A review of electronic interventions for prevention and treatment of overweight and obesity in young people

Authors


Ms B Nguyen, University of Sydney Clinical School, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail: thanhn@chw.edu.au

Summary

The objective of this systematic review is to provide a qualitative comparison of interactive electronic media interventions for the prevention or treatment of obesity and/or obesity-related behaviours in children and adolescents. Literature searches of 12 databases from the earliest publication date until March 2010 were conducted. Twenty-four studies in which children and/or adolescents interacted with electronic interventions delivered as adjunct or sole interventions for the prevention or treatment of obesity and/or obesity-related behaviours met the inclusion criteria. Fifteen focussed on obesity prevention and nine on treatment interventions. The average study quality design score was 45%. Most studies demonstrated some form of significant outcome (e.g. reported changes in dietary and/or physical activity behaviours) in participants receiving interactive electronic interventions, with 11 out of 15 studies leading to positive changes in measured or reported adiposity outcomes. In 87% of studies, the effects of interactive electronic interventions were not separately evaluated from other intervention components. These results should be viewed with caution because of the overall poor quality of the studies. Studies were mostly conducted in the USA, largely in minority populations, and the direct transferability of interventions to other populations is unclear. Further high quality research is needed in this area to accurately inform the evidence base.

Introduction

The global prevalence of child and adolescent obesity is increasing (1), with obesity now one of the most common chronic disorders in this age group (2). There is no universally effective approach to the prevention and treatment of obesity in young people (3,4). Comprehensive programmes, involving dietary and physical activity change along with environmental modification may assist in the prevention of obesity in children and adolescents (3), while lifestyle treatment programmes, including family-targeted interventions involving parents, have been effective in reducing the level of child and adolescent obesity at 6 and 12 months (4).

Recent advances in technology provide the opportunity to use youth-friendly and interactive modes of communication such as electronic media in both obesity management and prevention interventions. Benefits of interactive electronic interventions include availability of electronic technology to youth in both school and non-school settings, popular use among youth, incorporation of rich media, immediate and often tailored feedback, flexible programme access, cost effectiveness, the potential for wide programme reach and the ability to serve as an adjunct or stand alone programme (5). Interventions featuring interactive electronic media are increasingly being developed and evaluated. Therefore, the potential application of interactive electronic interventions in the prevention or treatment of obesity in young people warrants further investigation.

Two reviews have previously examined the use of innovative technologies on weight management outcomes in children and adolescents, both indicating that while electronic interventions show potential there is a need for further research in this area (5,6). These reviews were limited to randomized control trials (RCTs) (5,6) and quasi-experimental studies (5) and examined Internet (6) and compact disc read-only memory (CD-ROM) (5) interventions only. The present systematic review differs from these two previous reviews in that it extends to studies conducted outside of the USA, other study designs, all types of interactive electronic interventions addressing obesity and/or obesity-related behaviours, a variety of study settings and clearly delineates interventions focussed on obesity prevention or treatment, children and/or adolescents. The effectiveness of Web-based interventions in achieving weight loss and maintenance in overweight adults has also been reviewed. However, determination of intervention effectiveness was not possible because of the small number of comparable studies (7).

The objective of this systematic review is to provide a comparative evaluation of interactive electronic media interventions for the prevention or treatment of obesity and/or obesity-related behaviours in children and adolescents. Electronic interventions included in this review required participant interaction with the electronic technology as an adjunct or stand alone programme and were delivered via computer-based programmes, Internet sites, electronic messaging systems, emails, social networking media, e-whiteboards or related media.

Methods

Search strategy

Systematic literature searches were performed using 12 electronic databases: Medline, Embase, PsycINFO, Web of Science, Scopus, ERIC, All EBM Reviews (Cochrane DSR, ACP Journal Club, DARE, CCTR, CLEED, CLCMR and CLHTA), A+ Education, Australian Public Affairs Full Text, Linguistics and Language Behavior Abstracts, ProQuest Education journals and CBCA Education, Sport Discus.

As interventions involving interactive electronic media were expected to be recent, databases were searched for literature from the earliest publication date until March 2010. Numerous search terms were employed to denote interactive electronic media (e.g. communications media, Internet, electronic mail, multimedia, electronic media, web, online, email, social networking, social networking media, computer-mediated communications), prevention (e.g. prevention, prevention study, intervention, intervention studies, primary prevention, health promotion), treatment (e.g. treatment, intervention, management, weight management, therapy, therapeutics), overweight and obesity (e.g. obesity, overweight, body weight, weight), and children and adolescents (e.g. adolescent, child, children, pediatric, paediatric, teen, youth).

In addition, reference lists from obtained articles were scanned for potentially relevant articles, websites cited in relevant articles were viewed and relevant national health websites searched for ‘grey literature’.

Selection criteria

English language research publications were identified from peer-reviewed literature, ‘grey literature’, book chapters and dissertations. Studies with interactive electronic interventions delivered as either adjunct or sole interventions for the prevention or treatment of obesity and/or obesity-related behaviours in children and/or adolescents (up to 18 years of age) were included. Interactive electronic interventions were defined as those requiring participant interaction (e.g. following prompts, entering information, completing online tasks, receiving automated feedback) with the electronic technology and which were delivered via computer-based programmes, interactive Internet sites, electronic messaging systems, emails, social networking media (e.g. Facebook), e-whiteboards or related media.

Interventions targeting nutrition, physical activity and/or behavioural therapy without any restriction on the type of study design (RCTs, non-RCTs, longitudinal studies, quasi-experimental studies, pre–post studies), setting (school-, community- and/or clinic-based) or provider of the intervention, and which assessed change in either knowledge, mediators, behaviours and/or in physical status as outcomes were included.

Citation titles and abstracts were screened by two researchers for relevance to the review using the abovementioned selection criteria. Full text articles of potentially eligible citations were obtained and assessed using the selection criteria. Both researchers agreed on retrieved studies that were included for review.

Critical appraisal and data synthesis

In order to evaluate the quality and strength of evidence, the same two researchers appraised selected studies according to specific criteria. A quality assessment checklist was developed based on critical appraisal guides available from the Cochrane Collaboration website (8,9) and addressed questions relating to nine domains: true randomization (for RCTs only), allocation concealment, blinding, baseline comparability, follow-up, accurate reporting of outcomes, intention-to-treat analysis, validation of tools and separation of the e-intervention effects from other intervention components. RCTs and non-RCTs were rated on each of these nine domains and allocated a study quality score equal to the percentage of the maximum obtainable score. Non-RCTs differed from RCTs in that participants were not randomly allocated to groups. Other intervention studies, such as longitudinal studies and pre–post studies, were assessed using questions adapted from the CASP Appraisal Checklist tool (10). Study quality coding criteria and tabulated scores are provided in Tables 1 and 2.

Table 1.  Study quality coding criteria and appraisal (RCTs and non-RCTs)
StudyTrue randomizationAllocation concealmentBlindingBaseline comparabilityFollow-upAccurate outcome reportingITT analysisTool validationSeparation of e-intervention effectsScore (% of maximum)
  1. ITT, intention-to-treat analysis; N/A, not applicable; RCTs, randomized controlled trials.

Child overweight and obesity prevention interventions
 Goran et al. (13)NoUnknownUnknownYesYesYesYesUnknownNo44%
 Baranowski et al. (11)YesUnknownUnknownNoUnknownYesYesUnknownNo33%
Adolescent overweight and obesity prevention interventions
 Jones et al. (20)YesUnknownYesYesYesYesYesYesN/A88%
 Casazza et al. (15)N/AUnknownUnknownNoYesYesUnknownYesYes50%
 Haerens et al. (17,18)UnknownUnknownUnknownUnknownYesYesNoYesNo33%
 Jago et al. (19)UnknownUnknownNoNoUnknownYesYesYesNo33%
 Marks et al. (23)YesUnknownNoUnknownYesYesUnknownYesN/A50%
 Frenn et al. (16)N/AUnknownUnknownYesNoYesNoYesNo38%
 Luce et al. (22)N/AUnknownUnknownUnknownUnknownYesNoYesNo25%
 Long et al. (21)N/AUnknownNoUnknownUnknownYesUnknownYesNo25%
 Frenn et al. (14)N/AUnknownUnknownUnknownNoYesNoYesNo25%
 Winett et al. (25)N/ANoNoUnknownUnknownYesUnknownNoYes25%
 Russ et al. (24)N/ANoNoNoUnknownYesUnknownNoNo13%
Child overweight and obesity treatment interventions
 Moore (26)UnknownUnknownUnknownUnknownUnknownYesUnknownUnknownN/A13%
Adolescent overweight and obesity treatment interventions
 Doyle et al. (29)YesUnknownYesNoUnknownYesYesYesN/A63%
 Williamson et al. (27,34)YesUnknownNoUnknownYesYesYesYesNo56%
 Celio (28)YesUnknownYesYesYesYesYesYesN/A88%
 White et al. (32,33)YesUnknownUnknownYesUnknownYesYesYesNo56%
Table 2.  Study quality coding criteria and appraisal (other intervention studies)
StudyClear aimsSelection criteria providedAdequate control groupAppropriate tables and graphsAppropriate statistical methodsAdequate support of conclusionsResult applicability to local populationConsideration of all outcomesSeparation of e-intervention effectsScore (% of maximum)
  1. N/A, not applicable.

Child overweight and obesity prevention interventions
 Thompson et al. (12)YesYesN/AYesYesYesNoNoN/A71%
Adolescent overweight and obesity treatment interventions
 Hung et al. (30)YesYesN/AYesYesYesUnknownYesNo75%
 Schiel et al. (31)YesNoN/AYesUnknownYesUnknownUnknownNo38%

Only a qualitative analysis of included studies was undertaken because of the heterogeneity of studies relating to methodology, intervention and outcomes. Data were extracted using a standard form developed by the researchers (see Tables 3 and 4). Studies were described in terms of their design, sample characteristics, inclusion of a comparison group, parental involvement, outcomes, interactive electronic intervention (type, content, duration, stand alone or adjunct programme), incentives and programme use. Based on extracted data and critical appraisal assessments, a comparative narrative summary of included studies is provided. Any differences between researchers were resolved by discussion.

Table 3.  Summary of child and adolescent obesity prevention interactive electronic interventions
StudyDesignParticipantsControl conditionParental involvementMeasuresIntervention descriptionKey findings
  1. Attrition includes postenrolment or postrandomization dropouts and participants with missing data at postassessment.

  2. BMI, body mass index; CD-ROM, compact disc read-only memory; N/A, not applicable; RCT, randomized controlled trial.

Child overweight and obesity prevention interventions
Thompson et al. (12)Pre–post pilot study
Home-based
Houston, Texas, USA
n = 80; ages 8–10; 100% females; 100% African–American; BMI ≥ 50th percentile for age and sex
Final analysis: n = 73
Attrition: 9%
NoneNoneBaseline and 8 weeks: self-reported fruit, 100% fruit juice and vegetable consumption, self-reported physical activity, self-efficacy (for diet and physical activity) and programme usage (weekly log-on rate)
Adiposity measures: none
Technology: Internet (stand alone)
Duration: 8 weeks
Weekly modules (∼20 min per week) featuring role modelling comics, problem solving, goal setting and review
Incentive: weekly incentive worth $US5 for completion of activities
Significant improvements in self-reported fruit, fruit juice, and vegetable consumption, dietary self-efficacy, and physical activity
No significant difference in physical activity self-efficacy
Programme use: 74.5% average weekly participant log-on rate
Goran et al. (13)RCT
Schools randomized to treatment (two schools) or control (two schools)
School-based
West Covina, Los Angeles, USA
n = 209; 4th graders; ages 8.8–11.1; mean age = 9.5; 51% females; 58% Hispanic
Final analysis: n = 122
Attrition: 42%
Two schools received educational CD-ROMs not related to health topicsFamily homework assignments (not detailed)Baseline and 8 weeks: height, weight, body fat (bioimpedance analysis), BMI, physical activity (accelerometer) and self-reported psychosocial measures related to physical activity (self-efficacy, social norms and outcome expectancies)
Adiposity measures: weight, BMI, BMI z-score
Technology: Interactive CD-ROM game (not stand alone)
Duration: 8 weeks
Two schools received 12 h of intervention: 8 CD-ROM interactive lessons (45 min per lesson) based on social cognitive theory, supplemented by four classroom and four homework assignments (45 min per assignment)
Incentive: N/A
Significant obesity reduction (adjusted mean reductions of 0.07 for BMI z-score and 1.4% for percentage of body fat) in treatment girls only
Significant increase in light intensity physical activity in treatment girls only (reduction in boys); decrease in moderate intensity physical activity for both genders; but no significant difference in total physical activity
Marginal significant treatment effects on behavioural outcomes related to physical activity
Programme use: N/A
Baranowski et al. (11)Pilot RCT
Girls randomized to treatment (n = 19) or control (n = 16)
Summer day camp-based and home-based
Houston, Texas, USA
n = 35; age 8; 100% females; 100% African–American; BMI ≥ 50th percentile for age and sex; parents/carers involved
Final analysis: n = 35 (intention-to-treat approach)
Attrition: not mentioned
4-week summer day camp (usual camp activities) for girls followed by separate monthly home Internet programmes for girls and their parents/carers featuring links to general health and homework websitesSeparate home Internet programmes for parents/carers within each group
Parents in the treatment group exposed to educational lunch campaign during camp period and encouraged by their daughters to participate in physical activity and increase availability of fruit, fruit juice and vegetables at home
Baseline and 12 weeks: BMI, self-reported consumption of fruit, 100% fruit juice and vegetables, physical activity (accelerometer and questionnaire) and programme usage (weekly/ monthly participant log-on rate)
Adiposity measures: BMI
Technology: Internet (not stand alone)
Duration: 12 weeks
4-week summer day camp (usual camp activities and programme specific activities) followed by separate 8-week home Internet programmes for girls and their parents/carers
Girls: weekly Internet programme including role modelling comics, problem-solving, goal setting and review; weekly email and telephone reminders to log on to their website
Parents: weekly Internet programme included a role model parent character who commented on the girls' comic strips, a parent poll on best ways to encourage lifestyle changes, parent goal setting to support their daughters with their goals and review of their daughters' goal attainment
Incentives: $US10 (girls) and $US25 (adults) for completion of all assessments; regular $US100 lottery in each group
No significant changes in BMI, physical activity or fruit, vegetable and water consumption in the treatment group compared to the control group
The pilot study was underpowered but favourable trends were observed in dietary measures
Programme use: 48% of girls and 47% of parents overall weekly log-on rates
Adolescent overweight and obesity prevention interventions
Jones et al. (20)RCT
Stratified by school; students from two schools randomized to treatment (n = 52) or wait list control (n = 53)
Home-based
Idaho & California, USA
n = 105; 9th–12th graders; mean age = 15.1; 65% males; 64% Caucasian; ≥85% percentile for age-adjusted BMI
Final analysis: n = 87
Attrition: 17%
Wait list control offered an online or printed version of the programme at 9 monthsNoneBaseline, 16 weeks and 9 months: height, weight (self-reported at 16 weeks), BMI, BMI z-score, self-reported dietary fat and sugar intake, depressed mood, binge eating behaviour, and programme usage (average number of content screens accessed per week)
Adiposity measures: weight, BMI, BMI z-score
Technology: Internet (stand alone)
Duration:16 weeks
Weekly psycho-educational and behavioural interactive Internet intervention and asynchronous discussion group facilitated by a research assistant; weekly reminder letters and occasional motivational letters
Incentive: N/A
Significant reductions in BMI (mean change: 0.7 kg m−2) and BMI z-score (mean change: 0.18) in intervention group at 9 months
Significant reductions in objective and subjective binge episodes and weight and shape concerns in the intervention group post-treatment and at 9 months
No significant changes in dietary fat and sugar intake or depression
Programme use: 27% of treatment participants accessed the programme for ≥8 weeks
Casazza et al. (15)Non-RCT
Three selected schools (control, traditional education, computer education)
School-based
Florida, USA
n = 311; 9th–12th graders; ages 13–18; mean age = 15.8; 66% females; 52% non-Hispanic African–Americans
Final analysis: n = 275
Attrition: 12%
One control school receiving traditional education: lectures and pamphlets; five 45-min sessionsNoneBaseline and 16 weeks: BMI, self-reported nutrition knowledge, dietary habits, physical activity, knowledge, self-efficacy for diet and physical activity and social support
Adiposity measures: BMI
Technology: CD-ROM (stand alone)
Duration: 16 weeks
Computer intervention: educational CD-ROM; five 45-min sessions
Incentive: N/A
The computer intervention group reduced their BMI by 0.2 kg m−2 and improved their nutrition knowledge, physical activity, self-efficacy, social support, and decreased dietary fat and meals skipped
The traditional education group improved their nutrition knowledge, social support and self-efficacy only
Programme use: N/A
Haerens et al. (17,18)Cluster RCT
Random sample of schools randomized to intervention alone (five schools; n = 1006), with parental support (five schools; n = 1226) or control (five schools; n = 759)
School-based
West Flanders, Belgium
15 schools; n = 2840; 7th–8th graders; ages 11–15; mean age = 13.1; 63% males; ethnicity not detailed
Final analysis: n = 2287
Attrition: 25%
Five control schoolsIntervention group with parental involvement: healthy eating and physical activity education via an interactive school meeting (five schools only), school newsletters (three times per year) and a free CD-ROM with the adult computer-tailored intervention (first year only)Baseline, 1 year and 2 years: Weight, height, BMI, BMI z-score, self-reported physical activity (and assessed by accelerometers in a sub-sample) and dietary intake (fat, fruit, water and soft drinks)
Adiposity measures: weight, BMI, BMI z-score
Technology: CD-ROM (not stand alone)
Duration: 2 years
Intervention alone: healthy eating and physical activity promotion in school, individual physical fitness test during the second year and a CD-ROM class intervention providing tailored feedback for physical activity and fat and fruit intake (once per year)
Intervention with parents: healthy eating and physical activity information via school newsletters and a CD-ROM with the adult computer-tailored intervention
Incentive: N/A
In girls, BMI and BMI z-score increased significantly less in the intervention group with parental support (BMI increase: 0.22 and 0.55 kg m−2; BMI z-score increase: 0.07 and 0.17 after 1 and 2 years) compared with the control or intervention alone groups
No significant positive intervention effects on body mass were found in boys
At 1 and 2 years, significant positive effects on physical activity (including from accelerometer data) in both genders and on fat intake in girls were observed
Parental involvement helped decrease fat intake in girls at 1 year only
No significant positive intervention effects were found on fruit, soft drink and water consumption
Programme use: N/A
Jago et al. (19)Cluster RCT
Spring (16 troops) and fall (26 troops) cohorts randomized to treatment (21 troops; n = 240) or control (21 troops; n = 233)
Community- (troop meetings) based and home-based
Texas, USA
42 troops; n = 473; boy scouts; ages: 10–14; mean age = 13; 100% males; 74% Caucasian
Final analysis: n = 473
Attrition: 0%
Control group received a 9-week ‘mirror image’ fruit and vegetable interventionNoneBaseline, 9 weeks and 6 months: weight, BMI, BMI percentile, triceps skin-fold, physical activity (accelerometer) and programme use (weekly log-on rate)
Adiposity measures: weight, BMI, BMI percentiles, triceps skin-fold
Technology: Internet (not stand alone)
Duration: 9 weeks
20-min weekly skill building activities at troop meetings, drills booklet and Internet-based role modelling, goal setting, review and problem-solving promoting physical activity twice a week
Incentive: badge awarded to participants earning 70% of available points based on attendance, goal setting and achievements
Overall increase in BMI (0.4 kg m−2 increase after 9 months) and BMI percentile levels
12 min increase in light intensity physical activity and a trend towards a 12 min decrease in sedentary behaviour in spring participants only
No significant change among fall intervention participants or on moderate to vigorous physical activity
Programme use: at least 1 log-on per week for 75% and 78% of treatment and control participants respectively
Marks et al. (23)RCT
Students randomized to web (n = 181) or print (n = 178) group
Home-based
North Carolina, USA
n = 359; 6th–8th graders from four schools; mean age = 12.2; 100% females; 51% African–American
Final analysis: n = 319
Attrition: 11%
Print intervention: print workbook containing identical content and graphics to the websiteMinimal (information letter received)Baseline and 2 weeks: physical activity self-efficacy, physical activity intentions and self-reported physical activity
Adiposity measures (at baseline only): self-reported weight, BMI, BMI-for-age percentiles
Technology: Internet (stand alone)
Duration: 2 weeks
Participants encouraged to consult materials at least four times in 2 weeks
Web intervention: password protected access to an adapted, interactive LifeBytes website
Incentive: $US10 gift certificate
Both intervention groups significantly increased physical activity self-efficacy and intentions
The print group demonstrated significantly greater increases in physical activity intentions compared with the web group
Self-reported physical activity increased significantly in the print group only
Programme use: N/A
Frenn et al. (16)Quasi-experimental non-RCT
Students assigned to treatment or control based on classroom assignment
School-based
Wisconsin, USA
n = 132; 7th graders from six classes; ages 12–14; 64% females; ethnically diverse population; predominantly Hispanic
Final analysis: n = 103
Attrition: 12%
Three classes completing usual assignmentsNoneBaseline and 1 month: self-reported physical activity, percentage dietary fat and programme participation level (completion of programme modules)
Adiposity measures: none
Technology: Internet (not stand alone)
Duration: 1 month
Eight Internet sessions (40 min per session) with four 2- to 3-min videos along with computer-generated feedback and tailored individual feedback via emails
Incentive: $US1 school bookstore coupon for returned consent form and $US2 for completion of assessments
Intervention participants who completed more than half the sessions increased moderate/vigorous physical activity by 22 min (compared with a 46 min decrease in the control group) and decreased dietary fat by 0.8%
Programme use: not detailed
Luce et al. (22)Feasibility study
Students assigned to one of four groups based on an online algorithm: no risk (n = 111), eating disorder risk (n = 36), overweight risk (n = 16) and both risks (n = 5)
School- and home-based
California, USA
n = 176; 10th graders from a private school; 100% females; 57% Caucasian; mean BMI = 22.6 kg m−2
Final analysis: n = 174
Attrition: 1%
Participants not at risk of an eating disorder or being overweight completed the core health curriculum onlyNonePre–post outcomes: weight and shape concerns
Adiposity measures (at baseline only): self-reported weight, BMI
Technology: Internet (not stand alone)
Duration: not detailed
Students' level of risk for developing an eating disorder or becoming obese was assessed online and students were invited to participate in one of four interventions appropriate to their risk: universal core health curriculum, targeted body image (BI) enhancement curriculum, targeted weight management (WM) curriculum or combined BI and WM curriculum. All interventions incorporated online components. Only the core and BI interventions were delivered
Incentive: N/A
Over half of participants identified as being at risk of overweight or developing an eating disorder chose to receive the recommended targeted curricula
All groups showed significant improvements in weight and shape concerns
Programme use: N/A
Long et al. (21)Quasi-experimental, pre–post study
Students assigned to intervention (n = 63) or comparison (n = 58) group based on feasibility study
School-based
Texas, USA
n = 121; 7th–9th graders from two schools; ages 12–16; median age = 13; 52% females; 47% Caucasian
Final analysis: n = 121
Attrition: not mentioned
Control group received nutrition education from the standard school curriculumNoneBaseline and 1 month: self-efficacy for healthy eating, dietary knowledge, food choices, self-reported food intake (fruit, vegetable, fat)
Adiposity measures: none
Technology: Internet (not stand alone)
Duration: 1 month
Five hours of Web-based interactive nutrition education with a gaming approach and 10 h of behaviourally-based, activity oriented classroom curriculum
Incentive: N/A
Higher self-efficacy for healthy eating, greater dietary knowledge, and healthier usual food choices in the intervention group
No difference between groups in food consumption
Programme use: N/A
Frenn et al. (14)Quasi-experimental non-RCT
Students assigned to treatment (n = 67) or control (n = 63) based on classroom assignment
School-based
Wisconsin, USA
n = 341; 7th–8th graders from two low-middle income schools; ages 12–15; 55% females; ethnically diverse population; predominantly African–American
Final analysis: n = 130
Attrition: 62%
Students received the usual curriculumNonePre–post outcomes: self-reported moderate and vigorous physical activity and dietary fat intake, and programme participation level (completion of intervention modules)
Adiposity measures: none
Technology: Internet (not stand alone)
Duration: 1 academic year
Six sessions (50 min per session): four Internet/video sessions with online feedback, one healthy snack session and one gym class (one school only)
Incentive: N/A
No significant differences between treatment and control groups in dietary fat intake
Compared to girls in the control group, dietary fat intake was significantly reduced among African–American, Caucasian and African–American/native girls in the intervention group
Dietary fat decreased with each Internet session in which students participated
Moderate to vigorous physical activity duration decreased in both control and treatment groups but less in the treatment group; participants receiving the gym lab increased their moderate and vigorous physical activity
Programme use: not detailed
Winett et al. (25)Non-RCT
Health education classes assigned to the treatment (four classes; n = 103) or comparison (four classes; n = 77) condition based on computer lab availability
School-based (rural)
Virginia, USA
n = 180; 9th–10th graders; mean age = 15.4; 100% females; ethnicity not detailed
Final analysis: n = 180
Attrition: not mentioned
Comparison group received the basic health curriculumNonePre–post outcomes: self-reported intake of regular meals, fruit and vegetables, breads and cereals, high fat snacks, high fat dairy, soda drinks, fast food (for a sub-sample of 39 students) and aerobic activity
Adiposity measures: none
Technology: Internet (not stand alone)
Duration: programme run each semester during one academic year
Once a week for 5 weeks: 15–20 min interactive modules targeting healthy eating; Eat4Life programme used as an adjunct to a health education class and designed as a teen online magazine; both graphic and personalized online feedback provided
Incentive: N/A
Significant positive changes in several target nutrition areas (regular meals, fruit and vegetables, breads and cereals, fibre, soda drinks, fast food) and self-reported aerobic activity in the treatment group
Programme use: N/A
Russ et al. (24)Non-RCT, preliminary study
Two classes assigned to the treatment (n = 18) or comparison (n = 23) condition based on computer lab availability
School-based (rural)
Virginia, USA
n = 41; 10th graders from two classes; 100% females; ethnicity not detailed
Final analysis: n = 41
Attrition: not mentioned
Comparison class received the basic health curriculumNonePre–post outcomes: self-reported intake of regular meals, fruit and vegetables, breads and cereals, high fat snacks, high fat dairy, and soda drinks
Adiposity measures: none
Intervention: Internet (not stand alone)
Duration: not detailed, assuming 6 weeks
Once a week for 6 weeks: 15–20 min interactive modules targeting healthy eating and physical activity; Eat4Life programme used as an adjunct to a health education class and designed as a teen online magazine; both graphic and personalized online feedback provided
Incentive: N/A
Significant positive changes in target foods except for intake of soda drinks in the treatment group
Programme use: N/A
Table 4.  Summary of child and adolescent obesity treatment interactive electronic interventions
StudyDesignParticipantsControl conditionParental involvementMeasuresIntervention descriptionKey findings
  1. Attrition includes postenrolment or postrandomization dropouts and participants with missing data at postassessment.

  2. BMI, body mass index; DEXA, dual energy X-ray absorptiometry; RCT, randomized controlled trial.

Child overweight and obesity treatment interventions
Moore (26)Feasibility RCT
Eligible families randomly assigned to treatment or control
Home-based
Northern Nevada and Northern California, USA
n = 65; children and their primary care givers; ages 6–12; 70% females; 43% Caucasian; BMI ≥ 75th percentile for age and sex; mean BMI = 28.1 kg m−2
Final analysis: n = 30
Attrition: 58%
Control group received education from the American Academy of Pediatrics websiteFamily-based intervention involving primary care giversBaseline and 6 weeks (based on parental reports): BMI (based on parent-reported child weight), BMI z-score, child health status, health promotion behaviour (diet and physical activity), and weight control skills inventory
Adiposity measures: BMI (based on parent-reported child weight), BMI z-score
Technology: Internet (stand alone)
Duration: 6 weeks
Families in both groups instructed to review programme materials both independently and with their children for 1.5 h per week
Families received four individually-tailored, family-based, behavioural weight control skills modules
Incentives: N/A
Child health status maintenance and modest improvements in child health promotion behaviour and parental weight management knowledge in the intervention group
Stability of BMI and BMI z-scores from baseline to post-intervention for children in both groups, with no clear treatment effects
Programme use: N/A
Adolescent overweight and obesity treatment interventions
Doyle et al. (29)RCT
Participants randomly assigned to treatment or control
Community-based
California and Missouri, USA
n = 83; ages 12–18; mean age = 14.5; 62.5% females; 50% Caucasian; BMI ≥ 85th percentile
Final analysis: n = 80 (intention-to-treat approach)
Attrition: 4%
Control group received educational handouts on nutrition and physical activityMonthly newsletters mailed to parents and telephone support available to parentsBaseline, post-intervention and 4 months: weight, BMI, BMI z-score, self-reported eating attitudes and behaviours (weight, shape, eating concerns and dietary restraint) and programme use (percentage of screens accessed online and use of journals)
Adiposity measures: weight, BMI, BMI z-score
Technology: Internet (stand alone)
Duration: 16 weeks
Cognitive-behavioural weekly programme (Student Bodies 2) targeting behavioural weight loss and body image improvement, weekly newsletter with personalized feedback and asynchronous discussion group
Incentive: $US20 gift card lottery based on task completion
Significant reduction in BMI z-score (0.08 kg m−2) at 16 weeks in the intervention group
Although the intervention group maintained this BMI reduction at 4 months, it was not significantly different from the control group who also improved their BMI
No significant effects on eating disorder risk factors
Programme use: 30% of treatment participants accessing <10% of programme
Hung et al. (30)Quasi-experimental, pre-post study
School-based
Taipei, Taiwan
n = 38; adolescents from two schools; ages 12–14; Mean age = 12.62; 68% males; 100% Asian; BMI > 25 kg m−2
Final analysis: n = 37
Attrition: 3%
NoneNoneBaseline and 14 weeks: obesity indices (BMI, waist circumference, hip circumference, waist to hip ratio, mid-arm circumference, triceps), blood pressure, physical fitness and psychosocial variables (weight loss knowledge, body image, self esteem and weight loss self-efficacy)
Adiposity measures: BMI, waist circumference, hip circumference, waist to hip ratio, mid-arm circumference, triceps
Technology: Internet (not stand alone)
Duration: 14 weeks
Weight loss e-learning programme providing weight control information and motivation through games integrated with a student weight loss group consisting of weekly regular classes (45 min each), an exercise and activity course (40 min per session) twice a week, and individual counselling sessions 2–3 times per semester with the author or one of two school teachers (20–30 min per session)
Incentive: rewards for biggest BMI reduction, fitness improvement, knowledge increase and best attendance
Significant decreases in BMI (0.43 kg m−2), waist circumference and triceps skin-fold
Improvements in physical fitness and all psychosocial variables
Programme use: N/A
Schiel et al. (31)Longitudinal study
Hospital- and home-based
Germany
n = 140; obese children and adolescents hospitalized for weight reduction; 78% females; mean age = 13.7; ethnicity not detailed; mean BMI = 30.5 kg m−2
Final analysis: n = 140
Attrition: unclear
NoneNoneBaseline, 3 months, 6 months, 9 months and 12 months after hospital discharge: weight, BMI, BMI z-score and psychological assessment (wellbeing, treatment satisfaction, depression and motivation)
Adiposity measures: weight, BMI, BMI z-score
Intervention: telemedicine (not stand alone)
Duration: variable hospital admission lengths (mean length = 35 days); 12 month telemedicine support programme
Two study phases: Phase 1: structured treatment and teaching programme in hospital with the aim of weight reduction; Phase 2: follow-up with the TeleObe telemedicine support programme using Internet and/or a mobile phone; email and/or mobile phone reminders
TeleObe integrated data assessment, data collection, visualization and recommendations for further treatment by using Internet services and/or a mobile phone. If required, further treatment involved Internet and/or telephone counselling by a physician, psychologist or a nutrition or exercise educator
Incentives: N/A
In patients participating in the telemedicine support programme, there was a stabilization of both BMI and BMI z-score from hospital discharge to 12 months
Wellbeing and treatment satisfaction increased between onset of the telemedicine support programme and 6 months follow-up
Depression scores decreased significantly and remained stable up to 9 months follow-up
Motivation decreased despite a positive increase in eating and exercise behaviour scores
Further treatment was needed in 64% of patients during the follow-up period
Programme use: N/A
Williamson et al. (27,34)RCT
Stratified by BMI percentile and age; family pairs randomly assigned to treatment (n = 28) or control (n = 29)
Home-based
Louisiana, USA
n = 57; overweight girls and their overweight parents; ages 11–15; mean age = 13.2; 100% females; 100% African–Americans; BMI > 85th percentile for sex and age range; mean BMI percentile = 98.3
Final analysis: n = 57 (intention-to-treat approach)
Attrition: 30%
Parents and adolescents in the control group received a non-interactive Internet health education programme without any prescribed behavioural changes or Internet counselling, and four face-to-face nutrition education sessions with a dietitianParents in the treatment group received the Internet lifestyle behaviour modification programmeBaseline, 6 months, 12 months, 18 months and 24 months: weight, BMI, BMI percentiles (for girls only), percentage of body fat (DEXA), weight loss behaviours and programme use (number of website hits)
Adiposity measures: weight, BMI, BMI percentiles (for girls only), percentage of body fat (DEXA)
Intervention: Internet (not stand alone)
Duration: 2 years
Over 6 months: weekly nutrition education, interactive activities and Internet counselling behaviour modification using a family-orientated approach targeting lifestyle, eating and physical activity habits; four face-to-face counselling sessions during the first 12 weeks of the programme and asynchronous email communications with a counsellor
Access to the programme was available for 2 years
Incentives: $US700 voucher to purchase a computer worth ∼$US1000; small gifts for attending face-to-face sessions; $US30 and $US10 gift given respectively to parents and girls for completing each assessment; free Internet access
Compared with control participants, adolescents lost more mean body fat (group difference: 1.6%) and parents lost significantly more mean body weight (group difference: 2.1 kg) after 6 months of treatment
This weight loss was regained over the next 18 months and after 2 years differences in fat for adolescents and weight for parents did not differ between the intervention and control groups
Adolescents and parents in both groups improved weight loss behaviours
Programme use: more website hits over 6 months in treatment girls (625) and parents (557) compared to control girls (187) and parents (227)
Celio (28)RCT
Students randomly assigned to treatment (n = 32) or control (n = 29)
Community-based
California and Missouri, USA
n = 63; ages 12–18; mean age = 14; 62% females; 47.5% Caucasian; BMI > 85th percentile; mean BMI percentile = 97.7
Final analysis: n = 61(intention-to-treat approach)
Attrition: 8%
Control group received educational handouts on nutrition and physical activityMonthly newsletters mailed to parents and telephone support available to parentsBaseline and 16 weeks: weight, BMI, BMI z-score, eating disorder attitudes and behaviours, body satisfaction, self-reported physical and sedentary activity, intake of fruit, vegetables, high fat foods and programme use (percentage of screens accessed online and use of journals)
Adiposity measures: weight, BMI, BMI z-score
Technology: Internet (stand alone)
Duration: 16 weeks
Cognitive-behavioural weekly programme (Student Bodies 2) targeting behavioural weight loss and body image improvement, weekly newsletter with personalized feedback and asynchronous discussion group
Incentive: pedometer; lottery system based on task completion; control group offered the Internet programme at the end of the study
Significant reduction in BMI z-score (0.09 kg m−2), dietary restraint (however, this was not clinically significant) and high fat food consumption in the intervention group compared with the control group
No significant differences in physical or sedentary activity between groups
Programme use: 33% of the 353 screens were accessed over 16 weeks; completion of 26%–34% of journals
White et al. (32,33)RCT
Family pairs randomly assigned to treatment (n = 28) or control (n = 29)
Home-based
Louisiana, USA
n = 57; overweight girls and their obese parents; age: 11–15 years; mean age = 13.2; 100% females; 100% African–Americans; BMI > 85th percentile for sex and age range
Final sample: n = 57 (intention-to-treat approach)
Attrition: 12%
The control Internet programme provided basic nutrition and physical activity educationParents in the treatment group received the Internet lifestyle behaviour modification programmeBaseline and 6 months: weight, BMI percentage of body fat (DEXA), dietary self-efficacy, weight loss behaviours, usual eating patterns, psychological measures and programme use (number of website hits)
Adiposity measures: weight, BMI percentage body fat (DEXA)
Technology: Internet (not stand alone)
Duration: 6 months
Health Improvement Program for Teens (HIP-Teens): weekly nutrition education and Internet behaviour modification counselling (via emails with a case manager and automated feedback) using a family-orientated approach targeting healthy eating and physical activity habits
Incentives: free computer and Internet access
Compared with control participants, adolescents receiving the intervention lost more mean body fat (group difference: 1.4%) while parents receiving the intervention had a lower BMI (group difference: 0.8 kg m−2) at 6 months
Parent variables relating to family and life satisfaction were the strongest mediators of adolescent weight loss while changes in dietary practices were the strongest mediators for parental weight loss
Programme use: more website hits over 6 months in treatment girls (625) and parents (557) compared to control girls (187) and parents (227)

Results

Description of included studies

The literature search recovered 1856 citations of which 1832 were not considered to be relevant to the review (Fig. 1). Twenty-four articles relating to 21 separate interventions met the inclusion criteria. All included studies were published between 1998 and 2008. Out of the 24 articles, fifteen focussed on obesity prevention (three in children (11–13) and twelve in adolescents (14–25)), and nine focussed on treatment interventions (one in children (26) and eight in adolescents (27–34)). Fifteen studies reported adiposity outcomes at both baseline and follow-up (11,13,15,17–20,26,27,29–34) with body mass index (BMI) z-scores assessed in eight studies (13,17,18,20,26,28,29,31). Nineteen studies examined dietary intake and/or amount of physical activity (11–15,17–21,23–28,32–34), six investigated weight-related concerns or behaviours (20,22,28–30,34) and seven assessed psychosocial measures (12,13,15,21,23,30,34). Interactive electronic interventions delivered as stand alone (12,20,23,26,28,29) or adjunct (11,14,16–18,21,22,24,25,27,30–34) programmes included: CD-ROM (13,15,17,18), Internet and emails (27–29,32–34), Internet only (11,12,14,16,19–26,30) and telemedicine (31) technologies. Seven interventions included some form of parental involvement (11,13,17,18,26,27,29,32–34) with five interventions featuring an interactive Internet- or CD-ROM-based component for parents (11,17,18,26,27,32–34). The theoretical basis underlying most interventions related to social cognitive theory (35) or the transtheoretical model (36).

Figure 1.

Identifying studies for inclusion in systematic review.

Overall, the interventions involved 5812 young participants with an equal distribution of males and females. Out of the 21 interventions, 11 were described as RCTs (11,13,17–20,23,26–29,32–34), five as non-RCTs (14–16,24,25) and five involved other study designs (12,21,22,30,31). Eight out of the 21 interventions were based on ethnically diverse samples (13–16,21,23,26,28), four comprised African–Americans only (11,12,27,32–34), four included a majority of Caucasian participants (19,20,22,29), one involved Taiwanese participants only (30), and four did not describe participants' ethnicity (17,18,24,25,31). The majority (86%) of interventions were conducted in the USA (11–16,19–21,23,24,26–29,32–34), one was conducted in Germany (31), one in Belgium (17,18) and one in Taiwan (30). The duration of the interventions varied from 2 weeks to 2 years with 14 interventions lasting 16 weeks or less (11–13,15,16,19–21,23,24,26,28–30), two delivered over 6 months (27,32–34), two over 1 year (14,31), one lasting 2 years (17,18) and two being of unknown duration (22,25). One-third of all studies provided monetary (11,12,16,23,27–29,34) or non-monetary incentives (19,30,32,33) to participants and attrition averaged 19% in studies where it could be determined (12,13,15,16,19,20,22,23,26–30,32–34). Programme use was variable among the nine studies in which it was measured (11,12,19,20,27,29,32–34).

Quality of included studies

The study design quality coding criteria and appraisal for each intervention are outlined in Tables 1 and 2. No studies fulfilled all design quality requirements. Two studies met 88% of the requirements (20,28). Overall, the average study design quality score was 45% for all interventions; 42% for RCTs and non-RCTs (39% and 37% for prevention interventions in children and adolescents, respectively, 13% for treatment interventions in children, and 66% for treatment interventions in adolescents) and 61% for other intervention studies (71% for prevention interventions in children and 57% for treatment interventions in adolescents). Most studies (87%) did not separate the effects of the electronic intervention from other intervention components (11,13,14,16–19,21,22,24,27,31–34). Four of the 11 RCTs were not truly randomized or failed to adequately describe the randomization method (13,17,19,26). Details of allocation concealment (11,13–17,19–23,26–29,32–34), study blinding (11,13–17,22,26,32,33), baseline comparability (14,17,21–23,25–27,34), follow-up (11,19,21,22,24–26,29,32,33) and analysis (15,21,23–26) were not adequately reported for most studies. All RCTs and non-RCTs accurately reported outcomes and the majority used validated measurement tools (14–17,19–23,27–29,32–34).

Child studies

Prevention

Three US studies, including two RCTs (11,12) and one pre–post study (13), featured short-term interventions targeting obesity prevention in children aged 8–11 years (Table 3). Study sample sizes ranged from 35 girls (11) to 209 boys and girls (13).

Two of the studies assessed the impact of an 8-week home Internet programme on dietary and physical activity measures in African–American girls (11,12). One of these two studies included separate Internet programmes for participants' parents. This pilot RCT lacked statistical power to detect any significant effects of a combined summer day camp and home Internet programme on BMI, physical activity or dietary measures (11). Findings from the larger pre–post pilot study suggest that a stand alone home Internet programme can lead to significant improvements in dietary and physical activity behaviours in African–American girls at risk of obesity and higher participant log-on rates (12). However, this study lacked a control group and did not measure adiposity.

The third study, a CD-ROM-based RCT intervention supplemented by classroom and family-based homework assignments improved obesity indices (mean BMI z-score reduction: 0.07) and produced subtle changes in physical activity in girls only (13).

Treatment

Only one treatment intervention for children met the inclusion criteria. This US feasibility RCT compared a home Internet behavioural programme with a control website in 30 families with an at-risk or overweight 6- to 12-year-old child (26) (Table 4). After 6 weeks, this underpowered and poor quality (quality score: 13%) intervention reported stability in BMI z-scores without clear treatment effects and modest improvements in health promotion behaviour.

Adolescent studies

Prevention

Twelve studies targeted obesity prevention in adolescents (14–25) (Table 3). All but two (17,18) were conducted in the USA and five were RCTs (17–20,23). Interventions lasted between 2 weeks to 2 years with ethnically diverse sample populations ranging from 41 to 2840 participants aged 11–18 years. Interactive electronic interventions featured CD-ROM (15,17,18), Internet (14,16,19–22,24,25) and video (14,16) components and were mostly delivered in schools (14–18,21,22,24,25). Only one intervention included a parental component (17,18) and two interventions assessed programme use (19,20). Overall, significant positive outcomes were reported in relation to BMI and/or BMI z-score (15,18,20), dietary behaviours (14–17,20,21,24,25), physical activity behaviours (14–17,19,25), improved knowledge (15,21) and attitudes (15,20,21,23).

One CD-ROM-based study was a stand alone non-RCT intervention (15). At 16 weeks, the computer intervention group decreased their BMI by 0.2 kg m−2 and improved a greater number of obesity-related behaviours than the traditional education or control groups. The other two CD-ROM based studies examined different aspects of the only adolescent prevention intervention in this review that includes a parental component (17,18). This Belgian cluster RCT was delivered as an adjunct to health promotion activities in schools. Compared to either the intervention alone or control groups, the intervention with parental support was effective in reducing BMI z-score (0.07 and 0.17, respectively, at 1 and 2 years) 3 in girls only (18). Improvements in physical activity in both genders and dietary fat intake in girls at 1 year were sustained at 2 years in both intervention groups (i.e. with or without parental involvement) (17).

One out of the nine Internet-based studies was a stand alone programme (20). This 16-week high quality US RCT was associated with significant reductions in BMI z-score (0.18) and eating disorder behaviours at 9 months, despite modest programme use. Two of the remaining Internet-based studies were short-term RCTs showing improvements in BMI and light physical activity in Boy Scouts (19) and increases in physical activity self-efficacy and intentions in African–American girls (23). The remaining studies featured poor quality (with a score <25%) interventions other than RCTs and did not examine adiposity outcomes (14,16,21,22,24,25).

Treatment

Eight studies focused on obesity treatment interventions in adolescents with six based in the USA (27–29,32–34), one in Taiwan (30) and one in Germany (31) (Table 4). Interventions varied between 12 weeks and 2 years and involved 37 to 140 participants from various ethnic backgrounds between the ages of 11 to 18 years. Seven out of the eight studies included 62–100% female participants (27–29,31–34).

All electronic interventions were delivered via the Internet (27–34) and one involved a telemedicine support programme (31). Except for one school intervention (30), Internet programmes were predominantly home-based. Six out of the eight studies included parental involvement either via printed newsletters and telephone support (28,29), an Internet behavioural programme alone (32,33) or supplemented with face-to-face counselling (27,34). Six studies measured programme use (27–29,32–34). Overall, significant positive outcomes were reported in relation to BMI and/or BMI z-score (28–30), body fat (27,32–34), psychosocial variables (30,31), dietary and physical activity behaviours (31).

Two high quality US RCTs assessed the impact of a stand alone cognitive-behavioural programme on weight loss and body image improvement in 12 to 18 year olds (28,29). Following 16 weeks of intervention, both studies reported BMI z-score reductions (0.08–0.09 kg m−2) which were not maintained at 4 months (29). There were no significant effects on physical activity or sedentary activity (28).

The remaining six studies incorporated interactive electronic interventions as adjunct programmes. Four of these studies were RCTs involving a 6-month Internet behavioural programme targeting African–American girls and their parents (27,32–34). Compared to controls, adolescents receiving the intervention lost more mean body fat while their parents decreased their BMI (group difference: 0.8 kg m−2). Variables relating to parental satisfaction with family or life were the strongest mediators of adolescent weight loss (32,33). However, these group differences in adiposity subsided after 2 years (27,34). The two remaining studies observed a significant BMI reduction among Taiwanese students following an Internet-based weight loss programme (30) or stabilization of BMI z-score among obese youth receiving a telemedicine support programme (31).

Discussion

This systematic review provides a qualitative evaluation of 24 studies (4 based in children, 18 in adolescents) incorporating interactive electronic media interventions for the prevention or treatment of obesity and/or obesity-related behaviours in children and adolescents. The majority of studies were published in the last decade, highlighting this relatively novel research area and the growing interest in the potential application of interactive electronic media in youth obesity management or prevention interventions. Most studies featured interactive Internet sites or CD-ROM-based components as adjunct or stand alone programmes. Overall, 17 out of 20 studies that included a comparison group demonstrated positive obesity and/or obesity-related outcomes in favour of the intervention group. However, most studies did not separate the effects of interactive electronic media from other components in the intervention and showed poor overall study design quality. Despite being limited, the available evidence from this systematic review provides some insight in identifying current research gaps and informing future directions for designing youth obesity management or prevention programmes featuring interactive electronic media.

Quality of included studies

The evidence from this systematic review should be viewed with caution because of the heterogeneity of studies and overall poor study design quality. Of the identified studies, less than half were RCTs and only two were deemed to be high quality (with a score >80%) (20,28). Most RCTs and non-RCTs failed to describe randomization, allocation and blinding procedures and half failed to conduct or report intention-to-treat analyses.

Among the few prevention interventions in children, two studies reported positive outcomes in predominantly minority populations (12,13); one of these two studies lacked a control group (12) and the effects of the electronic intervention were not separated from other intervention components in the other study (13). The only treatment trial identified in children did not provide convincing evidence and had study limitations which included a small sample size, a high attrition rate, short intervention duration and poor reporting of methods (26).

The vast majority of adolescent obesity prevention and treatment studies were conducted in the USA, largely in ethnically diverse populations. Only two of these interventions from the same group of researchers and involving a 16-week cognitive-behavioural Internet intervention, achieved relatively high study quality scores (20,28). Overall, the direct transferability of these heterogeneous interventions and subsequent findings to other settings is unclear.

In view of these quality issues, we recommend that future studies rigorously report on methodology and have better design (e.g. inclusion of a control group, isolation of interactive electronic intervention effects, assessment of common core outcome measures, evaluation of programme adherence and possible association with improved outcomes).

Changes in adiposity outcomes

While most studies reporting adiposity outcomes seem to favour independent or adjunct interventions incorporating interactive electronic media, only one-third of studies assessed age and sex-specific BMI z-scores. Half of these studies, including two high quality prevention (20) and treatment (28) Internet stand alone programmes for adolescents, were RCTs showing significant BMI z-score reduction (ranging from 0.07 kg m−2 at 8 weeks to 0.18 kg m−2 at 9 months) in the intervention group (13,20,28,29). These findings are comparable in magnitude to those reported in a recent Cochrane review of lifestyle RCTs for the treatment of obesity in young people (pooled effect size: −0.06 in children; −0.14 in adolescents) (4).

The remaining studies in this review also demonstrated positive outcomes with a less significant increase in BMI z-score following a CD-ROM-based RCT (17,18) or maintenance of BMI z-score after a short-term Internet intervention (26) or long-term adjunct telemedicine programme (31).

Changes in obesity-related behaviours

Most studies suggest that interactive electronic interventions, used as adjunct or stand alone programmes, positively influence obesity-related outcomes including dietary behaviours (e.g. decreased dietary fat intake), reported and measured physical activity and psychosocial variables (e.g. self-efficacy). Several studies report mixed findings or no clear impact of interactive electronic interventions on obesity-related outcomes (11,13,14,17–21,24), and one reported better outcomes in the comparison group (23).

Parental involvement

Research indicates that paediatric weight management programmes involving parents have better outcomes than programmes that do not (37). However, less than half of the studies included in this review targeted both young people and their parents (11,13,17,18,26–29,32–34). In comparing these studies, the impact of parental involvement on children's obesity and/or obesity-related outcomes remains unclear because of different types of parental components involved, most studies not assessing the level of parental involvement and lacking a comparison group. In four RCTs with a comparison group and in which parents received a separate 6-month Internet behavioural programme (27,32–34), parent variables relating to family and life satisfaction were the strongest mediators of adolescent weight loss (32,33). However, positive adiposity outcomes were lost at 2 years (27,34). Further research is needed in investigating the implications of varying modes of parental involvement in youth interactive electronic interventions for the prevention or treatment of obesity.

Impact of interactive electronic interventions

Overall, many interventions incorporated multiple components and, while most showed positive results, 87% failed to separate the effects of the electronic intervention from other intervention components including school-based or community-based education, physical activity sessions and individual counselling. The individual effects of different electronic components (e.g. educational tasks, individualized emails, computer-tailored feedback, online discussion groups) within electronic interventions were also not evaluated. Only six out of 24 studies (two conducted in children, four in adolescents) featured stand alone electronic interventions (12,20,23,26,28,29). These Internet-based interventions demonstrated significant obesity reduction (20,28,29) despite indeterminate effects on obesity-related outcomes. Importantly, most interventions did not assess programme use and its impact on intervention effectiveness.

Strengths and limitations

Two recent systematic reviews highlight the potential for electronic interventions in improving weight-related behavioural change in children and adolescents but recommend that further research is conducted (5,6). Compared with the existing reviews, the current review includes a much broader range of study designs, settings and types of interactive electronic interventions. In this review, study quality was evaluated using established standards and studies were described on multiple dimensions in a systematic and detailed approach. The heterogeneity in study designs, settings, sample characteristics, intervention components and outcomes, precluded a quantitative analysis of the impact of interactive electronic interventions on prevention or treatment of obesity and/or obesity-related outcomes. The review was also limited by the small number of quality interventions and the lack of isolation of the effects of interactive electronic components.

Conclusions

Research gaps in the existing evidence base include high-quality well-designed long-term trials, particularly those relating to the prevention of obesity; studies incorporating innovative electronic media such as social networking media (e.g. Facebook) and e-whiteboards; studies that can be generalized to other populations; studies targeted towards both young people and their parents; studies that isolate the effects of interactive electronic media interventions; and studies that examine programme user engagement, adherence and the relationship between intervention dose and outcomes. While electronic interventions appear a promising approach for the prevention and treatment of obesity in children and adolescents, based on the available evidence it is clear that further high quality research is required to accurately inform the evidence base.

Conflict of Interest Statement

No conflicts of interest exist.

Acknowledgements

This study was supported in part with funds from New South Wales Health and from a Heart Foundation of Australia Grant-in-Aid G0853783.

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