Action-oriented obesity counseling attains weight stabilization and improves liver enzymes among overweight and obese children and adolescents

Abstract

Introduction: Pediatricians are encouraged to promote behavior modification to reduce childhood obesity and its co-morbidities, yet the effectiveness of office counseling is unclear. We aimed to evaluate if a low-intensity intervention (action-oriented counseling) in a clinic setting results in weight stabilization, and if the effect is modified by a diagnosis of non-alcoholic fatty liver disease (NAFLD). We hypothesized that patients with NAFLD would be more motivated to adhere to the lifestyle goals set in clinic, due to the diagnosis of an obesity-related condition; and, would therefore achieve greater weight reduction compared to similarly overweight and obese patients without a diagnosis of NAFLD. Methods: A retrospective chart review was conducted on 73 (35 male, 38 female) overweight and obese patients (BMI ≥ 85th percentile) attending a pediatric GI clinic between January 2006 and October 2011. Analysis was conducted to determine if lifestyle goals discussed with the patient at each clinic visit were associated with improved BMI, BMI z-score, and liver enzymes. Treatment outcomes among NAFLD patients and similarly obese patients without NAFLD were compared using t-tests and chi-square tests. Results: Of the children evaluated, 74.0% achieved a reduction or stabilization in BMI z-score after 3 months of follow-up. Among NAFLD patients, liver enzymes improved in 72% of those who were able to stabilize or reduce their BMI and among 43% of those who gained weight. Treatment outcome did not significantly differ based on having a diagnosis of NAFLD, although there was a trend towards greater improvements. Conclusion: Our study suggests that action oriented counseling including goalsetting in a low intensity, clinic based approach is effective in improving patient BMI, in the presence or absence of an obesity-related co-morbidity, such as NAFLD. Further, we demonstrated that lifestyle modification led to improvement of liver enzymes in NAFLD patients and may result in other clinically relevant improvements. Longer studies will be needed to determine if the improvements are sustained.

NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children

“…Nonetheless, there were a number of nonrandomized, uncontrolled cohorts that together demonstrate a trend of improvement in noninvasive markers of NAFLD (ALT and steatosis) with combined lifestyle and exercise (80–96). Multidisciplinary clinics designed to treat obesity have also reported improved liver enzymes and histology in children with NAFLD (81,97,98). Multidisciplinary lifestyle approaches of moderate to high intensity (>25 contact hours during 6 months) have been shown to be most effective in pediatric weight management (99).…”

“…Nonetheless, there were a number of nonrandomized, uncontrolled cohorts that together demonstrate a trend of improvement in noninvasive markers of NAFLD (ALT and steatosis) with combined lifestyle and exercise (80)(81)(82)(83)(84)(85)(86)(87)(88)(89)(90)(91)(92)(93)(94)(95)(96). Multidisciplinary clinics designed to treat obesity have also reported improved liver enzymes and histology in children with NAFLD (81,97,98) Additional testing for chronic liver diseases to consider: Screening labs: Complete blood count (CBC) with differential, AST, bilirubin (total, conjugated), alkaline phosphatase, GGT, international normalized ratio (INR), albumin, total protein, hemoglobin A1c Exclude infections (eg, hepatitis A IgM, hepatitis B surface antigen, hepatitis C antibody, other chronic viral infections) Exclude endocrine disorders (thyroid-stimulating hormone [TSH], free thyroxine [T4]) Exclude autoimmune causes of ALT elevation (total IgA, total IgG and tissue transglutaminase antibody, antinuclear antibody, antismooth muscle antibody, anti-liver-kidney microsomal antibody) Exclude genetic causes of ALT (ceruloplasmin and/or 24-hour urine copper, lysosomal acid lipase, alpha-1 antitrypsin phenotype) Imaging: Abdominal ultrasound to rule out anatomical abnormalities or assess features of portal hypertension, magnetic resonance imaging, or spectroscopy to measure hepatic fat Liver biopsy (histology, copper measurement, stain for microvesicular fat, assess fibrosis) Red flags for advanced liver disease-chronic fatigue, gastrointestinal (GI) bleeding, jaundice, splenomegaly, firm liver on examination, enlarged left lobe of the liver, low platelets, low white blood cell count, elevated direct bilirubin, elevated international normalized ratio (INR), long history of elevated liver enzymes (>2 years). hours during 6 months) have been shown to be most effective in pediatric weight management (99).…”

Non-alcoholic fatty liver disease and metabolic syndrome in childhood

“…Снижение массы тела приводило к нормализации аминотрансфераз в множестве клинических исследований [78,79,80,81, 82 и др.] и даже к улучшению гистологических данных [24,83,84]. Снижение веса должно дополнятся увеличением физической активности и изменениями образа жизни.…”