motivational interviewing to treat adolescents with ... · adolescents, but sample size and study...

dNutrition Program, Department of Individual, Family, and Community Education, aDivision of Adolescent Medicine, Department of Pediatrics, School of Medicine, and bDivision of Epidemiology, Biostatistics, and Preventive Medicine, Department of Internal Medicine, School of Medicine, University of New Mexico, Albuquerque, New Mexico; cUniversity of New Mexico Health Sciences Library and Informatics Center, Albuquerque, New Mexico; eSchool of Nursing, New Mexico State University, Las Cruces, New Mexico; and fDivision of Clinical Psychology, School of Medicine, Oregon Health and Science University, Portland, Oregon

Dr Vallabhan conceptualized and designed the study, collected data, conducted the data analysis, drafted the initial manuscript, and critically reviewed the final manuscript; Dr Jimenez conceptualized and designed the study, supervised data collection and analysis, drafted the initial manuscript, and critically reviewed the final manuscript; Mr Nash conceptualized and designed the study, collected data, drafted the initial manuscript, and critically reviewed the final manuscript; Drs

To cite: Vallabhan MK, Jimenez EY, Nash JL, et al. Motivational Interviewing to Treat Adolescents With Obesity: A Meta-analysis. Pediatrics. 2018;142(5):e20180733

CONTEXT: Successful treatment approaches are needed for obesity in adolescents. Motivational interviewing (MI), a counseling approach designed to enhance behavior change, shows promise in promoting healthy lifestyle changes.OBJECTIVE: Conduct a systematic review of MI for treating overweight and obesity in adolescents and meta-analysis of its effects on anthropometric and cardiometabolic outcomes.DATA SOURCES: We searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, Web of Science, Cochrane Library, and Google Scholar from January 1997 to April 2018.STUDY SELECTION: Four authors reviewed titles, abstracts, and full-text articles.DATA EXTRACTION: Two authors abstracted data and assessed risk of bias and quality of evidence.RESULTS: Seventeen studies met inclusion criteria; 11 were included in the meta-analysis. There were nonsignificant effects on reducing BMI (mean difference [MD] −0.27; 95% confidence interval −0.98 to 0.44) and BMI percentile (MD −1.07; confidence interval −3.63 to 1.48) and no discernable effects on BMI z score, waist circumference, glucose, triglycerides, cholesterol, or fasting insulin. Optimal information size necessary for detecting statistically significant MDs was not met for any outcome. Qualitative synthesis suggests MI may improve health-related behaviors, especially when added to complementary interventions.LIMITATIONS: Small sample sizes, overall moderate risk of bias, and short follow-up periods.CONCLUSIONS: MI alone does not seem effective for treating overweight and obesity in adolescents, but sample size and study dose, delivery, and duration issues complicate interpretation of the results. Larger, longer duration studies may be needed to properly assess MI for weight management in adolescents.

Motivational Interviewing to Treat Adolescents With Obesity: A Meta-analysisMonique K. Vallabhan, DNP, FNP-BC, MSN, RN, a Elizabeth Y. Jimenez, PhD, RD, LD, a, b Jacob L. Nash, MSLIS, c Diana Gonzales-Pacheco, DCN, RD, d Kathryn E. Coakley, PhD, RD, d Shelly R. Noe, DNP, PMHNP-BC, RN, e Conni J. DeBlieck, DNP, MSN, RN, e Linda C. Summers, PhD, FNP-BC, PFNP-BC, RN, e Sarah W. Feldstein-Ewing, PhD, f Alberta S. Kong, MD, MPHa

NIH

abstract

PEDIATRICS Volume 142, number 5, November 2018:e20180733 REVIEW ARTICLE by guest on June 13, 2020www.aappublications.org/newsDownloaded from

Obesity in youth is a serious public health concern, with global prevalence increasing 10-fold in just 40 years.1 In 2013–2014, the prevalence of obesity and extreme obesity in US adolescents were 20.6% and 9.1%, respectively, representing an increase in prevalence of ∼10% and 6% over a 20- to 25-year period.2 Excess weight in adolescence is associated with acute and long-term health consequences that are compounded when obesity is maintained into adulthood.2 – 5 There is strong evidence that the majority of adolescents with overweight and obesity become adults with obesity. The National Longitudinal Study of Youth 1979 found that 62% and 73% of men and women, respectively, with overweight in adolescence became adults with obesity, and 80% and 92% of women and men, respectively, who were adolescents with obesity became adults with obesity.6

The US Preventive Services Task Force (USPSTF) recently concluded that comprehensive lifestyle-based weight loss interventions with at minimum 26 contact hours over 2 to 12 months are likely helpful for achieving weight loss in children and adolescents with overweight or obesity.2 The effective intervention components varied, with sessions delivered both individually and via groups. They frequently included sessions targeting both the parent and child, nutrition education, and interactive physical activity sessions. Numerous approaches were included in the systematic evidence review, including motivational interviewing (MI); however, the authors did not examine the results by type of intervention. Small but promising decreases in BMI z scores were reported for lifestyle-based weight loss interventions overall. Interestingly, only 6 of the 42 studies included adolescent populations, and only 1 study with adolescents

revealed a statistically significant effect.

MI is one potential approach for promoting lifestyle change in the treatment of adolescents with overweight and obesity. MI is a patient-centered counseling style that explores, strengthens, and guides an individual’s motivation for change.7 It not only engages youth in health discussions but also encourages behavior change through therapeutic alliances.7 – 13

Miller first used MI with adults for alcohol abuse; however, there has been increasing interest in applying it to other health behaviors.14 Considerable evidence has indicated that MI may be effective to treat substance use disorders and to promote behavior change related to HIV, exercise, diet, tobacco use, and dental care in adults.15, 16 There is considerably less but promising evidence suggesting MI interventions may be effective for changing health behaviors in adolescents.17, 18 However, meta-analyses in 2009 and 2010 indicated the effectiveness of MI across target behaviors and providers is highly variable.19, 20 Variability in fidelity or “trueness to MI” have been cited as possible explanations for the inconsistencies in efficacy in MI-based intervention studies.21, 22

Two meta-analyses in 2014 suggested that MI interventions for promoting pediatric health behavior change appear to be effective.17, 23 Cushing et al17 reported a small, significant aggregate positive effect size for MI interventions targeting adolescents for short-term health behavior changes (g = 0.16, 95% confidence interval [CI] 0.05 to 0.27)17 that seemed to be sustained in the longer term. However, the authors aggregated outcome effects across several health behaviors and outcomes. Of the 15 studies that were included, only 5 included participants who were overweight and obese. Since this publication, an additional

8 randomized controlled trials (RCTs) plus 4 other types of studies in which MI-based interventions for adolescents with overweight and obesity were examined have been published.

We conducted a systematic review (SR) and meta-analysis to synthesize the currently available evidence assessing the effects of MI-based interventions on anthropometric (reduction in pounds, kilograms, BMI and/or BMI z score, or percentile from baseline to last available follow-up) and cardiometabolic outcomes in adolescents with overweight and obesity. We also qualitatively describe the impact of MI on health behaviors (nutrition, physical activity, and/or sleep) and/or quality of life in adolescents with overweight and obesity.

METHODS

Data Sources

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist to guide the conduct and reporting of this review. Before data extraction was complete, we developed and registered a protocol on PROSPERO (#CRD42017072342), available in full on the program Web site (http:// www. crd. york. ac. uk/ PROSPERO/ display_ record. php? ID= CRD42017072342).

The protocol predefined the objectives, methods, principal focus (concept) and context, research question, and inclusion and exclusion criteria for this SR and meta-analysis, and described the search, data extraction, and data synthesis strategies. We conducted searches on September 26, 2016 and April 16, 2018 and identified studies published from 1997 to 2017 in the following 7 databases: Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, PsychINFO, Web of Science, Cochrane Library,

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and Google Scholar. Search terms were “adolescent obesity” and “motivational interviewing” (see Supplemental Information for terms used and PubMed search).

Study Selection

For inclusion, studies were required to be published in the English language; to include adolescent participants (ages 12–19 at study enrollment) with overweight or obesity (BMI percentile ≥85%); to focus on an MI intervention targeting weight management; and to report at least 1 predetermined primary outcome (change in pounds, kilograms, BMI, BMI z score or percentile from baseline to last available follow-up) or secondary outcome (change in nutrition, physical activity, sleep behaviors, cardiometabolic outcomes, or quality of life). We excluded case studies, qualitative studies, editorials, and MI-based interventions focused on behavior change not directly related to weight management (eg, alcohol, substance, and condom use).

We used an SR citation–screening Web application, abstrackr, 24 to manage the abstract screening process. Four authors independently participated in screening of titles, abstracts, and full-text articles identified through the searches against the protocol. The first author resolved conflicts between the screeners. Five of the articles included in the Cushing et al17 meta-analysis in which MI for adolescent health behaviors was evaluated met our inclusion criteria and were included in this SR.

Excluded Studies

Nine additional articles met the inclusion criteria during title and abstract screening. However, on full-text review, 2 of these articles had participants that were mostly outside of our target age range, and 7 contained examinations of outcomes other than our predefined primary

or secondary outcomes of interest (see Fig 1).

Data Abstraction, Evaluation, and Synthesis

Two independent observers extracted information from each study and 2 authors checked data extraction for completeness and accuracy (see Table 1). When possible, we reported results only for adolescents 12 to 19 years of age when the study sample also included younger or older participants. If the mean participant age was less than age 12 years, we contacted authors for adolescent participant specific data.

We used Review Manager (RevMan), 41 the Cochrane Collaboration’s software for preparing SRs and meta-analyses, to organize, manage, and analyze the data using

an inverse-variance statistical method. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE)42 software (GRADEpro) to rate the quality of the evidence for outcomes as recommended by the Cochrane Handbook for Systematic Reviews.43 For each outcome, 2 authors independently extracted data and cross-checked against the data that were entered in RevMan. Throughout the article selection process, data abstraction, computation, calculation, evaluation, and synthesis process, 2 authors resolved disagreements through joint examination of the articles and discussion until consensus was reached.

We used The Cochrane Collaboration’s Tool43 for assessing risk of bias in RevMan41 to assess

PEDIATRICS Volume 142, number 5, November 2018 3

FIGURE 1Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram for studies of MI for treating adolescents with overweight and obesity, 1997–2017.

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VALLABHAN et al4

TABL

E 1

Char

acte

rist

ics

of In

clud

ed S

tudi

es o

f MI I

nter

vent

ions

for

Adol

esce

nts

With

Ove

rwei

ght o

r Ob

esity

Stud

yDe

sign

Part

icip

ants

Coun

try

Inte

rven

tion

Char

acte

rist

ics

Outc

omes

Mai

n Fi

ndin

gs

Sett

ing

Desc

ript

ion

Dose

Ball

et a

l25RC

TN

= 46

, age

d 12

–18

y; 6

1%

girl

s; 8

5%

whi

te

Cana

daM

ultid

isci

plin

ary

pedi

atri

c w

t m

anag

emen

t cl

inic

MI t

rain

ing:

2 d

in p

erso

n;

MI fi

delit

y: n

ot r

epor

ted;

in

terv

entio

n: n

utri

tion

and

PA

educ

atio

n, s

elf-m

onito

ring

, w

ith th

e ad

ditio

n of

MI a

nd

CBT;

Con

trol

: wai

t lis

t

16 4

5–60

-min

se

ssio

ns; f

ollo

w-

up: 1

6–20

wk

(1)

anth

ropo

met

ry (

wt,

BMI,

BMI z

sco

re, B

MI p

erce

ntile

, w

aist

cir

cum

fere

nce)

, (2

) ca

rdio

met

abol

ic

(tot

al c

hole

ster

ol, i

nsul

in,

gluc

ose)

, (3)

beh

avio

ral

(sel

f-rep

orte

d di

etar

y an

d/or

PA;

ped

omet

ers,

fitn

ess,

tr

eadm

ill)

No d

iffer

ence

s ov

eral

l. Co

mpl

eter

s on

ly h

ad 3

.9%

and

6.

5% d

ecre

ase

in B

MI z

sco

re

com

pare

d w

ith 0

.8%

incr

ease

in

con

trol

(P

< .0

01)

Bren

nan26

RCT

N =

63, a

ged

11–1

9 y;

54%

gi

rls

Aust

ralia

Psyc

holo

gy c

linic

sM

I tra

inin

g: in

tern

atio

nal

trai

ning

not

des

crib

ed;

MI fi

delit

y: v

ideo

tape

d in

terv

iew

s co

ded,

sco

res

not

repo

rted

; int

erve

ntio

n: 1

2 CB

T se

ssio

ns th

at in

clud

ed

nutr

ition

and

PA

educ

atio

n, 1

CB

T ph

one

call,

PI (

sess

ions

1–

7), w

ith th

e ad

ditio

n of

1

MI s

essi

on; c

ontr

ol: w

ait l

ist

1 60

-min

ses

sion

; fo

llow

-up:

4–6

mo

(1)

anth

ropo

met

ry (

wt,

body

fa

t, BM

I, BM

I z s

core

, bo

dy c

ircu

mfe

renc

e:

hip,

wai

st, u

pper

arm

, fo

rear

m);

(2)

fitne

ss (

cycl

e er

gom

eter

), m

etab

olic

ra

te (

calo

riom

etry

); (3

) be

havi

oral

(se

lf-re

port

ed

diet

ary

and/

or P

A,

acce

lero

met

er)

No d

iffer

ence

s ov

eral

l

Chah

al

et a

l27RC

TN

= 32

, age

d 10

–17;

38%

gi

rls

Cana

daPe

diat

ric

outp

atie

nt c

linic

MI t

rain

ing:

2, 3

-d in

per

son;

M

I fide

lity:

MI N

etw

ork

of T

rain

ers

and

clin

ical

ps

ycho

logi

st p

rovi

ded

ongo

ing

feed

back

, ran

dom

au

dio

reco

rdin

gs c

odin

g in

dica

ting

high

fide

lity;

in

terv

entio

n: n

utri

tion

and

PA e

duca

tion

to c

hild

-par

ent

dyad

s; c

ontr

ol: n

utri

tion

and

PA e

duca

tion

to c

hild

alo

ne

4 30

–45-

min

se

ssio

ns p

lus

4 fo

llow

-up

phon

e ca

lls; f

ollo

w-u

p:

6 m

o

(1)

anth

ropo

met

ry (

wt,

wai

st c

ircu

mfe

renc

e,

wt-t

o-he

ight

rat

io, B

MI),

(2

) ca

rdio

met

abol

ic (

tota

l ch

oles

tero

l, tr

igly

ceri

des,

HD

L-C,

LDL

-C, g

luco

se, n

on–

HDL-

C, in

sulin

, HOM

A-IR

), (3

) be

havi

oral

(se

lf-re

port

ed d

ieta

ry a

nd/o

r PA

, ac

cele

rom

eter

), (4

) qu

ality

of

life

(se

lf-re

port

ed)

No d

iffer

ence

s in

ant

hrop

omet

ry

or c

ardi

omet

abol

ic. I

n fa

vor

of a

lone

gro

up in

se

lf-re

port

ed fa

ts a

nd/o

r su

gars

(P

= .0

2) a

nd s

cree

n tim

e (P

= .0

2); b

oth

grou

ps

had

redu

ctio

ns in

BM

I (P

< .0

01),

wai

st c

ircu

mfe

renc

e (P

< .0

01),

tota

l cho

lest

erol

(P

< .0

01),

LDL-

C (P

< .0

01),

trig

lyce

ride

s (P

= .0

1), n

on–

HDL-

C (P

< .0

01),

insu

lin (

P =

.01)

, and

HOM

A-IR

(P

= .0

2)

and

impr

ovem

ents

in d

ieta

ry

and/

or P

A an

d qu

ality

of l

ife



Stud

yDe

sign

Part

icip

ants

Coun

try

Inte

rven

tion

Char

acte

rist

ics

Outc

omes

Mai

n Fi

ndin

gs

Sett

ing

Desc

ript

ion

Dose

Chri

stie

et

al28

RCT

N =

174,

age

d 12

–19

y; 6

3%

girl

s

Engl

and

Loca

l com

mun

ity

sett

ings

MI t

rain

ing:

2 d

in p

erso

n pl

us

3 d

trai

ning

on

obes

ity;

MI fi

delit

y: p

sych

olog

ist

obse

rved

eac

h pr

ovid

er

deliv

er s

essi

on 1

, rem

aini

ng

sess

ions

aud

io r

ecor

ded

and

code

d, 7

6% r

ated

go

od; i

nter

vent

ion:

MI

fam

ily (

PI)-

base

d nu

triti

on

and

PA e

duca

tion

with

so

lutio

n-fo

cuse

d be

havi

or

chan

ge a

ppro

ach;

con

trol

: en

hanc

ed s

tand

ard

of c

are

(Dep

artm

ent o

f Hea

lth

nutr

ition

and

PA

educ

atio

n)

12 4

0–45

-min

se

ssio

ns; f

ollo

w-

up: 6

.5 a

nd 1

3 m

o;

cont

rol:

1 60

-min

se

ssio

n

(1)

anth

ropo

met

ry (

wt,

BMI,

BMI z

sco

re, w

aist

ci

rcum

fere

nce,

fat m

ass)

, (2

) ca

rdio

met

abol

ic

(tri

glyc

erid

es, H

DL-C

, LD

L-C,

insu

lin, g

luco

se),

(3)

beha

vior

al

(acc

eloe

rom

etry

); (4

) qu

ality

of

life

(se

lf-re

port

ed),

psyc

holo

gica

l hea

lth

No d

iffer

ence

s ov

eral

l

Chri

stis

on

et a

l29a

Pre/

post

N =

18 o

f 100

to

tal (

18%

ag

ed 1

2–16

y);

55

% g

irls

; 55

% w

hite

Unite

d St

ates

Pedi

atri

c pr

imar

y ca

reM

I tra

inin

g: 2

, 1.5

h in

per

son;

M

I fide

lity:

1 r

ando

m

enco

unte

r pe

r pr

ovid

er,

audi

o re

cord

ing

code

d,

scor

es n

ot r

epor

ted;

in

terv

entio

n: M

I-bas

ed

coac

hing

tool

that

incl

uded

nu

triti

on a

nd P

A ed

ucat

ion

with

goa

l set

ting

with

chi

ld-

pare

nt d

yad

1 se

ssio

n; fo

llow

-up:

1

and

6 m

o(1

) be

havi

oral

(se

lf-re

port

ed

diet

ary

and/

or P

A), (

2)

anth

ropo

met

ry (

BMI)

No d

iffer

ence

s in

an

thro

pom

etri

cs. I

n fa

vor

of

MI i

n re

port

ed d

ieta

ry a

nd/

or P

A go

als

over

all (

P <

.001

); 7

of 1

8 re

port

ed m

eetin

g go

als

mos

t to

alm

ost a

lway

s;

patie

nt m

otiv

atio

n hi

gh in

MI-

adhe

rent

pro

vide

rs (

P =

.04)

.

Davi

s et

al30

RCT

N =

38, a

ged

14–1

6 y;

La

tina

girl

s

Unite

d St

ates

Life

styl

e in

terv

entio

n la

bora

tory

MI t

rain

ing:

1 in

per

son

plus

4

grou

p tr

aini

ngs

by M

INT

trai

ners

, ong

oing

coa

chin

g;

MI fi

delit

y: s

ubsa

mpl

e of

aud

io r

ecor

ding

s co

ded,

glo

bal r

atin

gs m

et

profi

cien

cy o

n av

erag

e ov

eral

l; in

terv

entio

n: P

A ci

rcui

t tra

inin

g (e

duca

tion,

ex

erci

se)

plus

the

addi

tion

of

MI;

cont

rol:

wai

t lis

t

Circ

uit t

rain

ing:

2×

per

wk;

cir

cuit

trai

ning

plu

s 4

MI

sess

ions

; fol

low

-up

: 16

wk

(1)

anth

ropo

met

ry (

wt,

BMI,

BMI p

erce

ntile

, hip

and

w

aist

cir

cum

fere

nce,

bod

y fa

t), (

2) c

ardi

omet

abol

ic

(glu

cose

, HOM

A-IR

), (3

) be

havi

oral

(se

lf-re

port

ed

diet

ary

and/

or P

A); fi

tnes

s (t

read

mill

)

No d

iffer

ence

s ov

eral

l. Ci

rcui

t tr

aini

ng w

ith o

r w

ithou

t M

I int

erve

ntio

n gr

oups

co

mpa

red

with

con

trol

s si

gnifi

cant

ly in

crea

sed

card

iore

spir

ator

y fit

ness

(1

5%, 1

6%, P

= .0

3).

TABL

E 1

Cont

inue

d


VALLABHAN et al6

Stud

yDe

sign

Part

icip

ants

Coun

try

Inte

rven

tion

Char

acte

rist

ics

Outc

omes

Mai

n Fi

ndin

gs

Sett

ing

Desc

ript

ion

Dose

Gour

lan

et

al31

RCT

N =

54, a

ged

11–1

8 y;

41%

gi

rls

Fran

ceHo

spita

lM

I tra

inin

g: 3

2 h

in p

erso

n, 4

0 h

read

ing;

MI fi

delit

y: r

ando

m

audi

o re

cord

ings

cod

ed,

scor

es a

bove

pro

ficie

ncy

exce

pt 1

cat

egor

y;

inte

rven

tion:

sta

ndar

d w

t lo

ss p

rogr

am (

PA e

duca

tion)

pl

us th

e ad

ditio

n of

MI;

cont

rol:

stan

dard

wt l

oss

prog

ram

(PA

edu

catio

n)

Both

gro

ups

rece

ived

2

30-m

in s

essi

ons;

M

I: 6

addi

tiona

l 20

-min

MI p

hone

se

ssio

ns; f

ollo

w-

up: 3

and

6 m

o

(1)

beha

vior

al (

self-

repo

rted

PA

, acc

eler

omet

er);

(2)

anth

ropo

met

ry (

BMI)

No d

iffer

ence

s ov

eral

l. In

fa

vor

of M

I in

BMI a

t 3 m

o (−

1 po

int,

P <

.001

), no

di

ffere

nces

at 6

mo;

gre

ater

PA

leng

th o

ver

time

(∼0.

25

and

0.5

h/d

at 3

mo

[P <

.0

01]

and

6 m

o [P

< .0

1])

and

ener

gy e

xpen

ditu

re (

∼10

and

25

kca

l/d

at 3

mo

[P <

.001

] an

d 6

mo

[P <

.01]

).Ko

ng e

t al32

RCT

N =

60, a

ged

13–1

6 y;

62%

gi

rls;

75%

Hi

span

ic

Unite

d St

ates

2 ur

ban,

sch

ool-

base

d he

alth

ce

nter

s

MI t

rain

ing:

2 d

in p

erso

n; M

I fid

elity

: 3 p

ilot M

I ses

sion

s au

dio

reco

rded

, rev

iew

ed

with

trai

ners

, coa

chin

g th

roug

hout

, cod

ing

not

repo

rted

; int

erve

ntio

n:

stan

dard

of c

are

(nut

ritio

n an

d PA

edu

catio

n) w

ith

MI-b

ased

ses

sion

s, p

aren

t te

leph

one

upda

tes;

con

trol

: st

anda

rd o

f car

e (n

utri

tion

and

PA e

duca

tion)

8 28

-min

(av

erag

e)

sess

ions

; co

ntro

l: 1

47-m

in

(ave

rage

) vi

sit,

revi

ew m

edic

al

resu

lts; f

ollo

w-u

p:

7 m

o

(1)

anth

ropo

met

ry (

wt,

BMI,

BMI p

erce

ntile

, wai

st

circ

umfe

renc

e), (

2)

card

iom

etab

olic

(gl

ucos

e,

HDL-

C, tr

igly

ceri

des,

insu

lin,

HOM

A-IR

), (3

) be

havi

oral

(s

elf-r

epor

ted

diet

ary

and/

or P

A, a

ccel

erom

eter

)

In fa

vor

of M

I in

BMI p

erce

ntile

(−

0.3%

, P =

.04)

, wai

st

circ

umfe

renc

e (0

cm

, P =

.04,

co

ntro

l +1.

7 cm

), se

dent

ary

beha

vior

s (t

elev

isio

n w

atch

ing

−0.

4 h/

d, P

= .0

4)

Love

-Os

bour

ne

et a

l33

RCT

N =

165,

age

d 14

–17

y; 5

2%

girl

s; 8

8%

Hisp

anic

Unite

d St

ates

2 sc

hool

-bas

ed

heal

th c

ente

rsM

I tra

inin

g: fu

ll d

in p

erso

n w

ith 1

follo

w-u

p se

ssio

n;

MI fi

delit

y: n

ot r

epor

ted;

in

terv

entio

n: s

tand

ard

of

care

(ph

ysic

al e

xam

inat

ion,

la

bora

tory

scr

eeni

ng)

with

M

I-bas

ed s

essi

ons

with

nu

triti

on a

nd P

A ed

ucat

ion,

w

eekl

y se

lf-m

onito

ring

logs

, te

xt m

essa

ge r

emin

ders

to

rand

om s

ampl

e; c

ontr

ol:

stan

dard

of c

are

(phy

sica

l ex

amin

atio

n, la

bora

tory

sc

reen

ing)

1–8

sess

ions

(m

ean

= 5)

; fol

low

-up:

6–

8 m

o

(1)

card

iom

etab

olic

(to

tal

chol

este

rol h

emog

lobi

n A1

c,

ALT)

, (2)

ant

hrop

omet

ry

(BM

I, BM

I z s

core

, BM

I pe

rcen

tile)

, (3)

beh

avio

ral

(sel

f-rep

orte

d di

etar

y an

d/or

PA)

; fitn

ess

test

ing

(end

uran

ce r

un)

No d

iffer

ence

s ov

eral

l

TABL

E 1

Cont

inue

d



Stud

yDe

sign

Part

icip

ants

Coun

try

Inte

rven

tion

Char

acte

rist

ics

Outc

omes

Mai

n Fi

ndin

gs

Sett

ing

Desc

ript

ion

Dose

Mac

Donn

ell

et a

l34RC

TN

= 44

, age

d 13

–17

y; 7

9%

girl

s, A

fric

an

Amer

ican

Unite

d St

ates

Urba

n ad

oles

cent

m

edic

ine

clin

icM

I tra

inin

g: 1

6 h

in p

erso

n pl

us w

eekl

y su

perv

isio

n; M

I fid

elity

: aud

io r

ecor

ding

s co

ded,

sco

res

not r

epor

ted;

in

terv

entio

n: M

I-bas

ed

coun

selin

g w

ith n

utri

tion

and

PA e

duca

tion

with

ad

oles

cent

-par

ent d

yads

; co

ntro

l: nu

triti

on e

duca

tion

for

adol

esce

nt-p

aren

t dya

ds

4 60

-min

ses

sion

s fo

r bo

th g

roup

s;

follo

w-u

p: 3

mo

(1)

anth

ropo

met

ry (

wt,

BMI);

(2

) be

havi

oral

(se

lf-re

port

ed

diet

ary

and/

or P

A)

No d

iffer

ence

s in

an

thro

pom

etri

cs. I

n fa

vor

of M

I sel

f-rep

orte

d fa

st fo

od

use

per

wk

(−1.

07 ti

mes

pe

r w

k, P

= .0

2), s

oft d

rink

fr

eque

ncy

per

wk

(−0.

75 o

n 6-

poin

t Lik

ert s

cale

, P =

.04)

, ac

tivity

mot

ivat

ion

(+7.

79 o

n 1–

7-po

int s

cale

for

11 it

ems,

P

= .0

3), b

ut d

ecre

ased

act

ivity

Mag

gio

et

al35

Coho

rtN

= 28

3, a

ged

3–17

y, (

36%

>1

2 y)

; 51%

gi

rls

Fran

cePe

diat

ric

obes

ity

care

pro

gram

MI t

rain

ing:

3 d

(M

I and

CBT

); M

I fide

lity:

not

rep

orte

d;

inte

rven

tion:

MI-b

ased

di

scus

sion

s w

ith n

utri

tion

and

PA e

duca

tion

plus

goa

l se

ttin

g w

ith c

hild

-par

ent

dyad

s, p

sych

olog

ical

ther

apy

for

men

tal h

ealth

pro

blem

s as

nee

ded

Firs

t ses

sion

1-h

, fo

llow

-up

sess

ions

30

–45-

min

, 1–3

m

o in

terv

als

betw

een

sess

ions

, m

ean

sess

ions

4.

6; fo

llow

-up:

m

ean

11.4

mo

(1)

anth

ropo

met

ry (

BMI,

BMI z

sc

ores

)No

diff

eren

ces

over

all

Neum

ark-

Szta

iner

et

al36

RCT

N =

356

girl

s,

aged

14–

16 y

; >7

5% r

acia

l an

d/or

eth

nic

min

oriti

es

Unite

d St

ates

12 u

rban

hig

h sc

hool

sM

I tra

inin

g: fu

ll d

in p

erso

n pl

us

ongo

ing

supp

ort;

MI fi

delit

y:

not r

epor

ted;

inte

rven

tion:

all

girl

s’ P

A (e

xerc

ise)

edu

catio

n cl

ass

first

sch

ool y

sem

este

r pl

us M

I-bas

ed c

ouns

elin

g w

ith

nutr

ition

edu

catio

n an

d se

lf-em

pow

erm

ent o

ver

scho

ol y

, lu

nch

mee

tings

, 6 p

ostc

ards

re

info

rcin

g cu

rric

ulum

m

aile

d ho

me

to p

aren

ts;

cont

rol:

all g

irls

’ PA

educ

atio

n cl

ass

duri

ng fi

rst s

choo

l y

sem

este

r

5–7

sess

ions

dur

ing

phys

ical

edu

catio

n cl

ass;

follo

w-u

p:

16 w

k

(1)

anth

ropo

met

ry (

BMI,

perc

ent o

f bod

y fa

t); (

2)

beha

vior

al (

self-

repo

rted

di

etar

y an

d/or

PA)

No d

iffer

ence

s in

an

thro

pom

etri

cs. I

n fa

vor

of M

I in

repo

rted

sed

enta

ry

activ

ity p

er d

(−

1.26

of 3

0-m

in b

lock

s, P

= .0

5), p

ortio

n co

ntro

l (1.

03, 1

–5-p

oint

ran

ge,

P =

.01)

, unh

ealth

y w

t con

trol

be

havi

ors

(13.

7%, P

= .0

2),

and

body

and

/or

self-

imag

e (b

ody

satis

fact

ion

1.06

, 5–

20-p

oint

ran

ge, P

= .0

4; s

elf-

wor

th 0

.85,

5–2

0-po

int r

ange

, P

= .0

3)

Pakp

our

et

al37

RCT

N =

357,

age

d 14

–18

y; 4

0%

girl

s

Iran

Pedi

atri

c ou

tpat

ient

clin

icM

I tra

inin

g: 4

8–51

h in

per

son;

M

I fide

lity:

ran

dom

aud

io

reco

rdin

gs c

oded

, sco

res

met

pro

ficie

ncy

for

all b

ut

1 ca

tego

ry; i

nter

vent

ion:

M

I-bas

ed c

ouns

elin

g w

ith

nutr

ition

and

PA

educ

atio

n w

ith th

e ad

ditio

n of

PI;

cont

rol:

pass

ive

cont

rol

grou

p

MI g

roup

s: 6

wee

kly

40-m

in s

essi

ons,

M

I plu

s pa

rent

gr

oup

rece

ived

an

addi

tiona

l 60-

min

se

ssio

n; fo

llow

-up:

12

mo

(1)

anth

ropo

met

ry (

BMI,

BMI z

sco

re, b

ody

fat,

bioe

lect

rica

l im

peda

nce,

w

aist

cir

cum

fere

nce)

, (2)

ca

rdio

met

abol

ic (

tota

l ch

oles

tero

l, tr

igly

ceri

des)

, (3

) be

havi

oral

(se

lf-re

port

ed d

ieta

ry a

nd/o

r PA

, ac

cele

rom

eter

), (4

) qu

ality

of

life

(se

lf-re

port

ed)

In fa

vor

of M

I + P

I in

chol

este

rol

(0.1

3 m

mol

/L, P

= .0

2),

trig

lyce

ride

s (0

.16

mm

ol/L

, P

= .0

01),

BMI (

2.05

, P =

.0

1), a

nd B

MI z

sco

re (

2.58

, P

= .0

2); P

A (P

= .0

01);

self-

repo

rted

die

tary

and

PA

mea

sure

s si

gnifi

cant

for

all b

ut v

eget

able

s an

d m

ilk;

qual

ity o

f life

sig

nific

ant f

or

all b

ut s

ocia

l fun

ctio

ning

and

to

tal s

core

. In

favo

r of

MI p

lus

pare

nt v

ersu

s M

I (P

= .0

5)

TABL

E 1

Cont

inue

d


VALLABHAN et al8

Stud

yDe

sign

Part

icip

ants

Coun

try

Inte

rven

tion

Char

acte

rist

ics

Outc

omes

Mai

n Fi

ndin

gs

Sett

ing

Desc

ript

ion

Dose

Polla

k

et a

l38Pr

e/po

stN

= 30

, age

s 12

–18

y;

63%

gir

ls,

27%

whi

te,

73%

Afr

ican

Am

eric

an

Unite

d St

ates

Gene

ral p

edia

tric

, fa

mily

pra

ctic

e pr

imar

y ca

re

MI t

rain

ing:

onl

ine

lear

ning

m

odul

es; M

I fide

lity:

aud

io

reco

rdin

gs c

oded

, sco

res

indi

cate

d lo

w-to

-mod

erat

e pr

ofici

ency

; int

erve

ntio

n:

MI-b

ased

dis

cuss

ions

with

nu

triti

on a

nd P

A ed

ucat

ion

1 se

ssio

n, m

ean

6.0

min

; fol

low

-up:

1

mo

(1)

anth

ropo

met

ry (

wt)

, (2)

be

havi

oral

(se

lf-re

port

ed

diet

ary

and/

or P

A)

Whe

n ph

ysic

ians

had

a h

ighe

r M

I spi

rit s

core

, pat

ient

s re

port

ed r

educ

ed s

ubje

ctiv

e w

t (P

= .0

2).

Resn

icow

et

al13

RCT

N =

147,

age

d 12

–16

y;

Afri

can

Amer

ican

gi

rls

Unite

d St

ates

Chur

ches

MI t

rain

ing:

16

h pl

us o

ngoi

ng

supe

rvis

ion;

MI fi

delit

y:

not r

epor

ted;

inte

rven

tion:

hi

gh-in

tens

ity w

eekl

y gr

oup

beha

vior

al s

essi

ons

with

ex

erci

se, n

utri

tion

and

PA e

duca

tion,

MI-b

ased

te

leph

one

calls

, 2-w

ay p

ager

s w

ith r

emin

der

mes

sage

s;

cont

rol:

mod

erat

e-in

tens

ity

mon

thly

ses

sion

s w

ith

nutr

ition

and

PA

educ

atio

n

High

inte

nsity

: 24–

26

sess

ions

, par

ents

pa

rtic

ipat

ed in

∼

12, p

lus

4–6

20–

30-m

in te

leph

one

calls

; mod

erat

e in

tens

ity c

ontr

ol: 6

se

ssio

ns, p

aren

ts

part

icip

ated

in

∼3;

follo

w-u

p: 6

an

d 12

mo

(1)

anth

ropo

met

ry (

wt,

BMI,

wai

st a

nd h

ip

circ

umfe

renc

e, b

ody

fat)

, (2

) ca

rdio

met

abol

ic (

tota

l ch

oles

tero

l, gl

ucos

e,

insu

lin),

(3)

fitne

ss (

20-m

sh

uttle

run

)

No d

iffer

ence

s ov

eral

l. Gi

rls

who

at

tend

ed >

3 qu

arte

rs o

f the

se

ssio

ns h

ad s

igni

fican

tly

low

er B

MI (

P =

.01)

in th

e hi

gh-in

tens

ity g

roup

.

Tuck

er

et a

l39a

Quas

i- ex

peri

men

tal

N =

130,

age

d 4–

18 y

(33

%

aged

12–

18);

44%

gir

ls,

80%

whi

te

Unite

d St

ates

Pedi

atri

c cl

inic

MI t

rain

ing:

3 d

; MI fi

delit

y: n

ot

repo

rted

; int

erve

ntio

n: c

hild

-pa

rent

dya

ds, s

tand

ard

care

(r

evie

w B

MI a

t wel

l-chi

ld

visi

t) p

lus

MI s

essi

ons

with

nu

triti

on a

nd P

A ed

ucat

ion,

ph

one

sess

ions

; con

trol

: st

anda

rd c

are

(rev

iew

BM

I at

wel

l-chi

ld v

isit)

1 30

-min

(av

erag

e)

sess

ion,

4 w

eekl

y ph

one

sess

ions

; 1-

and

6-m

o se

ssio

n,

peri

odic

pho

ne

sess

ions

; fol

low

-up

: 12

mo

(1)

anth

ropo

met

ry (

BMI,

BMI

perc

entil

e), (

2) b

ehav

iora

l (s

elf-r

epor

ted

diet

ary

and/

or P

A)

No d

iffer

ence

s in

an

thro

pom

etri

cs. I

n fa

vor

of

MI i

n se

lf-re

port

ed fr

uit a

nd/

or v

eget

able

inta

ke (

P <

.001

), PA

(P

= .0

04),

and

scre

en ti

me

(P =

.035

).

Wal

pole

et

al40

RCT

N =

40, a

ged

10–1

8 y,

57%

gi

rls,

65%

w

hite

Cana

daPe

diat

ric

outp

atie

nt c

linic

MI t

rain

ing:

in p

erso

n by

MIN

T tr

aine

r, on

goin

g su

perv

isio

n;

MI fi

delit

y: fe

edba

ck o

f aud

io

reco

rdin

gs, s

ubsa

mpl

e co

ded,

met

pro

ficie

ncy

on s

ever

al c

ateg

orie

s;

inte

rven

tion:

MI-b

ased

co

unse

ling

with

nut

ritio

n an

d PA

edu

catio

n; c

ontr

ol:

educ

atio

n on

soc

ial s

kills

6 30

-min

(av

erag

e)

sess

ions

; fol

low

-up

: 6 m

o

(1)

anth

ropo

met

ry (

BMI,

BMI z

sc

ore,

wai

st c

ircu

mfe

renc

e)No

diff

eren

ces

over

all.

MI g

roup

at

tend

ed m

ore

sess

ions

(P

= .0

54).

Self-

effic

acy

impr

oved

(P

= .0

04)

in b

oth

grou

ps o

ver

time.

ALT,

alan

ine

amin

otra

nsfe

rase

; HDL

-C, h

igh-

dens

ity li

popr

otei

n ch

oles

tero

l; HO

MA-

IR, h

omeo

stat

ic m

odel

ass

essm

ent f

or in

sulin

res

ista

nce;

LDL

-C, l

ow-d

ensi

ty li

popr

otei

n ch

oles

tero

l; M

INT,

mot

ivat

iona

l int

ervi

ewin

g ne

twor

k of

trai

ners

; PA,

phy

sica

l ac

tivity

; PI,

pare

nt in

volv

emen

t.a

Adol

esce

nt-s

peci

fic d

ata

rece

ived

from

aut

hor.

TABL

E 1

Cont

inue

d


included studies across 7 domains. We included randomized and nonrandomized studies in the risk of bias assessment and extracted data regarding each domain. Two authors rated each domain as being high, low, or unclear risk of bias using criteria indicated by the Cochrane Handbook for Systematic Reviews.43 We used the following rules for judging risk of bias for incomplete outcome data for each individual study: the final sample dipped below the sample size calculation, imbalance in numbers or reasons for missing data between groups, loss to follow-up >20%, 44, 45 or substantially different rates in attrition between groups.43

We assessed the quality of evidence using the GRADEpro tool, 42 which considers within-study risk of bias, directness of evidence, heterogeneity, precision of effect estimates, and risk of publication bias. We imported data from RevMan41 into GRADEpro.42 Two authors independently rated the quality of evidence for each comparison and outcome across the included studies and then produced a “Summary of Findings” table (see Table 2) using the GRADE Handbook42 criteria. When CIs

included or crossed 0, we conducted calculations for comparison groups for each outcome using *GPower Sample Size Calculator46 to determine optimal information size47 using a 1-sided α of .05 and power of .80. The actual means and SDs from the meta-analysis of each outcome were used to calculate effect sizes, which ranged from 0.01 to 0.27. Two authors conducted and cross-checked calculations.

When there was >1 follow-up period reported, we selected the point with the greatest improvement in outcome measurements. When >1 arm in the intervention using MI existed, we selected the intervention arm that had the greatest improvement in outcome measurements.

For consistency in measurement outcomes, 2 authors converted and cross-checked measurement units to the American Medical Association preferred units of measurements where needed.48 For studies missing required data elements, we e-mailed authors a request for the missing data, sent a second e-mail, and e-mailed a coauthor when needed. When possible, for studies where data were not available or authors did not respond to requests, we

computed SDs from the available data using formulas and methods recommended by the Agency for Healthcare Research and Quality for handling missing continuous data instead of omitting the study.49 Two authors conducted the computations and cross-checked for consistency.

Assessment of Heterogeneity

To investigate statistical heterogeneity, we used a fixed-effects model in RevMan41 and produced Forest plots with the I2 statistic. Forest plots provide visual variability in point estimates of the effect size and CIs; I2 quantifies the percentage of the variability in effect estimates due to heterogeneity rather than to sampling error (chance).50 A significant Q (Cochran Q = χ2) with P < .05 or I2 value >50% suggests substantial heterogeneity.43 If heterogeneity was present, we performed a random effects analysis, which equally weighs all included studies to account for between study variance due to sample size differences.51

Assessment of Reporting Biases

To investigate reporting bias, we used Funnel plots produced by


TABLE 2 Summary of Findings Comparing MI, No MI in Adolescents With Overweight or Obesity

Outcomes Follow-up mo

Participants (Studies) Quality of Evidence (GRADE)

I2 Statistic Reasons for Downgradinga, b

Effect Estimatec MD (95% CI)

BMI 3–13 1185 (10 RCTs) ⊕⊕⊕⊝ 31% (P = .16) Imprecision −0.27 (−0.98 to 0.44)Moderate

BMI percentile 4–7 72 (2 RCTs) ⊕⊕⊕⊝ 0% (P = .46) Imprecision −1.07% (−3.63 to 1.48)Moderate

BMI z score 4–13 628 (6 RCTs) ⊕⊕⊕⊝ 47% (P = .09) Imprecision −0.00 (−0.09 to 0.09)Moderate

Waist circumference 4–13 633 (7 RCTs) ⊕⊕⊕⊝ 0% (P = .45) Imprecision 0.56 cm (−1.07 to 2.19)Moderate

Glucose (fasting) 6–13 290 (3 RCTs) ⊕⊕⊕⊝ 17% (P = .30) Imprecision 0.11 mmol/L (0.01 to 0.21)Moderate

Triglycerides (fasting) 7–13 401 (3 RCTs) ⊕⊕⊝⊝ 77% (P = .01) Imprecision, Inconsistency

0.00 mmol/L (−0.31 to 0.31)Low

Total cholesterol (fasting) 6–12 356 (2 RCTs) ⊕⊕⊕⊝ 0% (P = .39) Imprecision 0.01 mmol/L (−0.17 to 0.18)Moderate

Insulin (fasting) 6–13 291 (3 RCTs) ⊕⊕⊕⊝ 18% (P = .30) Imprecision 5.24 pmol/L (−13.63 to 24.10)Moderate

a High risk of bias due to lack of blinding; less crucial in objective outcome measurements. Potential limitations unlikely lower the confidence in estimate of effect. No serious limitation; do not downgrade.b Participant age range included adolescent populations. When mean participant age was <12 y, authors were contacted for direct adolescent specific data. Greater percentage of girls than boys overall. No serious limitation; do not downgrade.c Inverse-variance statistical method using a fixed or random (when I2 >50%) effects analysis model with an MD effect measure produced by RevMan.


RevMan41 software, which provide visual scatter plots of the effect estimates against the study’s size. In the absence of bias and between study heterogeneity, the scatter will be due to sampling variation and the plot will resemble a symmetrical inverted funnel.51 Heterogeneity, reporting bias, and chance may lead to asymmetry.51

Data Synthesis

We reported outcomes from all 17 studies as an SR to synthesize the data and only included RCTs in the meta-analysis per the Cochrane Handbook, section 13.1.2.43 We excluded 6 studies from the meta-analysis. Four were nonrandomized studies; 1 RCT did not have follow-up mean or SD values that are necessary for meta-analysis, and we were unable to get these values or additional information from the authors to compute mean and SD values; and 1 RCT did not have a non-MI control group. Sufficient data were available for meta-analysis across 11 studies; we conducted meta-analyses using RevMan41 to produce overall estimated pooled treatment effects as relative effect estimates and mean differences (MDs) with 95% CIs for each outcome. We included the following outcomes in the meta-analysis: BMI, BMI percentile, BMI z score, waist circumference, fasting glucose, triglycerides, total cholesterol, and insulin. An MD was appropriate for this review because RCTs contained reports of outcomes as continuous data from standard measurement scales. Health behavior and quality of life outcomes are reported only as a qualitative synthesis.

Sensitivity Analysis

We performed a sensitivity analysis as set forth by the Cochrane Handbook, section 9.7.43 We requested, received, and included our eligibility age range (ages 12–19 at study enrollment) data in the analysis. Only 1 study that met

inclusion criteria was included in SR; this study was excluded from the meta-analysis because of missing data that could not be computed or imputed, but the study did not contain reports of effects on weight-related outcomes. We undertook the entire meta-analysis twice for all outcomes using a fixed-effect model followed by a random effects model, and the overall results were not affected.

RESULTS

Characteristics of Included Studies

Our electronic search yielded 1545 records through database searching and an additional 169 records through review of citations and hand searching. After we removed duplicates, there were 1336 abstracts. The first round of double screening excluded 1310 records on the basis of title and abstract. We identified 26 full-text articles for additional review and determined that 17 studies met the inclusion criteria for this SR, including 13 RCTs and 4 other types of studies (1 quasi-experimental, 1 cohort, and 2 pre and post). Eleven RCTs were included in the meta-analysis (see Fig 1). Full details of the included studies are provided in Table 1.

Systematic Review

All 17 studies examined anthropometrics, and only 3 reported significant effects on BMI, 31, 37 BMI percentile, 32 BMI z score, 37 and waist circumference32; 1 of these studies did not have lasting effects by the final follow-up period at 6 months.31 Seven studies examined cardiometabolic outcome measures, and only 1 reported significant decreases for total cholesterol and triglycerides that were not clinically relevant.37 Fourteen studies examined physical activity. Three studies reported significant effects on self-reported sedentary behaviors32, 36, 39; 2 reported contained

reports of significant effects on physical activity duration, 31, 37 energy expenditure, 31, 37 and self-reported activity measures37, 39; and 1 reported significant effects on fitness.30 Out of the 11 studies that examined self-reported dietary habits, 4 studies reported significant effects, 34, 36, 37, 39 and 1 study reported overall success in meeting diet and physical activity behavior goals.29 Three studies evaluated quality of life outcomes, and 1 reported significant effects on self-reported school functioning, emotional functioning, physical health, and psychosocial health.27, 28, 37 All 17 studies were focused on lifestyle changes and incorporated general education on nutrition and/or physical activity into the core MI-based intervention sessions. Fifteen studies included both didactic nutrition and physical activity education, with 2 of those also adding an exercise class component. Two studies were focused on didactic physical activity education, with 1 of those also adding an exercise class component. Three of the 16 studies augmented MI with cognitive behavioral therapy (CBT), and 11 studies involved parents. Nine of the 16 studies reported significant improvements in nutrition and/or physical activity habits.

Overall, there was high variability in the number of MI sessions included in the interventions. The majority of the studies had relatively short-term follow-up periods, and the biggest outcome improvements tended to occur in studies with follow-up periods that were 6 months or less. Reported improvements were primarily in nutrition and physical activity behaviors versus anthropometric or cardiometabolic outcomes.

Risk of Bias in Included Studies

Risk of bias assessments are presented for each domain as percentages across all 17 studies in the SR (see Fig 2) and for each


study (see Fig 3). Overall, risk of biases common to the majority of the included studies were related to lack of blinding of participants, personnel, and those assessing outcomes. In addition, approximately half of the studies were assessed as being at high risk for bias related to allocation concealment and incomplete outcome data. Overall, the risk of publication bias was deemed low; funnel plots produced for each relevant outcome from the 11 RCTs included in the meta-analysis (see Supplemental Information for Fig 4) appear to be fairly symmetrical, although smaller studies tend to have larger effect sizes.

Meta-analysis

We included 11 total RCTs in the meta-analysis, with a total of 1245 participants, follow-up duration of 3 to 13 months, 1 to 16 intervention sessions, and study sample sizes of 32 to 357 participants (see Table 1). Participants were predominantly female sex. Overall, there was evidence of heterogeneity for only 1 cardiometabolic outcome out of 8 outcomes that were examined (triglycerides, I2 = 77%, P = .01).

The results of the meta-analyses are presented in Table 2 (see Supplemental Information for Figs 5–12). We found nonsignificant average reductions in BMI and BMI percentile. There were no discernible effects on BMI z score, waist circumference, glucose, triglycerides, total cholesterol, or insulin. The optimal information size necessary for detecting a statistically significant MD was not met for any outcome. Dose response gradients or plausible confounders were not detected on the basis of criteria set forth by the GRADE Handbook.42

MI Fidelity

Although most of the studies reported MI training for providers, training efforts were highly variable, ranging from online learning modules to 3 full days of direct

training. The majority of the studies did not discuss ongoing coaching or supervision. Ten studies specified that Motivational Interviewing Treatment Integrity coding was done; coding indicated that providers delivering the MI intervention inconsistently met levels of MI proficiency across studies.

DISCUSSION

The main finding of this SR and meta-analysis on the use of MI to treat adolescents with overweight and obesity are nonsignificant reductions in some anthropometric outcomes, no discernable effects on cardiometabolic outcomes, and some qualitative evidence of positive effects on nutrition and physical activity behaviors and quality of life. Even pooling participants across studies, there was an issue with achieving adequate power for any of our primary outcomes, which must be considered as a viable explanation for the predominantly negative findings in the meta-analysis. Overall, the quality of evidence from the studies was rated predominantly moderate, indicating moderate confidence that the outcome estimate effects are near the true value across studies.43 In addition, sensitivity analysis indicated the results of

the analysis can be regarded with a relatively high degree of certainty.

Our findings are somewhat in contrast with those of Cushing et al, 17 in part because of different approaches to examining the data. Cushing et al17 found a small, significant positive effect size on health behaviors overall in adolescents (g = 0.16, 95% CI 0.05 to 0.27)17 using Hedges’ g calculation to determine an overall effect size for each study, and then aggregating those overall effect sizes across studies. Thus, their overall finding encompasses the effect of MI on several outcomes, including anthropometry, cardiometabolic outcomes, risky sexual behavior, repeat birth, sleep, dietary and physical activity behaviors, and asthma symptoms. Their findings for specific outcomes examined in this review, such as anthropometry, were fairly consistent with ours, with the weighted mean effect sizes for studies containing examinations of anthropometric outcomes hovering at ∼0 (g = −0.10 to 0.07).17 We felt that it was important to specifically examine the impact of MI on clinically relevant outcomes like weight status and cardiometabolic indicators because these factors are generally most closely associated with poor long-term health outcomes.


FIGURE 2Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.





Our findings also contradict another recent SR, whose authors indicated that multifaceted interventions, including family support and guided behavior modifications, seem effective for reducing BMI in adolescents with overweight and obesity.52 However, the authors included all weight loss interventions and did not exclusively examine MI interventions. Similar to our SR, there was considerable variability in effectiveness between interventions.

Bean et al53 argued that examining the effects of MI on outcomes beyond weight and cardiometabolic outcomes can increase understanding of the mechanisms of treatment effects. We found that there was some evidence that MI may help to improve diet and physical activity behaviors and quality of life in adolescents. However, we could not conduct separate meta-analyses for these outcomes because of variation in outcome measures across studies and limited quality of life outcome data. Many of the studies reported significant improvements in nutrition and physical activity behaviors, and of the 3 studies that evaluated quality of life, 1 reported even greater effects when parent involvement was added to MI compared with MI alone. MI may help adolescents engage effectively with other treatments that more directly affect nutrition and physical activity behaviors and quality of life.54, 55 This fits with the basic philosophy that MI primarily improves the collaborative relationship between the provider and client to build motivation to change.20

Most of the studies in the current SR included ≤6 MI sessions and managed patients for <1 year. It is likely that more ongoing contact may be necessary to impact anthropometric and cardiometabolic outcomes. The USPSTF2 found that at least 26 contact hours per year seemed to be the threshold necessary to promote weight loss in the context

VALLABHAN et al12

FIGURE 3Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.



FIGURE 4Panels A–H. A, BMI. B, BMI percentile. C, BMI z score. D, Waist circumference. E, Glucose. F, Triglycerides. G, Total cholesterol. H, Insulin.


of behavioral interventions for pediatric patients; none of the studies included in this review met this threshold. It is likely that intensive, ongoing support is necessary to address fluctuations in motivation and adherence and metabolic

and physiologic energy-balance adaptations that often frustrate long-term weight loss and maintenance efforts.56

Finally, many of the studies in the current SR did not assess treatment

fidelity and used provider training models that may not provide adequate support for implementing MI. Concerns regarding MI treatment fidelity are salient, given evidence that training workshops alone do not typically result in enduring changes in practice57 and that MI skill fluctuates between providers and over time.21, 58 According to an SR by Hall et al, 59 in the absence of supervision and ongoing training after initial training, the majority of clinicians are unlikely to achieve beginning efficiency in MI. Moreover, comfort with MI may not be achieved until at least 3 months, even with ongoing use and coaching, 58 and proficiency and skill may not be achieved until 6 to 12 months.60, 61 Given the relatively short duration of many of the studies in the current SR, it is possible that many of the providers delivering the MI intervention may not have achieved proficiency and skill. This was reflected in variable findings related to provider MI proficiency in studies in which MITI coding was conducted.

Results of this SR and meta-analysis should be interpreted in the context of the limitations. Overall, there was a range of evidence quality, with fairly small sample sizes and risks of bias related to lack of blinding of participants, personnel, and those assessing outcomes, allocation concealment, and incomplete outcome data. Other reviewers might reach different conclusions about the risks of bias and strength of the evidence on the basis of their own judgements. However, we applied stringent criteria in grading the evidence and have aimed for transparency regarding the judgements that we reached. In addition, women were overrepresented in the studies that were included, potentially limiting the generalizability of the results. Finally, none of the included studies met the USPSTF-recommended 26 contact hour threshold for

VALLABHAN et al14

FIGURE 5BMI (kg/m2). df, degree of freedom; IV, inverse variance.

FIGURE 6BMI percentile. df, degree of freedom; IV, inverse variance.

FIGURE 7BMI z score. df, degree of freedom; IV, inverse variance.

FIGURE 8Waist circumference (cm). df, degree of freedom; IV, inverse variance.


behavioral interventions for weight management in pediatric patients.

CONCLUSIONS

There is little indication in this SR and meta-analysis that MI impacts anthropometric and cardiometabolic outcomes in adolescents with overweight and obesity. This finding may reflect a true lack of effect,

or it may be related to issues with inadequate power or treatment dose, delivery, or duration. Future studies should attempt to address these shortcomings. There is some evidence that MI, especially in conjunction with other supportive interventions, may positively impact nutrition and physical activity behaviors and quality of life outcomes. Standardization

of nutrition and physical activity measures across interventions, as well as more routine measurement of quality of life, would facilitate a future meta-analysis on these outcomes. The full applicability of MI for weight management in adolescents is yet to be determined. However, the results of this SR and meta-analysis are applicable in clinical practice in that MI may effectively promote adolescent engagement and positive behavior changes, especially when used with complementary interventions.

ACKNOWLEDGMENTS

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. We thank Daveer Menchaca, medical student, Alyssa Mirabel, medical student, Nadine Montoya, dietetic intern, Christina Fallows, dietetic intern, and Jessica Hammond, dietetic intern for their assistance in the data extraction process.


Feldstein-Ewing and Kong conceptualized and designed the study and critically reviewed the final manuscript; Drs Gonzales-Pacheco, Coakley, Noe, DeBlieck, and Summers collected data and critically reviewed the final manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

This trial has been registered with PROSPERO (https:// www. crd. york. ac. uk/ PROSPERO) (identifier CRD42017072342).

ABBREVIATIONS

CBT: cognitive behavioral therapy

CI: confidence intervalGRADE: Grades of

Recommendation, Assessment, Development, and Evaluation

MD: mean differenceMI: motivational interviewingRCT: randomized controlled trialRevMan: Review ManagerSR: systematic reviewUSPSTF: US Preventive Services

Task Force

FIGURE 9Glucose (mmol/L). df, degree of freedom; IV, inverse variance.

FIGURE 10Triglycerides (mmol/L). df, degree of freedom; IV, inverse variance.

FIGURE 11Total cholesterol (mmol/L). df, degree of freedom; IV, inverse variance.

FIGURE 12Insulin (pmol/L). df, degree of freedom; IV, inverse variance.


https://www.crd.york.ac.uk/PROSPERO

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DOI: https:// doi. org/ 10. 1542/ peds. 2018- 0733

Accepted for publication Jul 31, 2018

Address correspondence to Monique K. Vallabhan, DNP, FNP-BC, MSN, RN, Division of Adolescent Medicine, University of New Mexico, 625 Silver Avenue SW, Suite 324, Albuquerque, NM 87102. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2018 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award R01HL118734 and supplement grant 3R01HL118734-03S1 (Principal Investigator Dr Kong). Funded by the National Institutes of Health (NIH).

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

COMPANION PAPER: A companion to this article can be found online at www. pediatrics. org/ cgi/ doi/ 10. 1542/ peds. 2018- 2471.


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DOI: 10.1542/peds.2018-0733 originally published online October 22, 2018; 2018;142;Pediatrics

Summers, Sarah W. Feldstein-Ewing and Alberta S. KongGonzales-Pacheco, Kathryn E. Coakley, Shelly R. Noe, Conni J. DeBlieck, Linda C.

Monique K. Vallabhan, Elizabeth Y. Jimenez, Jacob L. Nash, DianaMotivational Interviewing to Treat Adolescents With Obesity: A Meta-analysis

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DOI: 10.1542/peds.2018-0733 originally published online October 22, 2018; 2018;142;Pediatrics

Summers, Sarah W. Feldstein-Ewing and Alberta S. KongGonzales-Pacheco, Kathryn E. Coakley, Shelly R. Noe, Conni J. DeBlieck, Linda C.

Monique K. Vallabhan, Elizabeth Y. Jimenez, Jacob L. Nash, DianaMotivational Interviewing to Treat Adolescents With Obesity: A Meta-analysis

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