Open Journal of Pediatrics, 2012, 2, 236-243 OJPed
http://dx.doi.org/10.4236/ojped.2012.23037 Published Online September 2012 (http://www.SciRP.org/journal/ojped/)
Action-oriented obesity counseling attains weight
stabilization and improves liver enzymes among
overweight and obese children and adolescents
Allison C. Sylvetsky1, Jean A. Welsh2, Stephanie M. Walsh2,3, Miriam B. Vos2,3
1Department of Pediatrics, School of Medicine, Emory University, Atlanta, USA
2Nutrition and Health Sciences Program, Division of Biological and Biomedical Sciences, Laney Graduate School, Emory University,
Atlanta, USA
3Children’s Healthcare of Atlanta at Egleston, Atlanta, USA
Received 18 February 2012; revised 28 April 2012; accepted 14 May 2012
ABSTRACT
Introduction: Pediatricians are encouraged to pro-
mote behavior modification to reduce childhood obe-
sity and its co-morbidities, yet the effectiveness of
office counseling is unclear. We aimed to evaluate if a
low-intensity intervention (action-oriented counseling)
in a clinic setting results in weight stabilization, and if
the effect is modified by a diagnosis of non-alcoholic
fatty liver disease (NAFLD). We hypothesized that
patients with NAFLD would be more motivated to
adhere to the lifestyle goals set in clinic, due to the
diagnosis of an obesity-related condition; and, would
therefore achieve greater weight reduction compared
to similarly overweight and obese patients without a
diagnosis of NAFLD. Methods: A retrospective chart
review was conducted on 73 (35 male, 38 female)
overweight and obese patients (BMI ≥ 85th percentile)
attending a pediatric GI clinic between January 2006
and October 2011. Analysis was conducted to deter-
mine if lifestyle goals discussed with the patient at
each clinic visit were associated with improved BMI,
BMI z-score, and liver enzymes. Treatment outcomes
among NAFLD patients and similarly obese patients
without NAFLD were compared using t-tests and
chi-square tests. Results: Of the children evaluated,
74.0% achieved a reduction or stabilization in BMI
z-score after 3 months of follow-up. Among NAFLD
patients, liver enzymes improved in 72% of those who
were able to stabilize or reduce their BMI and among
43% of those who gained weight. Treatment outcome
did not significantly differ based on having a diagno-
sis of NAFLD, although there was a trend towards
greater improvements. Conclusion: Our study sug-
gests that action oriented counseling including goal-
setting in a low intensity, clinic based approach is ef-
fective in improving patient BMI, in the presence or
absence of an obesity-related co-morbidity, such as
NAFLD. Further, we demonstrated that lifestyle modi-
fication led to improvement of liver enzymes in
NAFLD patients and may result in other clinically
relevant improvements. Longer studies will be needed
to determine if the improvements are sustained.
Keywords: Obesity; Non-Alcoholic Fatty Liver Disease;
Lifestyle; Behavior Change
1. INTRODUCTION
The prevalence of childhood obesity has increased
dramatically [1] and is associated with type 2 diabetes,
cardiovascular disease and cancer, among other chronic
diseases [2]. This is alarming because children cate-
gorized as overweight and obese often continue on a
trajectory of weight gain and remain overweight and
obese as adults. The likelihood that the excess weight
gain continues into adulthood increases when a child’s
weight gain persists over a long time period and it is
therefore imperative that weight-related behaviors are
addressed as early as possible. Because obesity results
from a complex interplay of genetic, interpersonal, and
environmental factors, pediatricians are urged to work
with both patients and their families to encourage behavior
change [3]. However, predictors of successful treatment
outcomes are inconclusive among obese adults [4] and
have not been well-studied in a pediatric population.
Though randomized controlled trials with high inten-
sity interventions have led to successful weight outcomes
among children and adolescents [5,6], little data exist to
support effective obesity management in routine outpatient
clinic settings or to definitively determine the frequency
of intervention required. The most recent recommen-
dations from the US Preventive Task Force, suggests that
all obese children > 6 years of age be offered or referred
to a moderate to high intensity program involving >25

A. C. Sylvetsky et al. / Open Journal of Pediatrics 2 (2012) 236-243 237
hours of contact with the child and/or family over 6
months [7]. Although these multi-faceted and resource
intensive weight loss programs, involving weekly nutri-
tion education sessions, homework assignments, group
physical activity sessions, and frequent follow-up phone
calls, are effective for some [8-10], they are unaffordable
and impractical for many others. In many cases, re-
sources are lacking to support multidisciplinary teams
consisting of physicians, nurses, dieticians, physical thera-
pists and/or psychologists, as have been utilized in several
successful childhood obesity interventions [10-12].
Prior research has demonstrated that increasing
knowledge about obesity and its causes has limited
effectiveness in achieving lifestyle modification and
weight reduction [13], and it has been suggested that
motivation is more important than information in
facilitating behavior change [14]. In order to successfully
and sustainably modify patient behavior, the patient must
agree that they need to change their current habits and be
motivated to make healthier choices [15]. In utilizing a
patient-centered approach to lifestyle modification in our
clinic, we work with each patient and their family to
elicit behavior change through understanding their per-
ception of their current lifestyle habits, and empowering
them to change their environment and ultimately their
behaviors, without persuasion or criticism [16]. This pa-
tient-centered approach (motivational interviewing), has
achieved success in improving weight-related behavior
[17,18] and has also shown promise in teen smoking
cessation [19,20] and alteration of other risky activities
such as alcohol use [21] and unprotected sex [22].
Beyond initial weight loss, motivational interviewing has
been effective in sustained lifestyle modification, leading
to long-term weight maintenance [23].
The objective of this study was to determine if goal-
oriented counseling utilizing components of motivational
interviewing in relatively brief, infrequent clinic visits at
a pediatric gastroenterology practice were effective in
stabilizing BMI z-score in a diverse population of
overweight children and adolescents. Because our clinic
serves both overweight children without co-morbidities
and those with complications, we also sought to in-
vestigate if having a co-morbidity present enhanced the
success of the counseling, possibly due to increased
motivation. The most common co-morbidity in the clinic
is NAFLD (non-alcoholic fatty liver disease), a chronic,
obesity related liver disease. We hypothesized that NAFLD
patients would be more responsive to the lifestyle goals
set in the clinic due to their clinical diagnosis of an
obesity related condition and thus more effective in their
weight loss/stabilization efforts.
2. METHODS
We conducted a retrospective chart review of overweight
and obese patients (BMI > 85th percentile) attending the
Health 4 Life clinic at Children’s Healthcare of Atlanta
between January 2006 and October 2011. The Health 4
Life clinic was set up for children referred to GI for
obesity and/or obesity with liver enzyme elevation. To
meet the pre-determined chart review criteria, patients
needed to be 1) referred to and seen in the Health 4 Life
clinic; 2) attended ≥ 3 visits; 3) were followed for >90
days; and 4) had a primary indication of excess weight
gain or excess weight gain and elevated liver enzymes. A
total of 231 medical charts were reviewed by a single
investigator (AS) uninvolved with the clinic.
All patients were seen at the Children’s Healthcare of
Atlanta Health 4 Life clinic after referral by their primary
care physician for concerns relating to excess weight
gain or elevated liver enzymes along with excess weight
gain. We chose to study NAFLD because it is the most
common co-morbidity of obesity seen in our clinic;
whereas other gastrointestinal issues found in overweight
children (i.e. reflux, constipation), are not caused by
obesity. Each patient was seen by a pediatric gastro-
enterologist (MBV) and a nutritionist, both of whom
were experienced in and consistently used patient centered
action-oriented counseling, a method shown to be effec-
tive in modifying obesity-related behaviors [24].
Action-oriented strategies are based on the Stages of
Change Model [25], which builds upon on the patient’s
perceptions of their current behaviors and their motiva-
tion and intention to change [26]. Specifically, the clinic
visits followed the 5A’s format [24] (ask, advise, assess,
assist arrange), which is depicted in Table 1 and has
previously been shown to be effective in motivating
obese patients to lose weight [27]. Typical visits lasted
~45 minutes and included collecting information about
Table 1. Description of each of the “5 A’s”1 used in behavior
change counseling in the Health 4 Life clinic.
ASK
The “ask” stage involves asking the patient and thei
r
family about their current lifestyle habits and evaluating
their willingness to change. Willingness to change is
determined by asking the family to complete a
questionnaire, either verbally or on paper.
ADVISE
The “advise” stage involves discussing best practice
recommendations for the lifestyle habits discussed in the
previous stage.
ASSESS
We then “assess” what the patient and their family
would like to change, and what they perceive as
facilitators and barriers of successfully making
the changes discussed.
ARRANGE
We then “arrange” for a follow-up visit, at which poin
t
we will monitor the patient’s progress by repeating each
the 5 A’s.
1The “5 A’s” used in our Health 4 Life clinic are adapted from Joy et al.
2008.

A. C. Sylvetsky et al. / Open Journal of Pediatrics 2 (2012) 236-243 238
health habits, assessment of the family’s willingness to
change and their priorities for behavior change, and pro-
vider facilitated goal setting. Patients and their families
were asked about their current lifestyle, provided age
appropriate lifestyle recommendations targeted to their
situation, assessed for preference of area to work on and
barriers and then assisted in setting a practical, achiev-
able goal based on their responses. Because the clinic
was a referral clinic and most families were referred for
weight related concerns, they were generally already
motivated. At the end of each of the visits, two goals
were chosen by the family: one related to nutrition and
one to physical activity. Examples of goals set included
“limit TV to one hour a day on school days”, “go to the
park for 30 minutes 3 times a week”, or “limit sugar
drinks to 2 times a week”.
Most patients were seen 1 month after their initial visit
and then 2 - 6 months later. During follow-up visits, the
lifestyle goals set at the previous visit were discussed,
and with the pediatrician’s guidance, patients decided
which goals they wanted to continue to pursue. For the
purpose of this study, we defined the 3-month visit as the
visit closest to 90 days and the 6-month visit as the visit
closest to 180 days after the initial visit. Due to cancela-
tions, variable patient progress and need to follow up
patient liver enzymes elevations, there was considerable
variability in the time between visit intervals, as dis-
played in Table 2.
Information was extracted from dictated notes in the
patient medical charts. Height, weight, BMI, BMI z-score,
and date of birth were recorded for each patient at the
baseline visit. Among those referred to the clinic for
concerns regarding NAFLD, ALT and AST values were
also extracted. Since BMI changes naturally as children
grow, we used patients’ BMI z-scores (a measure of a
child’s weight relative to a reference population) calcu-
lated using the CDC 2000 Growth Charts as the refer-
ence [28] to monitor the weight trend of our patients [29].
A trend that demonstrated stabilization or decrease in BMI
Table 2. Variability (months) between initial visit and follow-
up visit “closest to 3 months” and “closest to 6 months” for all
patients, NAFLD patients, and non-NAFLD patients.
All NAFLD Non-NAFLD
Visit closest to 3 months
n 73 25 48
Median
(25th, 75th)
4.30
(3.73, 5.45)
4.80
(3.82, 5.65)
4.2
(3.73, 5.13)
All NAFLD Non-NAFLD
Visit closest to 6 months
n 56 22 34
Median
(25th, 75th)
8.18
(7.00, 9.86)
9.12
(7.24, 11.20)
7.6
(7.00, 8.93)
z-score was considered a positive outcome.
Each patient’s BMI z-score measured at baseline was
compared to the BMI z-score measured at the 3 month
and 6-month visits. Weight stabilization was defined as a
BMI z-score that was within ±0.04 units of the baseline
Weight reduction was classified as a BMI z-score de-
crease of ≥0.041, corresponding to a reduction of greater
than 2%. This has been previously demonstrated be a
clinically relevant reduction and lead to improvements in
metabolic risk factors including trigylcerides, low-den-
sity lipoprotein, body composition, and insulin sensitiv-
ity [30]. Percent change in AST and ALT between each
patient’s first and final visit to our clinic was calculated
to assess change in liver function over the treatment pe-
riod.
The Institutional Review Boards at Children’s Health-
care of Atlanta and at Emory University approved the
study protocol and the extraction of de-identified patient
data for use in our study. Patient consent was not ob-
tained because we extracted only de-identified data and
because collecting consent from patients seen several
years ago would have been prohibitive, given our study
design.
All statistics were performed in SAS 9.2 (SAS Insti-
tute, Cary, NC) and Microsoft Excel. Results are re-
ported as mean (standard error). Mean change in BMI
and BMI z-score between the baseline visit and 3-month
and 6-month visits, respectively, were compared using
ANOVA. x2 tests were used to compare proportions of
patients whose BMI z-score increased, decreased, or sta-
bilized between groups. All p-values two-sided and were
considered statistically significant if <0.05.
3. RESULTS
Seventy-three overweight children met the inclusion cri-
teria for our study, 25 of whom were diagnosed with
NAFLD and 48 of whom had no prior NAFLD diagnosis.
Characteristics of our sample at baseline are shown in
Table 3.
Seventy-four percent of the patients had main tained or
decreased their BMI z-score at the 3-month visit, 72.0%
(n = 18) and 75.3% (n = 36) in the NAFLD and
non-NAFLD groups, respectively. The proportions of
Table 3. Characteristics of the sample at baseline.
All NAFLD Non-NAFLDp
N 73 25 48
Male (%)35 (48) 18 (72) 19 (40%)
Female (%)38 (52) 7 (28) 28 (60%) p = 0.01
Age (years)212.47 (0.35)12.21 (0.49) 12.61 NS1
BMI z-score22.52 (0.05)2.45 (0.06) 2.56 (0.07)NS
1Not statistically significant at p < 0.05; 2Age, BMI z-score, and liver en-
zymes are presented as mean (standard error).

A. C. Sylvetsky et al. / Open Journal of Pediatrics 2 (2012) 236-243 239
children whose BMI z-score stabilized, increased, and
decreased from baseline to the 3-month visit are shown
in Figure 1. Among those with NAFLD 72% (n = 13) of
patients who demonstrated a favorable weight trajectory
at 3 months improved their ALT values, compared to
only 43% of those children who continued to gain weight.
Mean AST values decreased by 8.4%, from 73 ± 7 U/L
at the initial visit, to 61 ± 9 U/L at the final visit but were
not statistically significant. Mean ALT values decreased
by 25.6%, from 105 ± 9 at the initial visit to 80 ± 13 at
the subsequent visit and this was statistically significant
(p = 0.02).
Over 75% of the patients returned for the 6-month
visit, 88% (n = 22) in the NAFLD group and 70.8% in
the non-NAFLD group (n = 34). Follow-up at 6 months
was not statistically different based on gender, NAFLD
status, or weight trend at 3 months. The proportions of
children whose BMI z-score stabilized, increased, or
decreased at 6 months are shown in Figure 2. There was
no difference in the percentage of patients with a positive
The proportion of overweight/obese patients whose BMI z-score decreased weight (red), stabilized
(green), and increased (blue) at the 3 month follow-up clinic visit compared to baseline in the total
sample (left), NAFLD patients (center), and non-NAFLD patients (right). A cutoff of ±0.04 was used
to define stabilization for the purpose of this study and a reduction of more than 0.04 z-score was con-
sidered weight loss. 1Proportion of patients who decreased, stabilized, and increased their BMI z-score
at 3 month follow-up visit was not statistically different between the NAFLD and non-NAFLD pa-
tients (p = 0.45).
Figure 1. Proportion of overweight/obese patients1 whose BMI decreased, stabilized,
or increased after 3 months of follow-up.
The proportion of overweight/obese patients whose BMI z-score decreased weight (red), stabilized
(green), and increased (blue) at the 3 month follow-up clinic visit compared to baseline in the total
sample (left), NAFLD patients (center), and non-NAFLD patients (right). A cutoff of ±0.04 was used
to define stabilization for the purpose of this study and a reduction of more than 0.04 z-score was con-
sidered weight loss. 2Proportion of patients who decreased, stabilized, and increased their BMI z-score
at the 6 month follow-up visit was not statistically different between the NAFLD and non-NAFLD pa-
tients (p = 0.51).
Figure 2. Proportion of overweight/obese patients2 whose BMI decreased, stabilized,
or increased after 6 months of follow-up.

A. C. Sylvetsky et al. / Open Journal of Pediatrics 2 (2012) 236-243 240
outcome (stabilization or reduction) when comparing
patients with and without NAFLD.
4. DISCUSSION
Contrary to our hypothesis, we found that treatment out-
comes were positive in both patients with and without a
diagnosis of NAFLD. This was surprising because we
expected that those previously diagnosed with NAFLD
would be more motivated to change and would therefore
adhere more closely to the lifestyle goals discussed in
clinic. To our knowledge, this is the first study to com-
pare weight reduction outcomes between children with
and without an obesity-associated chronic disease in a
clinic setting. Various studies have examined predictors
of treatment success and follow-up in weight loss clinics
[31-33], yet most have examined demographic factors
rather than weight-related health conditions. Thus, the
association between overt pathological conditions re-
sulting from obesity and motivation to comply with life-
style change recommendations has not been well-studied.
Though our results suggest that children and adolescents
with NAFLD do not respond to treatment differently
than similarly obese children without a diagnosed co-
morbidity, this concept warrants further investigation.
Our study was designed to evaluate whether a low in-
tensity approach utilizing office-based, one-on-one visits
with a pediatric gastroenterologist and nutritionist were
effective in promoting weight stabilization, and to ex-
amine if treatment outcomes differed between over-
weight children with and without NAFLD. The key
component promoting behavior change was the use of
patient centered, action-oriented counseling techniques.
With these strategies, the patient-provider relationship
has been shown to develop quickly and improve the in-
tentions of patients to change their behaviors.
The results of our study suggest that counseling was
effective in short-term stabilization of BMI and in im-
proving liver enzymes in our clinic. The proportion of
our patients who achieved stabilization or reduction BMI
z-score was similar to success rates in other clinic-based
weight management programs [34]. Liver enzymes im-
proved in 72% of NAFLD patients who reduced or stabi-
lized their BMI z-score and in 43% of those whose BMI
z-score increased, emphasizing the importance of life-
style behavior change, independent of weight reduction.
Though most patients remained overweight or obese at
the 3-month and 6-month follow-up visits, our findings
suggest that lifestyle change, even in the absence of
weight loss, leads to metabolic improvement. This find-
ing is supported by previous research where improve-
ments liver enzymes were achieved with lifestyle change,
independent of weight reduction or with minimal weight
change [35-37].
Our Health 4 Life clinic was set up to treat patients
with elevated liver enzymes and/or excess weight gain,
and hence was based on a model of low intensity inter-
vention with patient visits 3 - 4 times in the over the first
year. Though our patients were seen in a sub-speciality
clinic, our office-based counseling was less resource and
time intensive than what is typically found in a most
formal obesity treatment programs. We did have the
added benefit of a nutritionist in addition to the clinician,
and given improved insurance support for nutrition visits
in primary care offices, our model could be replicated in
a general pediatric office as well as other pediatric gas-
troenterology offices. As such, our findings are encour-
aging for reduction of weight gain among obese patients
seen in both non-specialty and specialty clinics. Action-
oriented counseling by a different trained professional,
such as a medical assistant or licensed practical nurse
could also be a cost-effective approach for clinic based
programs.
The main limitations of our study were its retrospect-
tive nature and the high rate of attrition in our clinic,
which was comparable to drop-out rates reported in
similar pediatric clinics [38-40]. Attrition in pediatric
weight management clinics presents a challenge to BMI
z-score reduction and sustained lifestyle change, and has
been reported to range from 27% and 73% [41]. Those
patients who failed to return for follow-up may have also
stabilized or decreased their BMI; in several prior studies,
patients lost to follow-up did not differ in treatment out-
come compared to those who returned to the clinic
[39,42]. Meanwhile, other pediatric studies have demon-
strated that patients who adhere to the treatment program
are more likely to achieve weight reduction [43,44],
though outcome information is largely unavailable among
patients lost to follow-up in clinic-based initiatives.
Prior research has suggested that severely obese pa-
tients are less likely to return for follow-up, and given
that the mean BMI z-score at baseline was more than 2.5
standard deviations above the mean, this may explain the
high rate of attrition in our clinic [39]. Other predictors
of drop-out including black race, being of lower socio-
economic status [45], being an older adolescents, and
expressing low perceived quality of care [46], may also
have contributed to loss to follow-up among our patients,
though consistent predictors of attrition have not been
identified in weight clinics [4].
The large range of follow-up periods that were con-
sidered the “closest visit after 90 and 180 days was also a
limiting factor.” Depending on a patient’s specific condi-
tion and progress, follow-up visits were scheduled at
different intervals. This is typical of most clinics and
makes the study relevant to practicing physicians. Also,
we were unable to extract information about parental
BMI, race/ethnicity, socio-economic status, self-esteem,
or prior eating behaviors, as this information was not

A. C. Sylvetsky et al. / Open Journal of Pediatrics 2 (2012) 236-243 241
available in the medical charts, which were not designed
for research and may have confounded the observed as-
sociation between participation in action-oriented coun-
seling and weight stabilization. Importantly, we were
also unable to obtain the patient’s BMI z-score at the
time of referral, which may have predicted patient out-
comes in our Health 4 Life clinic.
It has been reported that pediatricians find it difficult
to effectively promote obesity reduction among their
patients. Pediatricians often believe that they are not
well-positioned to target weight control in their offices,
due to a lack of resources and other restrictions such as
reimbursement, billing, and lack of time [47]. The above
mentioned barriers coupled with low perceived patient
and family motivation to change [48], low enthusiasm
for weight management [49] and hesitation to address a
sensitive issue [47] among pediatricians, may contribute
to the perceived inadequate counseling for childhood
overweight in primary care. Parents, specifically those
who are overweight, can view weight-related advice pro-
vided in the pediatricians’ office as inadequate [50], re-
inforcing the necessity of targeting patient motivation
and improving action-oriented counseling abilities among
general practitioners.
In contrast, our clinic which was designed for pediatric
weight counseling and used patient centered counseling
with components of motivational interviewing, did not
find these to be barriers and worked with families to
build enthusiasm about healthy lifestyles. Our patients
and their families generally viewed the experience as
positive, and this was supported by the rapport established
with the clinician and the dietician [51] and the boosting
of patient self-esteem through focusing on successfully
implemented behavior change [52], both which have
previously been shown to increase parent satisfaction.
Our success lends some possible conclusions although
further research will be needed to make firm conclusions.
In demonstrating that clinic based patient centered
counseling can be successful in stabilizing the weight
status of overweight/obese patients who return for follow-
up clinic visits and also improves liver enzymes among
those with NAFLD, our findings further support the
ability of clinicians and nutritionists to provide effective
obesity counseling in the outpatient clinic setting and not
simply to rely on referral to high intensity, high resource
obesity programs. Second, we think that our study
supports the utilization of patient centered, action oriented
counseling combined with access to nutritionists. Both of
these are possible key contributors to our positive results
and should be evaluated further, particularly in the
primary care setting.
5. ACKNOWLEDGEMENTS
This project was supported in part by a grant from NIH/NIDDK
K23DK080953 (Vos) and by support from Strong4Life @ Children’s
Healthcare of Atlanta.
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