ARTICLE

Office-Based Motivational Interviewing

to Prevent Childhood Obesity
A Feasibility Study
Robert P. Schwartz, MD; Robin Hamre, MPH, RD; William H. Dietz, MD, PhD;
Richard C. Wasserman, MD, MPH; Eric J. Slora, PhD; Esther F. Myers, PhD, RD; Susan Sullivan, PhD;
Helaine Rockett, MS, RD; Kathleen A. Thoma, MA; Gema Dumitru, MD, MPH; Kenneth A. Resnicow, PhD

Objective: To determine whether pediatricians and di- sion from the physician, and parents of children in the
etitians can implement an office-based obesity preven- intensive intervention group received 2 motivational in-
tion program using motivational interviewing as the pri- terviewing sessions each from the pediatrician and the
mary intervention. registered dietitian.

Design: Nonrandomized clinical trial. Fifteen pediatri-
cians belonging to Pediatric Research in Office Settings,
a national practice-based research network, and 5 regis-
tered dietitians were assigned to 1 of 3 groups: (1) con-
trol; (2) minimal intervention (pediatrician only); or
(3) intensive intervention (pediatrician and registered
dietitian).
Setting: Primary care pediatric offices.
Participants: Ninety-one children presenting for well-
child care visits met eligibility criteria of being aged 3 to
7 years and having a body mass index (calculated as the
weight in kilograms divided by the height in meters
squared) at the 85th percentile or greater but lower than
the 95th percentile for the age or having a normal weight
and a parent with a body mass index of 30 or greater.
Interventions: Pediatricians and registered dietitians
in the intervention groups received motivational inter-
viewing training. Parents of children in the minimal in-
tervention group received 1 motivational interviewing ses-
Main Outcome Measure: Change in the body mass
index–for-age percentile.
Results: At 6 months’ follow-up, there was a decrease
of 0.6, 1.9, and 2.6 body mass index percentiles in the
control, minimal, and intensive groups, respectively. The
differences in body mass index percentile change be-
tween the 3 groups were nonsignificant (P=.85). The pa-
tient dropout rates were 2 (10%), 13 (32%), and 15 (50%)
for the control, minimal, and intensive groups, respec-
tively. Fifteen (94%) of the parents reported that the in-
tervention helped them think about changing their fami-
ly’s eating habits.
Conclusions: Motivational interviewing by pediatri-
cians and dietitians is a promising office-based strategy
for preventing childhood obesity. However, additional
studies are needed to demonstrate the efficacy of this in-
tervention in practice settings.
Arch Pediatr Adolesc Med. 2007;161:495-501

Author Affiliations are listed at
the end of this article.
G
IVEN PHYSICIANS’ LONGI-
tudinal relationships
with families and their
regular monitoring of pa-
tients’ weight and height,
the pediatric primary care office repre-
sents an important setting for the preven-
tion or treatment of childhood obesity.
Nevertheless, almost 80% of pediatri-
cians report frustration with their ability
to make an impact on pediatric obesity.1
An important barrier may be pediatri-
cians’ real or perceived deficiencies in mo-
tivational and behavioral counseling skills
for obesity management.2,3 Enhancing pe-
diatricians’ ability to motivate their pa-
tients might improve confidence in their
counseling, alter their feelings about their
patients’ willingness to change, and ulti-
mately improve clinical outcomes.
Motivational interviewing (MI) is a pa-
tient-centered method of counseling that
seeks to elicit intrinsic motivation for
changing behavior and encourages pa-
tients to understand and resolve their am-
bivalence to such change.4,5 Motivational
interviewing appears to be particularly ef-
fective for individuals who are initially re-
sistant to changing their behavior.4-7 The
goal of MI is to help individuals express
their own reasons for changing or main-
taining the status quo and understand how
their current behavior might affect their
ability to achieve their life goals.6 The tone

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007 WWW.ARCHPEDIATRICS.COM
495
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
 sion, ethnic and racial diversity of patients, and an urban-
Table 1. Study Design* rural balance. The assignment of 5 practices to each arm was
also nonrandom, including geographic proximity to 1 or more
Minimal Intensive of the investigators, which afforded the ability to closely moni-
Control Intervention Intervention tor study progress and access to participating RDs. Sites were
Protocol Group Group Group assigned to intervention and control groups in a cluster trial
Study orientation and MI MD only MD and RD scheme. Only 1 pediatrician in each practice participated in the
training study. The study was approved by the institutional review boards
Initial measurements X X X of the American Academy of Pediatrics, the Centers for Dis-
and BMI ease Control and Prevention (CDC), Morehouse School of Medi-
YAQ† X X X cine, the Indian Health Service, and Wake Forest University
Video and tip sheets‡ Safety X X School of Medicine.
handouts Using a validated scale and stadiometer, staff from each pe-
MI sessions 1 mo with 1 and 3 mo with
diatric office measured and recorded the height (to fractions
MD only MD and RD§
Audiotape MI session X X
of an inch) and weight (in pounds) of each child while also re-
and receive feedback cording the date of measurement, date of birth, and sex. For
6-mo Measurements, X X X parents, height and weight were self-reported after informed
BMI, and YAQ consent; the BMIs of children and parents were calculated to
determine eligibility for the study. Criteria included the child
Abbreviations: BMI, body mass index (calculated as weight in kilograms being aged 3 to 7 years, being a patient seen at a well-child care
divided by height in meters squared); MD, physician; MI, motivational visit with a BMI for age and sex at the 85th percentile or greater
interviewing; RD, registered dietitian; YAQ, Youth/Adolescent Food Frequency but below the 95th percentile or at the 50th percentile or greater
Questionnaire. but below the 85th percentile with at least 1 parent’s BMI being
*X denotes that the item was done or completed. No entry indicates that the
item was not done.
30 or greater. Patients and families were required to speak the
†The YAQ was modified for this study. English language and have a working telephone. Children in
‡Tip sheets included information on healthy eating and activity. foster care, institutions, or group care were excluded, as were
§Parents of children in the intensive intervention group received 2 MD and children with chronic medical disorders. Recruitment began
2 RD MI sessions. April 1, 2004, and the study was completed by June 30, 2005.
Each practice was asked to recruit 10 patients.
The intervention phase lasted 6 months. Pediatricians and
of MI is nonjudgmental, empathetic, and encourag- RDs in the minimal and intensive groups attended a study ori-
ing.4,6 entation and completed a 2-day MI training session before the
intervention. Another 2-day training session 1 year later was
Motivational interviewing counselors rely heavily on
needed because of the prolonged time between the initial MI
reflective listening and encourage patients to find their training and the start of recruitment required to gain approval
own meanings for change as well as their own solu- from all of the institutional review boards. During the train-
tions.4,6 Although MI has been used to modify diet and ing, which was conducted by one of us (K.A.R.) and his staff,
physical activity in adults, the evidence base for its use the pediatricians and RDs were provided a didactic overview
in children is just beginning to emerge.7-9 of the essential principles and techniques of MI. Key strategies
This feasibility study had 4 objectives: (1) to deter- such as asking open-ended questions, using reflective listen-
mine whether physicians and registered dietitians (RDs) ing, considering the pros and cons of change, decreasing re-
can successfully implement an office-based obesity pre- sistance, and assessing the patient’s interest and confidence in
vention program using MI as the primary intervention; making change were modeled by the trainers and practiced in
small groups by the physicians and RDs. Simulated encoun-
(2) to examine the feasibility of integrating RDs into a
ters were observed and rated by the training staff. The training
primary care office-based obesity prevention program; sessions included instruction in anthropometry with practice
(3) to refine the study protocol and logistics in antici- in measurement and validation of the scale and stadiometer ac-
pation of a larger clinical trial; and (4) to examine, in the cording to a protocol (available on the CDC Web site, http:
context of a short-term, nonrandomized study design, the //www.cdc.gov/growthcharts). The pediatricians in the con-
impact of MI on patient body mass index (BMI) (calcu- trol group did not attend the study orientation session or the
lated as the weight in kilograms divided by the height in MI training. They received instruction in the protocol, includ-
meters squared). ing measurement technique, through a telephone conference
with study staff. A log and all study forms and documents were
kept in a folder separate from the patient’s record to ensure con-
METHODS fidentiality in all of the study groups.
Study parents in all of the 3 groups were given the Youth/
We recruited 15 pediatricians from separate practices belong- Adolescent Food Frequency Questionnaire (YAQ),10 which was
ing to Pediatric Research in Office Settings, the national practice- modified to include questions on activity, dining at restau-
based research network of the American Academy of Pediat- rants, and watching television. The YAQ was returned to the
rics. At the time of the study, Pediatric Research in Office Settings pediatric office at the 1-month visit (described later) or by mail
comprised 1963 practitioners from 725 pediatric practices in (control group). Completed questionnaires were mailed to the
the 50 states and Puerto Rico. The RDs were recruited through Channing Laboratory, Boston, Mass, for analysis. In place of
the Pediatric Nutrition Practice Group of the American Di- an obesity-oriented intervention, the parents in the control group
etetic Association. received 2 safety handouts provided by the American Acad-
The study had 3 arms: (1) control (standard care); (2) mini- emy of Pediatrics. Parents in all of the groups completing the
mal intervention (physician only); and (3) intensive interven- YAQ received a $10 gift certificate.
tion (physician and RD) (Table 1). The 15 pediatricians were The modified YAQ (the standard YAQ is a reproducible and
chosen in nonrandom fashion to achieve geographical disper- valid questionnaire)10 included food groups and sets of ques-

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007 WWW.ARCHPEDIATRICS.COM
496
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
 Table 2. Enrollment in the Study
Study Group Offices, No. Patients Enrolled, No.*
Control 5 21
Minimal‡ 4 40
Intensive§ 5 30
Abbreviation: NA, not applicable.
*Each office had a goal of enrolling 10 patients.
†Dropouts were patients who did not return for their 1-month or 6-month visit.
‡One office dropped out before the study began. Two patients were weighed and measured at the 6-month visit but did not complete the second
Youth/Adolescent Food Frequency Questionnaire.
§Three patients were weighed and measured at the 6-month visit but did not complete the second Youth/Adolescent Food Frequency Questionnaire.
tions covering 5 areas reported to be associated with weight
gain in children: sweetened drinks, snacks and desserts, fruits
and vegetables, dining out, and television viewing.11-21 For this
study, the portion sizes on the YAQ were adjusted for the chil-
dren’s ages (ages 3-7 years), and the period was “what your child
ate over the past month.”
Dining out was determined by asking respondents, “How
many times in the past 7 days did your child eat food or drink
beverages from any of the following types of eating establish-
ments: fast food; take out; dining out?” To determine the av-
erage number of television hours viewed per day, families were
asked to report the hours their children spent watching tele-
vision on a typical weekday and typical weekend day (either
Saturday or Sunday).
The BMI percentile for age was determined with the CDC
protocol, which involved using the CDC Statistical Analysis Sys-
tem code to match the combination of the calculated BMI, date
of birth, and sex of each child to the 2000 CDC growth chart
(http://www.cdc.gov/growthcharts). The parents in the mini-
mal and intensive intervention groups returned for a 1-month
visit to receive MI counseling (Table 1). Review of a 2-page
checklist assessing eating and television viewing behaviors
helped the pediatricians and RDs identify topics for MI at that
session. In the minimal study arm, the pediatrician met with
the parent for a scheduled 10- to 15-minute MI session; the MI
intervention was also scheduled for 10 to 15 minutes in the in-
tensive group but was followed by a 45- to 50-minute MI ses-
sion with the RD. The parents in the minimal and intensive
groups were given tip sheets on healthy eating and activity as
well as a video that modeled parental behavior around feeding
issues, both of which were produced by the CDC and tested
by 2 of us (R.H. and W.H.D.) in focus groups before the study
began.
One or 2 of the first MI sessions presented by each pedia-
trician (minimal and intensive groups) and RD (intensive group
only) were audiotaped and used for clinical supervision and
quality control. A trained psychologist (Santhi Periasamy, PhD)
analyzed the audiotapes and provided telephone feedback and
coaching in MI to the pediatricians and RDs. After an audio-
taped MI session, parents were requested to complete an evalu-
ation form to assess their perceptions of counseling by the phy-
sician and RD. Parents of children in the intensive group returned
for a 3-month visit in which they received additional MI ses-
sions with the pediatrician and the RD. Children from all of
the 3 study arms returned for a 6-month visit in which they
were weighed and measured. Parents completed a second YAQ
at this time and received an additional $10 gift certificate.
Analysis of variance was used to examine within- and be-
tween-group changes in BMI. Change in BMI percentile was
adjusted for the number of days between the baseline and fol-
low-up visits, as the average time to follow-up was approxi-
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007
497
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
Patients Attending Patients Attending Patients Attending
1-mo Visit, No. 3-mo Visit, No. 6-mo Visit, No.†
NA NA 19
32 NA 27
18 12 15
mately 40 days longer in the intensive group than in the mini-
mal and control groups.
The modified YAQ was analyzed using SAS statistical soft-
ware version 9.1 (SAS Institute, Inc, Cary, NC). Arithmetic
means were calculated for servings of food groups, days of din-
ing out, and hours of television viewing. We used the paired t
test estimated by SAS Proc Univariate to test whether a single
group experienced significant change from before the inter-
vention to after it concluded. To compare the before-after mean
change between 2 groups, we used the t test for independent
samples estimated using SAS Proc TTest. We tested for equal
variances between the groups, and we report the unequal vari-
ances t test results when appropriate. The postintervention (6-
month) values were adjusted for baseline differences between
the 3 groups (control, minimal, and intensive).
RESULTS
A total of 91 eligible patients were enrolled from 14 prac-
tices between April 1, 2004, and November 30, 2004
(Table 2). Thirty-eight (41%) of the children were boys.
Children in the control group (mean age, 5.3 years) were
slightly older than those in the minimal and intensive
groups (both mean ages, 4.7 years). Fifty-two (57%) of
the children met the criteria of BMI at the 85th percen-
tile or greater but below the 95th percentile for age with
or without an overweight parent. The remaining 39 chil-
dren (43%) qualified by having a BMI at the 50th per-
centile or greater but below the 85th percentile and hav-
ing a parent with a BMI of 30 or greater. There were no
between-group differences in the percentages qualify-
ing by the 2 main entry criteria. One of the 5 minimal
intervention practices dropped out before the study be-
gan. Two practices enrolled no patients, 2 enrolled 1 pa-
tient each, and the remaining 10 practices averaged 9 pa-
tients recruited (the goal was 10 patients per practice).
The enrollment of patients was lowest for the control
group. Dropouts were those patients who did not re-
turn for the 1-month (minimal and intensive groups) or
6-month (all groups) visits. The patient dropout rates were
2 (10%), 13 (32%), and 15 (50%) for the control, mini-
mal, and intensive groups, respectively. Three patients
in the intensive group had only 1 (instead of 2) sessions
with a pediatrician and an RD. Overall, 61 (67%) of the
patients completed the study. Children who dropped out
of the study (n=30) did not differ significantly from the
61 children in the cohort with regard to age (P=.89), sex
WWW.ARCHPEDIATRICS.COM
 COMMENT
Table 3. Baseline and 6-Month Body Mass Index–for-Age
Percentile by Group
The main objective of this pilot study was to determine
Change in BMI the feasibility of primary care pediatricians and RDs imple-
BMI Percentile, Percentile, menting an office-based obesity prevention program using
Visit Patients, No. Mean (SD) Mean (SE)*
MI as the chief intervention strategy. We wished to ex-
Control group amine methodological and logistic issues such as recruit-
Baseline 19 84.4 (11.3) −0.6 (2.4) ment of practices and patients, training of the pediatri-
6-mo 19 84.0 (11.5)
Minimal group
cians and RDs, retention of participants, anthropometric
Baseline 27 83.2 (10.7) −1.9 (2.0) measurements, and collection of data. Because of the short
6-mo 27 81.4 (12.6) study duration (6 months) and methodological prob-
Intensive group lems caused by nonrandom assignment of patients and
Baseline 15 81.8 (12.5) −2.6 (2.8) physicians to intervention and control groups, we did not
6-mo 15 78.7 (18.1) expect that the observed changes in BMI (non–
statistically significant decreases of 0.6, 1.9, and 2.6 BMI
Abbreviation: BMI, body mass index (calculated as the weight in kilograms
divided by the height in meters squared).
percentiles in the control, minimal, and intensive groups,
*Adjusted for time to follow-up. respectively) would form the basis for judgment regard-
ing effectiveness of the intervention. Important factors
(P=.37), baseline BMI (P = .81), or baseline BMI percen- compromising data collection included recruitment prob-
tile (P=.96). Thus, there was no evidence of selective at- lems (especially in the control group) and a high drop-
trition in the study. out rate (intensive group). Changes in eating behaviors
and television viewing generally did not correlate with
BMI OUTCOMES BMI changes (data not shown). However, parental, phy-
sician, and RD satisfaction with the MI intervention was
At the 6-month follow-up, there were mean decreases in high, and more than 90% of the parents reported that the
BMI of 0.6, 1.9, and 2.6 percentiles in the control, mini- pediatrician and RD helped them think about changing
mal, and intensive intervention groups, respectively their family’s eating habits.
(Table 3). Adjusting for days from follow-up, the dif- Feedback obtained from the pediatricians, RDs, par-
ferences between the groups were not statistically sig- ents, and office staff suggested significant changes for a
nificant (P=.85). future expanded clinical trial. We outline here the les-
sons derived from our experience that are applicable for
CHANGES IN BEHAVIOR PATTERNS future obesity research in practice settings.

Fifty-six (62%) of the 91 patients completed the YAQ at IMPROVING RECRUITMENT

the beginning and end (6-month visit) of the study. Two
patients in the minimal group and 3 in the intensive group
were measured and weighed at 6 months but did not have
a follow-up survey completed by their parents.
Parents in the minimal group reported a significant
within-group decrease in their child’s intake of snacks,
a change that was significantly greater (P=.01) than the
experience in the control group (Table 4). Parents in
the intensive group reported a significant net decrease
(P = .04) in dining out compared with the minimal
group. For sweetened drinks, intake of fruits and veg-
etables, and television viewing, no significant within- or
between-group differences were observed (P⬎.05).
PARENT EVALUATION
OF COUNSELING SESSIONS
Eight parents from the minimal group and 8 from the in-
tensive group who completed the evaluation form (after
an audiotaped MI session at 1 month) rated their reac-
tions to the counseling sessions with the physician (mini-
mal and intensive groups) and the RD (intensive group
only) (Table 5). Fifteen (94%) of the parents reported
being very satisfied with the pediatrician visit, and all were
very satisfied with the RD visit. Fifteen (94%) of the par-
ents reported that the pediatrician and RD helped them
think about changing their family’s eating habits.
Our study protocol stipulated eligibility for 2 groups of
children aged 3 to 7 years: (1) those with a BMI for age
and sex at the 85th percentile or greater but below the
95th percentile; and (2) those with a BMI at the 50th per-
centile or greater but below the 85th percentile for whom
1 parent’s BMI was 30 or greater. This requirement meant
that a parent had to report his or her own height and
weight (after consent was obtained) before study entry.
Physicians were frustrated when they spent time in re-
cruitment but the child did not qualify for the study ow-
ing to the parent’s BMI. For a future study, we plan to
eliminate parents’ BMI from the eligibility criteria, ex-
pand the age group to ages 2 to 8 years, and expand the
BMI criteria to the 85th percentile or greater but below
the 97th percentile to accommodate the pediatricians’ de-
sire to enroll younger children and children who are
heavier but not morbidly obese.
In our feasibility pilot study, we restricted recruit-
ment to well-child care visits. The pediatricians told us
that there were missed opportunities when children who
might have qualified for the study were seen at sick care
visits. We therefore recommend recruitment at sick and
well care visits for future studies.
Physicians expressed dissatisfaction with excessive pa-
perwork and the time required to fill out recruitment and
other forms. In addition to minimizing the number of

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007 WWW.ARCHPEDIATRICS.COM
498
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
 Table 4. Diet, Dining Out, and Television Viewing Behavior of 56 Children

Control Group, Mean (SD) Minimal Group, Mean (SD) Intensive Group, Mean (SD)
(n = 19) (n = 25) (n = 12)

Variable Baseline Visit 6-mo Visit* Baseline Visit 6-mo Visit* Baseline Visit 6-mo Visit*
Sweetened drinks, glasses/d† 1.49 (0.92) 1.81 (0.27) 1.94 (1.54) 1.40 (0.24) 2.36 (1.33) 1.91 (0.35)
Snacks and desserts, servings/d‡ 2.07 (1.06) 2.48 (0.20)§ 2.63 (1.95) 1.76 (0.17)§ 2.35 (1.34) 2.15 (0.25)
Dining out, times/wk 㛳 2.26 (1.48) 2.49 (0.46) 2.28 (1.43) 2.89 (0.40)¶ 5.67 (5.30) 1.97 (0.63)¶
Fruits and vegetables, servings/d# 2.92 (1.78) 4.10 (0.32) 3.66 (2.04) 3.27 (0.28) 3.40 (2.10) 3.60 (0.40)
Television viewing, h/d 1.63 (0.56) 1.69 (0.14) 1.83 (0.73) 1.60 (0.12) 2.33 (1.18) 1.89 (0.18)

*The 6-month (postintervention) values were adjusted for differences between the 3 groups (control, minimal, and intensive) at the baseline visit.
†Includes juice, juice drinks, lemonade, soda, Kool-Aid (Kraft Foods Global, Inc, Northfield, Ill), sweetened tea, and instant breakfast drink.
‡Includes potato and corn chips, nachos, Fruit Roll-Ups (General Mills, Inc, Minneapolis, Minn), crackers, Pop-Tarts (Kellogg Co, Battle Creek, Mich), snack
cakes, cake, sweet rolls, doughnuts, cookies, pies, candy, JELL-O (Kraft Foods Global, Inc), pudding, frozen yogurt, ice cream, and milk shakes.
§For snacks and desserts, the minimal intervention group had a significant net decrease (P = .01) between the baseline and 6-month visits as compared with
the control group.
㛳Includes fast-food restaurants, other restaurants, takeout from restaurants, and delivered food.
¶For dining out, the intensive intervention group had a significant net decrease (P = .04) compared with the minimal intervention group.
#Does not include potatoes, french fries, or tater tots.

forms, we will require that each practice identify a spe-

cific member of the office staff (nurse or medical assis-
tant) to oversee study operations. This individual would
attend the protocol training with the pediatrician and be
the on-site study coordinator.
Enrollment of patients was lowest in the control group.
The control pediatricians may have felt less ownership
in the study because they did not attend the orientation
session and received their protocol instruction through
a telephone conference with study staff. For a future study,
the control pediatricians will attend a half-day study ori-
entation and continuing medical education workshop on
pediatric obesity. At the conclusion of the study, the con-
trol pediatricians will be offered full training in MI.
IMPROVING PARTICIPANT RETENTION
The overall patient dropout rate was 33%, but it varied
widely by group and was highest in the intensive group.
Most departures from the intensive group occurred be-
fore the 1-month visit (at 1 month, the dropout rates were
44% in the intensive group vs 20% in the minimal group).
This rather large differential suggests that motivation may
have differed among patients, physicians, or both in these
2 groups. Several strategies could improve participant re-
tention. Incentives could be given to physicians for pa-
tients completing the study. Better incentives could be
given to parents for completing the study question-
naires. Because the 1-year gap between the initial orien-
tation and the MI training to obtain clearance from all
of the institutional review boards necessitated a second
MI training session for the pediatricians and RDs, we will
minimize the time between MI training and the first study
counseling session in the future. After consent was ob-
tained, the patients were given an appointment for a
1-month counseling visit. As previously noted, the no-
show rate for this visit was high. The pediatricians be-
lieved that some parents lost their enthusiasm for the study
during this time. In the future, we will suggest that the
first visit occur as soon as possible after enrollment. Re-
quiring a dedicated office assistant as a study coordina-
Table 5. Parental Perceptions of Counseling
by 16 Pediatricians and 8 Dietitians*
Parents Agreeing
Item on Questionnaire “A Lot,” No. (%)†
My pediatrician listened to me 16 (100)
My pediatrician asked my opinion about things 14 (88)
My pediatrician asked permission before giving 13 (81)
information or advice
My pediatrician helped me think about changing 15 (94)
my family’s food habits
My pediatrician was supportive or encouraging 15 (94)
My pediatrician discussed values important to me 14 (88)
My pediatrician helped me think about changing 10 (63)
my family’s television habits
My nutritionist listened to me 8 (100)
My nutritionist asked my opinion about things 8 (100)
My nutritionist asked permission before giving 7 (88)
information or advice
My nutritionist helped me think about changing 8 (100)
my family’s food habits
*There were 8 pediatricians in the minimal group and 8 pediatricians in
the intensive group. They had the same motivational interviewing training.
These 2 groups were combined owing to small numbers.
†Possible answers were “not at all,” “a little,” “somewhat,” “a lot,” and
“can’t say.”
tor should facilitate recruitment, retention, and overall
study implementation. Difficulties were encountered in
coordinating the schedules of the pediatricians and RDs.
To alleviate this problem in a future study, we will allow
telephone follow-up for the RDs as an alternative to face-
to-face contacts after the initial counseling session. Tele-
phone-delivered MI sessions have been shown to be ef-
fective in other settings,22 and we believe that this approach
provides a potentially reimbursable model for dissemina-
tion if our intervention is proven effective. No-show visits
were costly to the pediatricians and RDs, so we recom-
mend reimbursing the pediatricians and RDs for no-show
visits not cancelled within 24 hours. Finally, we plan to
overpower the study by a few practices to account for prac-
tices dropping out or not meeting recruitment goals.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007 WWW.ARCHPEDIATRICS.COM
499
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
 RANDOMIZATION OF PATIENTS
A limiting factor in our study was the nonrandom as-
signment of clinics to treatment groups, a process that
was based on factors such as availability of collaborat-
ing RDs and the willingness of the pediatricians to com-
ply with study procedures. Such nonrandom assign-
ment could have biased the study toward rejection of the
null hypothesis. In regard to potential clustering of ef-
fects, only 1 physician in each practice participated in
the study. However, there may have been a correlation
between patients from practices in close geographic prox-
imity. Any future study should be a randomized con-
trolled clinical trial with cluster randomization used to
avoid contamination between subjects but with prac-
tices separated geographically.
MI TRAINING
The pediatricians and RDs felt they needed more role-
playing experience using open-ended questions, reflec-
tive listening, building motivation, and eliciting change
talk. The feedback from the audiotaped MI sessions by
the clinical psychologist (Santhi Periasamy, PhD) was
positively received and considered valuable. In our next
study, we will expand the time for role-playing and pro-
vide training for the investigators in behavioral therapy
as it relates to pediatric obesity. Finally, we plan to pro-
duce an interactive DVD demonstrating clinical sce-
narios relevant to the study as a supplement and booster
to the MI training.
DIET AND ACTIVITY MEASURES
In our present study, we used an extensive food and ac-
tivity questionnaire that required 30 to 40 minutes for
completion. Both parents and physicians complained about
its length and complexity and a few parents refused to com-
plete the final questionnaire. Prior to the first MI counsel-
ing session, parents also filled out a 2-page checklist as-
sessing their child’s eating, activity, and television viewing
behaviors. This latter form required only 5 minutes to com-
plete. We believe that a brief dietary and activity patterns
approach will be more feasible in a general office setting
and can effectively identify potential change opportuni-
ties for the child and family. Therefore, for a future study,
we plan to use an abbreviated 2- to 3-page survey focus-
ing on 5 priority behaviors associated with pediatric obe-
sity (sugar-sweetened drinks, snacks, dining out, fruit and
vegetable intake, and television viewing).11-21
CONCLUSIONS
The pediatric primary care office remains a potentially
important setting for the prevention or treatment of obe-
sity in children and adolescents. This feasibility study dem-
onstrates that pediatricians and RDs can be taught to use
some of the tools and techniques of MI and that this ap-
proach is well received by parents. Many challenges re-
main in designing and implementing research to test the
effectiveness of the MI approach in practice settings, but
(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007
500
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.
practice-based research networks afford the opportu-
nity to conduct the additional studies needed to make
the office setting an effective site for obesity interven-
tion.
Accepted for Publication: December 13, 2006.
Author Affiliations: Department of Pediatrics, Wake For-
est University School of Medicine, Winston-Salem, NC
(Dr Schwartz); Centers for Disease Control and Preven-
tion, Atlanta, Ga (Ms Hamre and Drs Dietz and Dumi-
tru); University of Vermont College of Medicine, Burl-
ington (Dr Wasserman); Pediatric Research in Office
Settings, American Academy of Pediatrics, Elk Grove Vil-
lage, Ill (Drs Wasserman, Slora, and Sullivan and
Ms Thoma); American Dietetic Association, Chicago, Ill
(Dr Myers); Channing Laboratory, Department of Medi-
cine, Brigham and Women’s Hospital and Harvard Medi-
cal School, Boston, Mass (Ms Rockett); and University
of Michigan School of Public Health, Ann Arbor (Dr Resni-
cow).
Correspondence: Robert P. Schwartz, MD, Department
of Pediatrics, Wake Forest University School of Medi-
cine, Medical Center Boulevard, Winston-Salem, NC
27157 (rschwrtz@wfubmc.edu).
Author Contributions: Study concept and design: Schwartz,
Hamre, Dietz, Wasserman, Slora, Myers, and Thoma. Ac-
quisition of data: Schwartz, Slora, Sullivan, Thoma, and
Dumitru. Analysis and interpretation of data: Schwartz,
Hamre, Dietz, Wasserman, Myers, Sullivan, Rockett,
Thoma, Dumitru, and Resnicow. Drafting of the manu-
script: Schwartz, Dietz, and Dumitru. Critical revision of
the manuscript for important intellectual content: Schwartz,
Hamre, Dietz, Wasserman, Slora, Myers, Sullivan, Rock-
ett, Thoma, Dumitru, and Resnicow. Statistical analysis:
Sullivan and Rockett. Obtained funding: Schwartz, Hamre,
Dietz, Wasserman, Slora, and Myers. Administrative, tech-
nical, and material support: Schwartz, Dietz, Wasser-
man, Slora, Sullivan, Rockett, Thoma, Dumitru, and Resni-
cow. Study supervision: Schwartz, Wasserman, Slora, and
Thoma.
Financial Disclosure: None reported.
Funding/Support: This study was supported by the Cen-
ters for Disease Control and Prevention, the Genentech
Foundation for Growth and Development, the Ameri-
can Dietetic Association Foundation, the American Di-
etetic Association, the Health Resources and Services Ad-
ministration Maternal and Child Health Bureau, Mead
Johnson Nutritionals, and the American Academy of Pe-
diatrics.
Role of the Sponsor: The findings and conclusions in this
article are those of the authors and do not necessarily rep-
resent the views of the Centers for Disease Control and
Prevention.
Acknowledgment: We are grateful to the following pe-
diatricians and dietitians for their participation in the
study: Nimi Auerbach, PhD, Iris Buchanan, MD, Julie Dil-
lon, MS, RD, Lou DiNicola, MD, Pamela Dockery-
Howard, MD, William Gloyd, MD, Jaquelin Gotlieb, MD,
Dawanna James, RD, Harris Lilienfeld, MD, Jeanette
McDaniel, MD, Greta McFarland, MD, Aida Miles, RD,
MMSc, Mark Pashayan, MD, David Rice, MD, Laura Simp-
son, MPH, RD, Lori Sandrol, MD, and Michael Zolicof-
WWW.ARCHPEDIATRICS.COM
fer, MD. We thank Maria Jefferds, PhD, for assistance in
the second training session, Claire Griffiths for help with
the bibliography, Nicole Kerr, RD, MPH, for message and
concept testing, Karen Klein, MA, ELS, for editorial con-
tributions, and Melissa Tuttle for secretarial services in
the preparation of the manuscript.
REFERENCES
1. Jelalian E, Boergers J, Alday CS, Frank R. Survey of physician attitudes and prac-
tices related to pediatric obesity. Clin Pediatr (Phila). 2003;42:235-245.
2. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee
recommendations. Pediatrics. 1998;102:E29. http://www.pediatrics.org/cgi
/content/full/102/3/e29. Accessed February 15, 2007.
3. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and
adolescent obesity: attitudes, barriers, skills, and training needs among health
care professionals. Pediatrics. 2002;110:210-214.
4. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change.
2nd ed. New York, NY: Guilford Press; 2002.
5. Rollnick S, Mason P, Butler C. Health Behavior Change: A Guide for Practitioners.
London, England: Churchill Livingstone; 1999.
6. Resnicow K, DiIorio C, Soet JE, Ernst D, Borrelli B, Hecht J. Motivational inter-
viewing in health promotion: it sounds like something is changing. Health Psychol.
2002;21:444-451.
7. Resnicow K, DiIorio C, Soet JE. Motivational interviewing in medical and public
health settings. In: Miller WR, Rollnick S, eds. Motivational Interviewing: Pre-
paring People for Change. 2nd ed. New York, NY: Guilford Press; 2002:251-
269.
8. Sindelar HA, Abrantes AM, Hart C, Lewander W, Spirito A. Motivational inter-
viewing in pediatric practice. Curr Probl Pediatr Adolesc Health Care. 2004;
34:322-339.
9. Erickson SJ, Gerstle M, Feldstein SW. Brief interventions and motivational in-
terviewing with children, adolescents, and their parents in pediatric healthcare
settings: a review. Arch Pediatr Adolesc Med. 2005;159:1173-1180.
10. Rockett HR, Breitenbach M, Frazier AL, et al. Validation of a youth/adolescent
food frequency questionnaire. Prev Med. 1997;26:808-816.
11. Perrin EM, Flower KB, Garrett J, Ammerman AS. Preventing and treating obe-
sity: pediatricians’ self-efficacy, barriers, resources, and advocacy. Ambul Pediatr.
2005;5:150-156.
12. Bowman SA, Gortmaker SL, Ebbeling CB, et al. Effects of fast food consumption
on energy intake and diet quality among children in a national household survey.
Pediatrics. 2004;113:112-118.
13. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing
consumption of carbonated drinks: cluster randomised controlled trial. BMJ. 2004;
328:1237-1239.
14. Mrdjenovic G, Levitsky DA. Nutritional and energetic consequences of sweetened
drink consumption in 6 to 13 year old children. J Pediatr. 2003;142:604-610.
15. Jahns L, Siega-Riz AM, Popkin BM. The increasing prevalence of snacking among
US children from 1977 to 1996. J Pediatr. 2001;138:493-498.
16. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-
sweetened drinks and childhood obesity: a prospective observational analysis.
Lancet. 2001;357:505-508.
17. Welsh JA, Cogswell ME, Rogers S, Rockett H, Mei Z, Grummer-Strawn LM. Over-
weight among low-income preschool children associated with consumption of sweet
drinks: Missouri, 1999-2002. Pediatrics. 2005;115:e223-e229. http://pediatrics
.aappublications.org/cgi/reprint/115/2/e223. Accessed February 15, 2007.
18. Krebs-Smith SM, Cook A, Subar AF, Cleveland L, Friday J, Kahle LL. Fruit and
vegetable intakes of children and adolescents in the United States. Arch Pediatr
Adolesc Med. 1996;150:81-86.
19. Robinson TN. Reducing children’s television viewing to prevent obesity: a ran-
domized controlled trial. JAMA. 1999;282:1561-1567.
20. Crespo CJ, Smit E, Troiano RP, Bartlett SS, Macera CA, Andersen RE. Television
watching, energy intake and obesity in US children: results from the third Na-
tional Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Ado-
lesc Med. 2001;155:360-365.
21. Viner RM, Cole TJ. Television viewing in early childhood predicts adult body mass
index. J Pediatr. 2005;147:429-435.
22. Resnicow K, Jackson A, Wang T, et al. A motivational interviewing intervention
to increase fruit and vegetable intake through Black churches: results of the Eat
for Life trial. Am J Public Health. 2001;91:1686-1693.

Announcement

Topic Collections. The Archives offers collections of

articles in specific topic areas to make it easier for phy-
sicians to find the most recent publications in a field.
These are available by subspecialty, study type, disease,
or problem. In addition, you can sign up to receive a
Collection E-Mail Alert when new articles on specific
topics are published. Go to http://archpedi.ama-assn.org
/collections to see these collections of articles.

(REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161, MAY 2007 WWW.ARCHPEDIATRICS.COM
501
Downloaded from www.archpediatrics.com at University of Alabama-Birmingham, on May 9, 2007
©2007 American Medical Association. All rights reserved.