic analysis. Results In total, 19 adolescents (12 Anglophone and 7 Francophone; 15.1±1.7 years old; 3.5±0.6 BMI z-score; n = 11 female; n = 13 Caucasian) participated. Adolescents reported diverse barriers to and enablers of healthy nutrition, physical and sedentary activities, and sleep habits, which we organized into the following themes: physiological mechanisms and physical health status, self-regulation for behavior change, controllability and competence beliefs, social relationships and interactions, and accessibility to and availability of opportunities for lifestyle enhancement. Across these themes and lifestyle areas, we identified three shared barriers and/or enablers, including the degree of controllability, the impact of mental health, and social pressures related to weight management. Conclusions This research provides evidence that can be used to tailor interventions and health services delivery, including a focus on psychosocial well-being, to support adolescents with obesity in making and maintaining healthy lifestyle behavior changes.

Many children and their families do not benefit from multidisciplinary clinical care (MCC) for paediatric weight management because they do not enrol in (initiate) treatment. The purpose of this report was to highlight practical recommendations to enhance the enrolment of Canadian children in MCC, which were drawn from multisite Canadian studies (quantitative and qualitative) that we completed recently. Recommendations to stakeholders, including primary care providers, MCC providers and decisions makers, were organized according to opportunities, motivation and barriers to enrol. Findings from our research suggested that enrolment in MCC can be improved by increasing opportunities and motivation to enrol as well as reducing the impact of enrolment barriers.

Objective To explore adolescents’ and health care providers’ (HCPs) perspectives on adolescents’ involvement in decision-making within multidisciplinary clinical care for pediatric weight management. Methods In this multi-centre, qualitative description study, we purposefully recruited 13-17-year-olds with overweight or obesity and HCPs from two pediatric weight management clinics in Edmonton and Ottawa, Canada. Participants completed one-on-one, in-person, semi-structured interviews (adolescents) or focus groups (HCPs), which were audio-recorded, transcribed verbatim, and managed using NVivo 11. Data were analyzed by two independent researchers using inductive thematic analysis and the congruent methodological approach for group interactions. Results A total of 19 adolescents and 16 HCPs participated. Three themes were identified in relation to adolescents’ decision-making for weight management, including (i) conditions for adolescent involvement, (ii) preferences for adolescent involvement, and (iii) extent of parental involvement. Conclusions Although adolescents and HCPs positively valued adolescents’ involvement in making decisions regarding their weight and health, the extent to which adolescents wished to be involved in the decision-making process varied between individuals and families. Practice Implications HCPs are encouraged to include adolescents and families in their health services delivery, including consulting individually with adolescents and tailoring care to their expectations regarding decision-making.

Engagement denotes the extent to which, and how, individuals participate in weight management (WM) services. Effective WM services should generate meaningful outcomes and promote high participant engagement; however, research is predominantly focused on the former. Given that engagement is a poorly understood phenomenon, and that engagement-related concepts are often used synonymously (e.g., dropout and attrition), the engagement pathway is hereby introduced. This pathway defines key concepts (e.g., recruitment, adherence, attrition) and their relationships in the enrolment, intervention, and maintenance stages of treatment. The pathway will help researchers and practitioners better understand engagement-related concepts whilst encouraging greater conceptual consistency between studies.

Shared decision-making (SDM) is central to personalising health and medical decisions. This decisional model encourages patients to act as managers of their own care while maintaining a partnership with health professionals. Although applied to some conditions, SDM has been used infrequently in pediatric weight management (PWM). Herein, we highlight the applicability and usefulness of SDM in making several important decisions related to PWM, including referral-making to different levels of care and treatment initiation and implementation. We conclude by describing possible challenges that may arise when implementing this model and suggest strategies to optimise the use of SDM in PWM.

AIM Home visits have successfully been used to deliver various health services, but what role could they play in paediatric weight management? Low treatment initiation and high attrition prompted our multidisciplinary paediatric weight management clinic to investigate how families perceived the benefits and barriers of home visits. METHODS We focused on children with obesity aged 2-17 who were enrolled in our tertiary-level clinic in Alberta, Canada. None had received a home visit. The families were interviewed face-to-face from October 2015 to October 2016, and we used a qualitative description methodological framework and manifest content analysis. The parents were the main interviewees. RESULTS Of the 56 families, 89% were interested in a home visit, 82% wanted support from a dietician and 54% from an exercise specialist. The perceived benefits of home visits included comprehensive assessment (95%), convenience (86%), tailored care (29%) and family involvement (13%), while the costs and barriers included clinicians' potential judgmental attitudes (30%), loss of privacy (19%) and distractions (10%). Some thought clinicians would find home visits inconvenient (25%), with bureaucratic challenges (14%) and sustainability issues (5%). CONCLUSION Families felt home visits were a convenient option for managing paediatric obesity and identified important benefits and barriers that could guide such interventions.

We read with interest the recently published clinical practice guidelines for preventing and treating childhood obesity (1). The authors reported their evaluation of the quality of the evidence and an assessment of the strength of recommendations according to objective criteria across a diverse literature. In our view, however, this excellent and comprehensive report does not mention two relevant issues: attrition and enrollment. These issues are likely to be of concern for clinicians, administrators, and researchers because they can have a substantial impact on clinical care.

Although prolonged engagement in paediatric weight management (PWM) is associated with positive treatment outcomes, little is currently known about enablers of long-term programme attendance. The purpose of our study was to explore families' reasons for and facilitators of their continued attendance at health services for PWM. Semi-structured, individual interviews were conducted with parents of children (10-17 year old; body mass index ≥85th percentile) who completed the active phase of treatment in one of four Canadian multidisciplinary clinics for PWM. Interview data were recorded digitally, transcribed verbatim and analysed thematically. Parents' (n = 40) reasons for continued clinic attendance included ongoing concerns (eg, parental concern about their child's health), actual and expected benefits from treatment (eg, lifestyle improvements) and perceived quality of care (eg, structured, comprehensive, tailored health services). Several logistical and motivational factors contributed to continued attendance, including flexible work schedules, flexible appointment times, financial resources and children's motivation for treatment. Helping families address treatment barriers and ensuring that weight management services meet families' treatment expectations are promising strategies to enhance retention in PWM to optimize health outcomes.

To assess parental awareness of their child's dental status and the relationship between parental awareness and children's dental attendance. Participants were children aged 6 years or younger and their African parents who had lived in Canada for up to 10 years. Demographics and parents' perceived dental status were collected. Children's normative dental status was determined by dental examinations. 125 pairs of parents and children aged 21-72 months were included. 52% of the children never had a dental visit. Dental status of 44% of children was rated as good by parents, among them, 56% had dental decay. Parental assessments did not coincide with the clinical assessments of 62% of children. No correlation was found between parental awareness and children's dental attendance. Children of African immigrants are at high risk for developing severe dental decay because of low parental awareness and lack of regular dental visits.

Objective Although parents are uniquely positioned to offer first-hand insights that can be used to improve health services for managing pediatric obesity, their perspective is underexplored. Our objective was to characterize parents' recommendations for enhancing tertiary-level health services for managing pediatric obesity in Canada. Methods Semistructured, one-on-one interviews were conducted with parents of children who initiated treatment at 1 of 4 Canadian tertiary-level, multidisciplinary weight management clinics. Parent perspectives were elicited regarding the strengths and weaknesses of the health services they received as well as areas for potential improvement. Interviews were audio-recorded and transcribed verbatim. We used qualitative description as the methodological framework and manifest content analysis as the analytical strategy. Results Parents (n = 65; 88% female; 72% Caucasian; 74% with at least some postsecondary education; 52% >$50,000 CDN household income) provided a range of recommendations that were organized according to health care: 1) accessibility, 2) content, and 3) delivery. The most common recommendations included increasing scheduling options (44%; n = 29), tailoring services to families' needs and circumstances (29%; n = 19), placing greater emphasis on physical activity (29%; n = 19), altering program duration (29%; n = 19), incorporating interactive elements (25%; n = 16), information provision (25%; n = 16), and providing services at sites closer to participants' homes (24%; n = 15). Conclusions Parents' recommendations to enhance health services for managing pediatric obesity concerned modifiable factors related to accessibility, content, and delivery of care. Further research is needed to evaluate whether implementing suggested recommendations improves clinically relevant outcomes including attrition, quality of care, and success in weight management.

[Author Affiliation]Arnaldo Perez. Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.Geoff D.C. Ball. Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.Address correspondence to: Geoff D.C. Ball, PhD, RD, Department of Pediatrics, University of Alberta, 4-515 Edmonton Clinic Health Academy, 11405m 87th Avenue, Edmonton, Alberta, Canada T6G IC9, E-mail: gdball@ualberta.caTo the Editor:In a recent editorial in Childhood Obesity, Katz commented on the phenomenon of parents' misperception of children's excess weight.1 Although the editorial focused on engaging children and their families in obesity management, he challenged a common belief in the weight misperception literature, which is to combat misperception of excess weight with objective information. Upon review of the misperception literature, we believe there is value in going "beyond oblivobesity" to consider a number of misunderstandings related to the conceptualization, interpretation, and attempt to address the discrepancy between perceived and actual weight status of children.1. Parents are unaware of their children's obesity. Most studies on parental weight misperception have relied on anthropometric measures (e.g., BMI) to determine children's weight status.2 Given that these metrics only provide an indirect estimate of obesity, parental unawareness of child obesity can only ever be estimated indirectly as well. Further, unawareness is just one aspect of weight misperception; the latter not only implies that parents are unaware of their children's actual weight status, but also that they assign to their children a weight status other than the actual status. Compared to unawareness, misperception may exert a greater influence on whether parents choose to "accept" objective data (e.g., BMI plotted on a growth chart) showing that their children meet the clinical definition for obesity.2. Parents fail to recognize their children's weight problem. Conceptually, it is important to differentiate between misclassifying the identity of a condition (which is the main focus of studies on perceived weight status) and being concerned about a condition (perceiving it as a problem). Health concern in general, and weight concern in particular, depend on (1) the severity attached to the consequences of the condition and (2) the perceived personal susceptibility to those consequences. In this regard, accurate recognition of excess weight is necessary, but not sufficient, to be concerned about obesity. For instance, both Genovesi and colleagues3 and Jain and colleagues4 found that most parents in their studies were aware of, but not concerned about, their children's excess weight.3. Parents will not take preventive actions to address obesity unless a weight problem is recognized. Compared to parents who failed to recognize their children's excess weight, Neumark-Sztainer and colleagues5 found that those who recognized it correctly were not more likely to promote healthier lifestyle behaviors for their children. Qualitative evidence has shown that children's psychosocial well-being and quality of life were more common reasons for parents to engage in pediatric weight management versus concerns about children's weight and physical health.6,7 It is sometimes forgotten in the dominant discourse about nutrition, physical activity, and obesity that individuals may perform healthy lifestyle behaviors not because a problem exists or because one is expected, but for the simple sake of living a healthy and enjoyable life.4. Parents who do not recognize their children's obesity are in denial. Given that children's excess weight is visually apparent, it is often assumed that parents should recognize it unless they are in denial. As a defense or coping mechanism, 8 denial denotes a causal attribution to account for weight misperception that cannot be demonstrated by simply comparing the perceived and actual weight status. …