Evaluation of an eHealth intervention aiming to promote healthy food habits from infancy -the Norwegian randomized controlled trial Early Food for Future Health

A systematic review of economic evaluations of web-based or telephone-delivered interventions for preventing overweight and obesity and/or improving obesity-related behaviors

Obesity prevention interventions with behavioral or lifestyle-related components delivered via web-based or telephone technologies have been reported as comparatively low cost as compared with other intervention delivery modes, yet to date, no synthesized evidence of cost-effectiveness has been published. This study aimed to conduct a systematic review of economic evaluations of obesity prevention interventions with a telehealth or eHealth intervention component. A systematic search of six academic databases was conducted through October 2020. Studies were included if they reported full economic evaluations of interventions aimed at preventing overweight or obesity, or interventions aimed at improving obesity-related behaviors, with at least one intervention component delivered by telephone (telehealth) or web-based technology (eHealth). Findings were reported narratively, based on the Consolidated Health Economic Evaluation Reporting Standards. Twenty-seven economic evaluations were included from 20 studies meeting the inclusion criteria. Sixteen of the included interventions had a telehealth component, whereas 11 had an eHealth component. Seventeen interventions were evaluated using cost-utility analysis, five with cost-effectiveness analysis, and five undertook both cost-effectiveness and cost-utility analyses. Only eight cost-utility analyses reported that the intervention was cost-effective. Comparison of results from cost-effectiveness analyses was limited by heterogeneity in methods and outcome units reported. The evidence supporting the cost-effectiveness of interventions with a telehealth or eHealth delivery component is currently inconclusive. Although obesity prevention telehealth and eHealth interventions are gaining popularity, more evidence is required on their effectiveness and cost-effectiveness.

Barriers and enablers to caregivers' responsive feeding behaviour: A systematic review to inform childhood obesity prevention

Responsive infant feeding is a critical component of childhood obesity prevention. However, there is little guidance for caregivers on how to do this successfully. The first step to developing an intervention to promote responsive feeding is to systematically identify its barriers and enablers. Searches were conducted in CINAHL, Cochrane Library, Medline, Embase, PubMed, PsycINFO, Maternity, and Infant Care from inception to November 2020. All study designs were included if they reported a barrier or enabler to responsive feeding during the first 2 years of life. We used a "best fit" framework synthesis, with the Capacity, Opportunity, Motivation, and Behaviour (COM-B) model. The Mixed Method Appraisal Tool (MMAT) was used to assess study quality. Forty-three studies were included in the review. Barriers (n = 36) and enablers (n = 21) were identified across five COM-B domains: psychological capacity, physical and social opportunity, and reflective and automatic motivation. Enablers were recognition of infant feeding cues, feeding knowledge and family and friends. Caregiver attitude toward control of feeding was a barrier, together with health care professional advice about formula feeding and breastfeeding expectation. These barriers and enablers provide a comprehensive evidence base to guide intervention development to improve responsive feeding and prevent obesity across individual and population levels.

The association between childhood adiposity and appetite assessed using the Child Eating Behavior Questionnaire and Baby Eating Behavior Questionnaire: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to quantify associations between Child Eating Behavior Questionnaire (CEBQ) and Baby Eating Behavior Questionnaire (BEBQ) appetitive traits (food approach: Food Responsiveness [FR], Enjoyment of Food [EF], Emotional Overeating [EOE], and Desire to Drink [DD]; food avoidant: Satiety Responsiveness [SR], Slowness in Eating [SE], Emotional Undereating [EUE], Food Fussiness [FF]) and measures of child adiposity. Searches of six databases up to February 2019 identified 72 studies (CEBQ, n = 67; BEBQ, n = 5), and 27 met the meta-analysis criteria. For cross-sectional studies reporting unadjusted correlations with body mass index z-scores (BMIz) (n = 19), all traits were associated with BMIz in expected directions (positive: FR, EF, EOE, and DD; negative: SR, SE, EUE, and FF). Pooled estimates ranged from r = 0.22 (FR) to r = -0.21 (SR). For cross-sectional studies reporting regression coefficients (n = 10), three traits (FR, EF, and EOE) associated positively, and three traits (SR, SE, and EUE) negatively, with BMIz (β = -0.31 [SR] to β = 0.22 [FR]). Eleven studies reported prospective relationships from appetite to adiposity measures for six scales (positive: FR, EF, EOE, and DD; negative: SR and SE). Five studies reported relationships from adiposity measures to appetite for five traits (positive: FR, EF, and EOE; negative: SR). All BEBQ traits were consistently cross-sectionally associated with adiposity measures. Overall, CEBQ/BEBQ-assessed appetitive traits show consistent cross-sectional relationships with measures of child adiposity.

The impact of feeding experiences during infancy on later child eating behaviours

PURPOSE OF REVIEW

Individual differences in appetite and eating behaviours appear early in infancy. This review synthesizes recent research investigating the impact of feeding experiences during infancy on later appetite and energy intake regulation, and appraises the consistency and longevity of any effects.

RECENT FINDINGS

Three themes of early feeding experiences were identified; breastfeeding, infants' first foods and caregivers' feeding practices. Recent findings suggest that breastfeeding alone is unlikely to promote better regulation of food intake later in childhood. It remains unclear whether the method of first food introduction (e.g., baby-led weaning vs traditional spoon feeding), or types of food introduced (e.g. ultra-processed foods), affect later child eating self-regulation. Randomised controlled trials (RCTs) on receiving guidance for responsive feeding showed some benefits; lower child body mass index z-scores in toddlerhood, parents reported less likelihood to pressure their child to eat or use food as a reward and lower emotional eating in the child.

SUMMARY

There is little consistent new evidence for the lasting impact of any one specific infant feeding experience on later eating self-regulation. More RCTs using observed and measured behaviours, with longer follow-ups of children's eating behaviours, and those conducted across different populations are warranted.

Changing parental feeding practices through web-based interventions: A systematic review and meta-analysis

Web-based parent interventions designed to promote children’s healthy eating patterns can enhance parents’ engagement and facilitate behavior change. However, it is still unclear how much the existing programs focus on changing parental feeding practices, and if so, which behavioral methodologies are used and how effective these interventions are in changing these parental behaviors. This systematic review and meta-analysis studied randomized controlled trials of web-based interventions targeting parents of 0-12-year-old children, aiming to promote children’s healthy diet or prevent nutrition-related problems and reporting parental feeding behaviors as one of the outcomes. We conducted an electronic search in four databases from the earliest publication date until February 2020. Of the 1271 records found, we retained twelve studies about nine programs, comprising 1766 parents that completed the baseline evaluation. We found recent interventions, mainly directed to parents of young children, with small, non-clinical samples, and mostly theory-based. The programs were heterogeneous regarding the type of intervention delivered and its duration. The most assessed parental feeding practices were Restriction, Pressure to eat, and Food availability/accessibility. The behavior change techniques Instruction on how to perform the behavior, Demonstration of the behavior, and Identification of self as role model were frequently used. Meta-analytic results indicated that most programs’ effects were small for the evaluated parental practices, except for Food availability/accessibility that benefited the intervention group only when all follow-up measurements were considered. The development of high-quality and controlled trials with larger samples is needed to determine with greater certainty the interventions’ impact on parental feeding behaviors. The more frequent inclusion of measures to evaluate parental practices to support children’s autonomy and of self-regulatory strategies as intervention components should be considered when designing programs.

Effect of a Parent-Focused eHealth Intervention on Children's Fruit, Vegetable, and Discretionary Food Intake (Food4toddlers): Randomized Controlled Trial

Background

In Western countries, children’s diets are often low in fruits and vegetables and high in discretionary foods. Diet in early life tends to track through childhood and youth and even into adulthood. Interventions should, therefore, be delivered in periods when habitual traits are established, as in toddlerhood when children adapt to their family’s diet.

Objective

In this study, we assessed the effect of the Food4toddlers eHealth intervention, which aimed to enhance toddlers’ diets by shaping their food and eating environment.

Methods

The Food4toddlers randomized controlled trial was conducted in Norway in 2017-2018. Parent-child dyads were recruited through social media. In total, 298 parents completed an online questionnaire at baseline (mean child age 10.9 months, SD 1.2). Postintervention questionnaires were completed immediately after the intervention (ie, follow-up 1; mean child age 17.8 months, SD 1.3) and 6 months after the intervention (ie, follow-up 2; mean child age 24.2 months, SD 1.9). The intervention was guided by social cognitive theory, which targets the linked relationship between the person, the behavior, and the environment. The intervention group (148/298, 49.7%) got access to the Food4toddlers website for 6 months from baseline. The website included information on diet and on how to create a healthy food and eating environment as well as activities, recipes, and collaboration opportunities. To assess intervention effects on child diet from baseline to follow-up 1 and from baseline to follow-up 2, we used generalized estimating equations and a time × group interaction term. Between-group differences in changes over time for frequency and variety of fruits and vegetables and frequency of discretionary foods were assessed.

Results

At follow-up 1, a significant time × group interaction was observed for the frequency of vegetable intake (P=.02). The difference between groups in the change from baseline to follow-up 1 was 0.46 vegetable items per day (95% CI 0.06-0.86) in favor of the intervention group. No other significant between-group differences in dietary changes from baseline to follow-up 1 or follow-up 2 were observed. However, there is a clear time trend showing that the intake of discretionary foods increases by time from less than 1 item per week at baseline to more than 4 items per week at 2 years of age (P<.001), regardless of group.

Conclusions

A positive intervention effect was observed for the frequency of vegetable intake at follow-up 1 but not at follow-up 2. No other between-group effects on diet were observed. eHealth interventions of longer duration, including reminders after the main content of the intervention has been delivered, may be needed to obtain long-terms effects, along with tailoring in a digital or a personal form.

Trial Registration

International Standard Randomized Controlled Trial Number (ISRCTN) 92980420; https://doi.org/10.1186/ISRCTN92980420

Systematic review of randomised controlled trials to improve dietary intake for the prevention of obesity in infants aged 0-24 months

Improving dietary intake early in life is a common behavioural target in obesity prevention trials. We undertook a systematic review of randomised controlled trials aiming to improve dietary intake of complementary foods during infancy (0-24 months). PubMed, Cochrane Library, EMBASE, Medline, and PsycInfo were searched for trials focussed on obesity prevention conducted between January 2000 and August 2019 where dietary intake was an outcome. Two reviewers screened studies and extracted data from selected articles. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2 tools. The protocol was registered on Open Science Framework (https://osf.io/6srg7/). Seventeen articles from 12 trials were selected for data extraction. Statistically significant group differences in outcomes were observed in 36 of 165 (21.8%) of dietary variables examined. Measurement and analysis of outcomes varied between studies. Overall risk of bias was rated as high, primarily due to missing outcome data. Improving dietary intake at this age appears challenging based on a relatively limited number of studies. Future research could consider dietary pattern analyses, which may provide more meaningful outcomes for this age group. Opportunities exist for further exploration of maternal-focussed interventions, responsive feeding interventions, and interventions delivered outside of homes.

A systematic review of screen-time literature to inform educational policy and practice during COVID-19

There is an urgent need for consensus around the matter of screen time (ST) during the COVID-19 pandemic. Some governments announced restrictions for online schooling time per day to protect students from perceived risks of prolonged screen-use, but critics and an emerging body of research question such regulations. Our review of 52 empirical studies found (a) an overwhelming majority of literature shows effect sizes too small to be of practical or clinical significance, and (b) findings more specifically on educational ST are inconclusive and critically underrepresented. These facts, along with the undeniable benefits of online learning in the absence of brick-and-mortar schooling and the ominous forecasts of learning loss caused by prolonged school closure, inform our recommendations for a more moderate policy and practical stance on restrictions - one that is focused on responsibly leveraging the educational and social benefits of ST in a world still recovering from the COVID-19 pandemic.

Psychological Correlates of Sedentary Screen Time Behaviour Among Children and Adolescents: a Narrative Review

PURPOSE OF REVIEW

The aims of this narrative review were to (1) synthesise the literature on the relationship between screen time and important mental health outcomes and (2) examine the underpinning factors that can influence this association.

RECENT FINDINGS

Paralleling the rise of mental health issues in children and adolescents is the ubiquitous overuse of screens, but it is unclear how screen time is related to important mental health outcomes and whether this association differs by gender, age and screen type.

METHODS

Medline/PubMed, PsychINFO and Google Scholar databases were searched on December 2019 for articles published mainly in the last 5 years. The search focused on two main concepts: (i) screen time and (ii) mental health outcomes including anxiety, depression, psychological and psychosocial well-being and body image concerns.

RESULTS

Sixty studies were included in the review. Higher levels of screen time were associated with more severe depressive symptoms. We found moderate evidence for an association between screen time and poor psychological well-being and body dissatisfaction especially among females. Relationships between screen time and anxiety were inconsistent and somewhat gender specific. Social media use was consistently associated with poorer mental health. Higher levels of screen time are generally associated with poorer mental health outcomes, but associations are influenced by screen type, gender and age. Practitioners, parents, policy makers and researchers should collectively identify and evaluate strategies to reduce screen time, or to use screens more adaptively, as a means of promoting better mental health among children and adolescents.

Impact of preconception, pregnancy, and postpartum culinary nutrition education interventions: a systematic review

CONTEXT

Frequent consumption of home-prepared meals is associated with higher diet quality in children and adults. Therefore, increasing the culinary skills of women and couples during their childbearing years may be an effective strategy for the prevention of overweight and obesity.

OBJECTIVE

To determine the impact of culinary nutrition-education interventions for women with or without their partners during preconception, pregnancy, or postpartum (PPP) on parental cooking skills, nutrition knowledge, parent/child diet quality, or health outcomes.

DATA SOURCES

Eligibility criteria were defined using a PICOS framework. A systematic search strategy was developed to identify eligible studies and was implemented in 11 electronic databases. Reference lists of selected systematic reviews were manually searched for additional studies.

DATA EXTRACTION

Study characteristics and outcomes were extracted from eligible studies by 1 reviewer and checked by a second reviewer.

DATA ANALYSIS

A narrative synthesis of the findings of eligible studies was prepared including descriptive statistics. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and Synthesis Without Meta-Analysis in systematic reviews reporting guideline.

RESULTS

A total of 6951 articles were identified from the search strategy and 31 studies during pregnancy or postpartum were included. By category, the number of studies with a favorable outcome per total number of studies measuring outcome were as follows: parental food/cooking skills (n = 5 of 5), nutrition knowledge (n = 6 of 11), parent/child diet quality (n = 10 of 19), infant feeding (n = 6 of 11), eating behavior (n = 2 of 5), maternal (n = 2 of 5) and child anthropometry (n = 6 of 10), mental health and development n = (2 of 3), and clinical indictors (n = 1 of 1).

CONCLUSIONS

Culinary nutrition-education interventions during pregnancy and the postpartum period show promise in improving cooking skills, diet quality, and a variety of health-related outcomes. The precise effect of these interventions during PPP is limited by the quality and heterogeneity of study designs to date.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42020154966.

A Dietary Mobile App for Patients Undergoing Hemodialysis: Prospective Pilot Study to Improve Dietary Intakes

Background

Mobile technology has an impact on the health care sector, also within dietetics. Mobile health (mHealth) apps may be used for dietary assessment and self-monitoring, allowing for real-time reporting of food intakes. Changing eating behaviors is quite challenging, and patients undergoing hemodialysis, particularly, struggle to meet the target intakes set by dietary guidelines. Usage of mobile apps that are developed in a person-centered approach and in line with recommendations may support both patients and health care practitioners.

Objective

This study is a pilot that aims at estimating the potential efficacy of a dietary intervention using a theory-based, person-centered smartphone app. Results will be used to improve both the app and a planned large-scale trial intended to assess app efficacy thoroughly.

Methods

A prospective pilot study was performed at the hemodialysis unit of Al Qassimi Hospital (The Emirate of Sharjah). All patients that fulfilled the study inclusion criteria were considered eligible to be enrolled in the pilot study. Upon successful installation of the app, users met with a dietitian once a week. Outcomes were measured at baseline (T0) and 2 weeks post app usage (T1). This pilot is reported as per guidelines for nonrandomized pilot and feasibility studies and in line with the CONSORT 2010 checklist for reporting pilot or feasibility trials.

Results

A total of 23 patients completed the pilot intervention. Mean energy intakes increased from 24.4 kcal/kg/day (SD 8.0) to 29.1 kcal/kg/day (SD 7.8) with a medium effect size (d=0.6, 95% CI 0.0-1.2). Mean protein intakes increased from 0.9 g/kg/day (SD 0.3) to 1.3 g/kg/day (SD 0.5) with a large effect size (d=1.0, 95% CI 0.4-1.6); mean intake of high biological value (%HBV) proteins also increased from 58.6% (SD 10.1) to 70.1% (SD 10.7) with a large effect size (d=1.1, 95% CI 0.5-1.7). Dietary intakes of minerals did not change, apart from sodium which decreased from a mean intake of 2218.8 mg/day (SD 631.6) to 1895.3 mg/day (SD 581.0) with a medium effect size (d=0.5, 95% CI 0.1-1.1). Mean serum phosphorus, potassium, and albumin levels did not change relevantly. Mean serum iron increased from 7.9 mg/dL (SD 2.8) to 11.5 mg/dL (SD 7.9) postintervention with a medium effect size (d=0.6, 95% CI 0.0-1.2).

Conclusions

This pilot study showed that the KELA.AE app has the potential to improve dietary intakes. Processes related to procedure, resources, tools, and app improvement for a future trial were assessed. A more extended intervention using a randomized controlled trial is required to estimate parameters concerning app efficacy accurately.

Process Evaluation of an eHealth Intervention (Food4toddlers) to Improve Toddlers' Diet: Randomized Controlled Trial

BACKGROUND

Parents seek trustworthy information online to promote healthy eating for their toddlers. Such information must be perceived as relevant and easy to implement and use.

OBJECTIVE

The objectives of this study were to conduct a process evaluation of the electronic health (eHealth) intervention (Food4toddlers) targeting food environment, parental feeding practices, and toddlers' diet and to examine possible differences in these areas according to education and family composition.

METHODS

A 2-armed randomized controlled trial, including 298 parent-toddler dyads from Norway, was conducted in 2017. In total, 148 parents in the intervention group received access to an intervention website for 6 months. Data on website usage were retrieved from the learning management platform used (NEO). Participants' satisfaction with the intervention was asked for in a postintervention questionnaire. Chi-square and t tests were used to examine differences in usage and satisfaction between education and family composition groups.

RESULTS

Most participants were mothers (144/148, 97.2%), lived in two-adult households (148/148, 100%), and were born in Norway (132/148, 89.1%). Mean parental age was 31.5 years (SD 4.2). More than 87.8% (129/147) had a university education degree and 56.5% (83/147) had over 4 years of university education. Most (128/148, 86.5%) intervention participants entered the website at least once (mean days of access 7.4 [SD 7.1]). Most parents reported the website as appropriate to the child's age (71/83, 86%) and self-explanatory (79/83, 95%) and appreciated the interface (52/83, 63%) and layout (46/83, 55%). In total, 61% (51/83) stated that they learned something new from the intervention. Parents with over 4 years of university education and in 1-child households used the intervention website more than those with 4 years or less of university education (8.4 vs 5.9 days in total, P=.04) and households with more than 1 child (8.3 vs 5.8 days in total, P=.04), respectively.

CONCLUSIONS

The Food4toddlers intervention website was found to be relevant by most participants in the intervention group, although usage of the website differed according to educational level and family composition. For eHealth interventions to be effective, intervention materials such as websites must be used by the target group. Our results highlight the need to include users from different groups when developing interventions.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN92980420; http://www.isrctn.com/ISRCTN92980420.

Content and Quality of Infant Feeding Smartphone Apps: Five-Year Update on a Systematic Search and Evaluation

Background

Parents use apps to access information on child health, but there are no standards for providing evidence-based advice, support, and information. Well-developed apps that promote appropriate infant feeding and play can support healthy growth and development. A 2015 systematic assessment of smartphone apps in Australia about infant feeding and play found that most apps had minimal information, with poor readability and app quality.

Objective

This study aimed to systematically evaluate the information and quality of smartphone apps providing information on breastfeeding, formula feeding, introducing solids, or infant play for consumers.

Methods

The Google Play store and Apple App Store were searched for free and paid Android and iPhone Operating System (iOS) apps using keywords for infant feeding, breastfeeding, formula feeding, and tummy time. The apps were evaluated between September 2018 and January 2019 for information content based on Australian guidelines, app quality using the 5-point Mobile App Rating Scale, readability, and suitability of health information.

Results

A total of 2196 unique apps were found and screened. Overall, 47 apps were evaluated, totaling 59 evaluations for apps across both the Android and iOS platforms. In all, 11 apps had affiliations to universities and health services as app developers, writers, or editors. Furthermore, 33 apps were commercially developed. The information contained within the apps was poor: 64% (38/59) of the evaluations found no or low coverage of information found in the Australian guidelines on infant feeding and activity, and 53% (31/59) of the evaluations found incomplete or incorrect information with regard to the depth of information provided. Subjective app assessment by health care practitioners on whether they would use, purchase, or recommend the app ranged from poor to acceptable (median 2.50). Objective assessment of the apps’ engagement, functionality, aesthetics, and information was scored as acceptable (median 3.63). The median readability score for the apps was at the American Grade 8 reading level. The suitability of health information was rated superior or adequate for content, reading demand, layout, and interaction with the readers.

Conclusions

The quality of smartphone apps on infant feeding and activity was moderate based on the objective measurements of engagement, functionality, aesthetics, and information from a reliable source. The overall quality of information on infant feeding and activity was poor, indicated by low coverage of topics and incomplete or partially complete information. The key areas for improvement involved providing evidence-based information consistent with the Australian National Health and Medical Research Council’s Infant Feeding Guidelines. Apps supported and developed by health care professionals with adequate health service funding can ensure that parents are provided with credible and reliable resources.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Testing the effects of interventions to increase consumption of fruit and vegetables, including those focused on specific child-feeding strategies or broader multicomponent interventions targeting the home or childcare environment is required to assess the potential to reduce this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 January 2020. We searched Proquest Dissertations and Theses in November 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 80 trials with 218 trial arms and 12,965 participants. Fifty trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education only in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 23 of the 80 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption, equivalent to an increase of 5.30 grams as-desired consumption of vegetables (SMD 0.50, 95% CI 0.29 to 0.71; 19 trials, 2140 participants; mean post-intervention follow-up = 8.3 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.32, 95% CI 0.09 to 0.55; 9 trials, 2961 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.34 cups of fruit and vegetables a day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.13, 95% CI -0.02 to 0.28; 11 trials, 3050 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) or unintended adverse consequences of interventions (2 trials), limiting our ability to assess these outcomes. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 80 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited in terms of quality of evidence and magnitude of effect. Of the types of interventions identified, there was moderate-quality evidence that multicomponent interventions probably lead to, and low-quality evidence that child-feeding practice may lead to, only small increases in fruit and vegetable consumption in children aged five years and under. It is uncertain whether parent nutrition education or child nutrition education interventions alone are effective in increasing fruit and vegetable consumption in children aged five years and under. Our confidence in effect estimates for all intervention approaches, with the exception of multicomponent interventions, is limited on the basis of the very low to low-quality evidence. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Understanding feeding practices of Latinx mothers of infants and toddlers at risk for childhood obesity: A qualitative study

Infancy and toddlerhood are critical stages for the development of habits that can lead to future obesity, and caregivers have an important influence on these habits. We conducted this qualitative semistructured interview study to explore the feeding practices of Latinx mothers of young children who are at risk for childhood obesity in order to identify targets for obesity prevention. We interviewed Latinx mothers (N = 14) of a child ages 6–18 months with a weight‐for‐length ratio > 85th percentile at the time of recruitment. Two researchers independently read through the interviews, identified sections of the interviews pertaining to feeding, and used constant comparative methods to identify the following common themes: mothers overwhelmingly reported permissive feeding styles, driving overfeeding and frequent night‐time feeding. Mothers expressed some difficulty with transitioning to solid foods and reported desiring to feed their child healthy foods by minimizing juice and giving vegetables. Paediatricians and WIC staff were viewed by mothers as trustworthy sources of nutrition information. Most identified a connection between their child's weight and diet, but many lacked the insight or capacity to change their current practices. The mothers in our study provide insight into factors that may predispose young children to obesity and thus potential avenues to support these families. Healthcare providers can better serve them by giving clear, actionable advice on healthy feeding practices for their child, while understanding constraints that may make healthy habits difficult to implement. Paediatricians should be honest about their child's weight status early on to allow time for intervention.

Interventions for increasing fruit and vegetable consumption in children aged five years and under

BACKGROUND

Insufficient consumption of fruits and vegetables in childhood increases the risk of future non-communicable diseases, including cardiovascular disease. Interventions to increase consumption of fruit and vegetables, such as those focused on specific child-feeding strategies and parent nutrition education interventions in early childhood may therefore be an effective strategy in reducing this disease burden.

OBJECTIVES

To assess the effectiveness, cost effectiveness and associated adverse events of interventions designed to increase the consumption of fruit, vegetables or both amongst children aged five years and under.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and two clinical trials registries to identify eligible trials on 25 August 2019. We searched Proquest Dissertations and Theses in May 2019. We reviewed reference lists of included trials and handsearched three international nutrition journals. We contacted authors of included trials to identify further potentially relevant trials.

SELECTION CRITERIA

We included randomised controlled trials, including cluster-randomised controlled trials and cross-over trials, of any intervention primarily targeting consumption of fruit, vegetables or both among children aged five years and under, and incorporating a dietary or biochemical assessment of fruit or vegetable consumption. Two review authors independently screened titles and abstracts of identified papers; a third review author resolved disagreements.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risks of bias of included trials; a third review author resolved disagreements. Due to unexplained heterogeneity, we used random-effects models in meta-analyses for the primary review outcomes where we identified sufficient trials. We calculated standardised mean differences (SMDs) to account for the heterogeneity of fruit and vegetable consumption measures. We conducted assessments of risks of bias and evaluated the quality of evidence (GRADE approach) using Cochrane procedures.

MAIN RESULTS

We included 78 trials with 214 trial arms and 13,746 participants. Forty-eight trials examined the impact of child-feeding practices (e.g. repeated food exposure) in increasing child vegetable intake. Fifteen trials examined the impact of parent nutrition education in increasing child fruit and vegetable intake. Fourteen trials examined the impact of multicomponent interventions (e.g. parent nutrition education and preschool policy changes) in increasing child fruit and vegetable intake. Two trials examined the effect of a nutrition education intervention delivered to children in increasing child fruit and vegetable intake. One trial examined the impact of a child-focused mindfulness intervention in increasing vegetable intake. We judged 20 of the 78 included trials as free from high risks of bias across all domains. Performance, detection and attrition bias were the most common domains judged at high risk of bias for the remaining trials. There is very low-quality evidence that child-feeding practices versus no intervention may have a small positive effect on child vegetable consumption equivalent to an increase of 4.45 g as-desired consumption of vegetables (SMD 0.42, 95% CI 0.23 to 0.60; 18 trials, 2004 participants; mean post-intervention follow-up = 8.2 weeks). Multicomponent interventions versus no intervention has a small effect on child consumption of fruit and vegetables (SMD 0.34, 95% CI 0.10 to 0.57; 9 trials, 3022 participants; moderate-quality evidence; mean post-intervention follow-up = 5.4 weeks), equivalent to an increase of 0.36 cups of fruit and vegetables per day. It is uncertain whether there are any short-term differences in child consumption of fruit and vegetables in meta-analyses of trials examining parent nutrition education versus no intervention (SMD 0.12, 95% CI -0.03 to 0.28; 11 trials, 3078 participants; very low-quality evidence; mean post-intervention follow-up = 13.2 weeks). We were unable to pool child nutrition education interventions in meta-analysis; both trials reported a positive intervention effect on child consumption of fruit and vegetables (low-quality evidence). Very few trials reported long-term effectiveness (6 trials), cost effectiveness (1 trial) and unintended adverse consequences of interventions (2 trials), limiting their assessment. Trials reported receiving governmental or charitable funds, except for four trials reporting industry funding.

AUTHORS' CONCLUSIONS

Despite identifying 78 eligible trials of various intervention approaches, the evidence for how to increase children's fruit and vegetable consumption remains limited. There was very low-quality evidence that child-feeding practice may lead to, and moderate-quality evidence that multicomponent interventions probably lead to small increases in fruit and vegetable consumption in children aged five years and younger. It is uncertain whether parent nutrition education interventions are effective in increasing fruit and vegetable consumption in children aged five years and younger. Given that the quality of the evidence is very low or low, future research will likely change estimates and conclusions. Long-term follow-up of at least 12 months is required and future research should adopt more rigorous methods to advance the field. This is a living systematic review. Living systematic reviews offer a new approach to review updating, in which the review is continually updated, incorporating relevant new evidence as it becomes available. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

Examining the effects of an eHealth intervention from infant age 6 to 12 months on child eating behaviors and maternal feeding practices one year after cessation: The Norwegian randomized controlled trial Early Food for Future Health

OBJECTIVES

The Norwegian randomized controlled trial Early Food for Future Health provided parental anticipatory guidance on early protective feeding practices from child age 6 to 12 months through an eHealth intervention. Previously published outcomes at child age 12 months indicated that the eHealth intervention increased daily vegetable/fruit intake and promoted more beneficial mealtime routines. The objective of the current paper is to evaluate the effects of the intervention at child age 24 months, one year after cessation.

METHODS

Parents of infants aged 3-5 months were recruited via social media and child health clinics during spring 2016. At child age 5.5 months, 715 mothers were randomized to either control (n = 358) or intervention (n = 360) arm. Primary study-outcomes were child eating behaviors, dietary intake, mealtime routines and maternal feeding practices and feeding styles. Secondary outcome was child anthropometry.

RESULTS

In total 295 mothers (41%) completed the follow-up questionnaire at child age 24 months. Regarding fruit intake, 54.3% in the intervention group had a high score compared with 48.3% of the control group (p = 0.29). For intake of vegetables, 54.5% in the intervention group had a high score compared with 50.7% in the control group (p = 0.49). A total of 65.7% of the children in the intervention group were eating breakfast together with family ≥ 4 times per week, compared with 57.3% of the children in the control group (p = 0.12). There was no difference between the groups for child anthropometric outcomes at child age 24 months.

CONCLUSIONS

At child age 24 months, we found no evidence of sustained intervention-effects. Although dietary patterns and mealtime routines at child age 24 months were reasonably consistent and in the same directions as at child age 12 months, the between-group differences were not significant. The large loss to follow-up may have limited power and validity and makes it difficult to draw overall conclusions. Future research is needed to improve knowledge of how short-time effects could be retained over longer term, taking into account that larger samples are necessary when planning longer-term follow-up studies.

TRIAL REGISTRATION

ISRCTN, ISRCTN13601567.