MI Studies Targeting Pediatric Obesity

We identified two studies in which MI was used to intervene in pediatric obesity. The first of these studies, the Healthy Lifestyles Pilot Study, focused on prevention of overweight among children 3 to 7 yr old. The second study, Go Girls, was a multicomponent intervention for overweight African American adolescents aged 12 to 16 that included MI as a key intervention element.

Healthy Lifestyles Pilot Study

The Healthy Lifestyles Study (HLS) (unpublished data) and Go Girls was conducted in 2004-2005 as a partnership of the Centers for Disease Control and Prevention, the American Academy of Pediatrics (AAP), and the American Dietetic Association. The primary aim of the HLS pilot was to examine the feasibility and potential efficacy of pediatrician and dietitian MI counseling for preventing childhood obesity in primary care pediatrics. Study sites were members of the AAP Pediatric Research in Office Settings (PROS) network, which is a practice-based research network established by the AAP in 1986 (55). Fifteen PROS practices were randomly assigned to one of three conditions: control; minimal intervention; or intensive intervention. Five practices were allocated to each arm. The intervention phase lasted 6 mo. Each of the 15 PROS practices was asked to recruit 10 patients. Subject eligibility included children ages 3 to 7 yr with either a BMI-for-age-and-sex between the 85th and 95th percentiles or a combination of at least one parent with a BMI greater than 30 and a BMI-for-age-and-sex between the 50th and 85th percentiles. Parents in all groups were administered questionnaires at baseline and again 6 mo later. The only intervention provided to participants in the control group consisted of two safety education tip sheets. Parents of children in the minimal intervention group received a single, brief MI counseling session from their pediatrician 1 mo after baseline. Pediatricians in the minimal intervention group were trained to provide counseling in a 2-d MI workshop. In contrast, participants in the intensive intervention group engaged in four MI counseling sessions. Two sessions were led by the patient's pediatrician, and two sessions were guided by a dietitian. These counseling sessions were delivered at 1 mo and 3 mo post-enrollment. The physicians

Table 2

MI Pediatric Weight, Diet, and Activity Trials: Study Design

Study

Starting n Age Outcome/Design

Intervention

Interventionist

Healthy Lifestyles 93

Dietz, Schwartz Wasserman, Slora Resnicow, Myers Hainre (unpublished)

Go Girls 147

Resnicow et al.

2005

DISC 127

Berg-Smith et al.

1999

DIABETES

Chamion et al. 40

2003

Knight et al. 20

2003

3-7 BMI Pilot

12-16 BMI RCT

13-17 Diet Lipids

No Control

14-18 HBAlc Nonparticipants as controls

13-16 Perceptions about DM

Standard Care Mod 4 MI (MD) High =2 MI (MD) h 2 MI (RD)

Multicomponent Group session & 4-6 phone MI

1 in-person MI 1 phone MI

Variable 1-9 mean 4.7

6 1-h sessions (jhlitative response

Pediatricians Dietitians

Health Educators Psychologists

Health Educators Dietitians

Investigator

Senior registrar and dietitians were trained at a joint, 2-d MI workshop. The dietitian-led sessions were longer than the sessions with the pediatricians, generally in the range of 30 to 45 min. Sick visits continued as usual for children in both groups. Recruitment occurred from April through November 2004. One minimal intervention practice dropped out, leaving a total of 93 enrolled patients from 14 practices.

To assess competence in MI skill, clinicians participating in the HLS pilot completed a measure of MI fidelity developed by the HLS investigators called the 1-PASS. The 1-PASS consists of self-evaluation rating forms for one or two patient encounters on which performance on several MI dimensions is scored on a scale of 1 to 7. Scores of 4.0 and higher are considered as indicators of adequate to proficient MI skill. Using audiotapes of the HLS intervention encounters, a trained psychologist rated each MI session using One-Pass MI Fidelity Rating Systemm (1-PASS) and then discussed her score with each clinician. Overall scores for the first patient encounters ranged from 3.2 for moderate-intensity pediatricians to 4.4 for high-intensity dietitians. Overall scores were slightly higher in the second encounters, ranging from 3.7 to 5.8 for pediatricians and dietitians combined. For the six clinicians who participated in two supervisor feedback sessions, mean MI skills scores increased 1.1 points between the first and second encounters.

A subset of 16 parents, consisting of eight parents from the minimal intervention group and eight parents from the high-intensity intervention group, was asked to rate their reactions to their counseling sessions. Overall, 88% of parents reported being very satisfied with their pediatrician visit and 100% reported being very satisfied with their dietitian visit. Parents' ratings of the "client-centeredness" (e.g., "listened to me," "asked my opinion") of their encounters with the pediatricians and dietitians were highly positive. In addition, 100% of parents indicated that they talked about the same amount of time as their pediatrician or dietitian during the visit, which is the target proportion of client participation for MI counseling encounters. Results of the trial on BMI will be available in 2007.

Go Girls

Go Girls was a church-based nutrition and physical activity program designed for overweight African American adolescent females (56). Ten predominantly middle-socioeconomic-status churches were randomized to either a high-intensity (20-26 sessions) or moderate-intensity (6 sessions) culturally tailored behavioral group intervention delivered over 6 mo. Each session included an experiential behavioral activity, approx 30 min of physical activity, and preparation and tasting of healthy foods. In the high-intensity group, girls also received 4 to 6 MI telephone counseling calls. Counselors were either health educators with master's degrees or doctorally trained psychologists. All counselors received 2 d of experiential MI training by the first author of this chapter, plus ongoing clinical supervision by doctoral-level psychologists. The telephone calls were synchronized with the group sessions to ensure that the MI calls focused on participants' plans and progress regarding the same topics covered during each weekly group session. The calls lasted approx 20 to 30 min each and were generally conducted in the afternoon or evening.

From the 10 churches, 123 girls completed the baseline and 6-mo follow-up assessments. The primary outcome was BMI. The 6-mo assessments indicated a net difference of 0.5 BMI units between the high and moderate intensity. This difference was not statistically significant (p =0.20). Additionally, there was no association between change in BMI and the number of MI calls completed in the high-intensity group. An additional follow-up assessment was conducted at 1 yr post-baseline, and findings mirrored those found at 6 mo.

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