INTRODUCTION

The World Health Organization (WHO) estimated that factors related to nutrition influence 45% of deaths in children under five years old¹. Child malnutrition has increased worldwide, for children under five years, stunting affects 149.2 (22.0%) million, wasting 45.4 (6.7%) million and overweight 38.9 (5.7%) million. In addition, the impact on lifestyles due to COVID-19 could increase all forms of malnutrition².

Consuming a healthy diet early in life helps to prevent malnutrition in all its forms, it is important to ensure an adequate growth and development, moreover, reduce the risk of developing noncommunicable diseases (NCDs)^3,4.

Eearly years of life are critical periods to develop a healthy lifestyle, therefore, eating behaviours must be taught in early childhood^5,6. After the first three years of life, brain development is able to build the learning networks, thus, in the previous years it acquired the necessary elasticity where the nerve cells multiply rapidly, forming the structures that allow the learning process⁷. All this development and grow process needs a good font of good energy in order to succeed. Nevertheless, there are many factors that could influence this critical stage in preschoolers, such as access for parents to nutritional education⁸. What can influence the present feeding and the future feeding styles in this stage where they begin to take shape.

An innovative form to address health needs is eHealth, defined as the use of Information and Communication Technologies (ICT) in support of health related fields⁹. ICT are defined as tools and resources to transmit, store, create or share information, including computers, the Internet (websites, blogs, mails) live broadcasting technologies, recorded broadcasting technologies and telephony¹⁰. ICT-based interventions have been previously reviewed for different authors.

A systematic review focused on adolescents, reported effectiveness for increasing the intake of vegetables and decreasing junk food consumption. However, it was recognized that an additional comparison is necessary to identify if ICT are superior or equally effective than traditional programs¹¹. Another systematic review about the effectiveness of technology-based interventions to address obesity in children, showed that video games, web-bases or mobile phone communications with further research have the potential of positive impact on weight-related outcomes¹². In addition, for children, previous reviews already focused on interventions to prevent specific forms of malnutrition such as overweight¹³ and obesity¹⁴.

Others interventions evaluated the effectiveness of which ICT interventions improve specific dietary patterns as fruit and vegetables intake¹⁵. And more recently, one review evaluated interventions with direct parental involvement¹⁶, and just one more evaluated the use of digital tools¹⁷. Given its importance for health, it is important to begin to explore the benefits of ICT in preschool children and whether they can affect their future lives.

Although previous interventions, ICT-based or traditional approaches, exist, have not been compared. Specifically, in preschoolers, it is not clear about the benefits of ICT. In effort to address this evidence gap, this systematic review aimed to compare interventions using ICT tools in comparison to traditional approaches, targeting parents to improve healthy diet or BMI in preschoolers. Specifically, to know its effectiveness, which tools have been used and the main success factors in the interventions.

METHODOLOGY

This systematic review was registered on PROSPERO (ID. CRD42021251037) followed the PRISMA 2020 guidelines¹⁸, to state the comparisons the Population, Intervention, Comparison and Outcomes (PICO) framework was used as follows. P: preschoolers without diseases or treatments that influence weight or metabolism and their parents. I: interventions to improve a healthy diet or healthy BMI with ICT approach that include preschoolers and their parents. C: interventions with traditional approaches. O: Primary outcomes: “changes in healthy diet or healthy BMI” and “durability of the outcome (follow-up) and Secondary outcomes: “additional positive outcomes reported by the authors or impact between groups, duration or durability of the intervention and follow-up”.

RESULTS

The following PRISMA flow diagram (Figure 1) shows the search and selection process. Two studies appeared to meet the inclusion criteria, however, some of the studies included were focused on different target groups, interventions did not have educational components, or some did not include parents. Therefore, they were excluded^15,16. Eventually, a total of 8 studies were included.

Figure 1. PRISMA Flow Diagram. 

General characteristics and risk of bias of included studies are represented in Table 1 ^20-27. Two had a not defined setting by the nature of the intervention (ICT-T exclusively). See Supplementary Materialmaterial suplementario.

In Table 2 ^20-27 is reported effectiveness of the interventions. For CHD, the only study with negative effects reported that intake of fruits and vegetables (FV) and unsweetened beverages per day was more pronounced for children in the CG at baseline and follow-up. Otherwise, studies with positive effects had significant differences for all its measures, e.g., FV, sugar-sweetened beverages intake (SSB) and water consumption. For CBMI, the study with negative effects was the same that reported negative effects for CHD. For those with positive effects, one reported maintaining a healthy BMI percentile and less increase on the IG, while the other study showed significant differences for BMI-for-age Z score.

In Table 3 ^20-27 is reported intervention components. For ICT-T, there was a prevalence for telephony, e.g., telephone calls, while for the TA, there was a prevalence for direct contact, e.g., motivational interviewing (MI). Two studies used only ICT-T for their interventions, while the rest of the studies used mixed tools with predominantly use of TA. There were important differences between duration and intensity from each characteristic of the interventions, for some of them, duration and intensity were not specified. Four interventions added community components (e.g., use of parks); whereas two interventions used more creative tools to interact with parents and children (e.g., puppets). It is worth mentioning that telephone calls were used more than any other ICT-T for two specific components of the interventions: MI and coaching to change behaviours.

DISCUSSION

In the study with positive effects for CHD and CBMI, differentiating characteristics were identified. Were used mixed tools, created cartoons or fantasy characters to inspire healthy behaviors and had group activities. In comparison to other interventions in childcare centers or scholar settings, where parents only had instructions to do activities at home, in this study, its school-based activities had a continuation at home because parents were trained and encouraged to provide evidence of completion of a given activity. Moreover, studies had fictional characters as fruits and vegetables for its stories, but the characters used in the intervention with positive effects, were preschool-aged children and animals.

Additionally, most of its components had a daily intensity, in contrast to the intervention that had negative effects, where the dose of interventions was not defined.

Few studies had changes for FV intake. The result is consistent with a recent systematic review, reported that there were no short-term differences in child consumption of FV in meta-analyses of trials examining nutrition education and interventions¹⁵. In comparison, the only two studies that showed positive effects for CBMI were applied during scholar years, which is consistent with previous reviews where it mentioned that time is a main factor to evaluate the effectiveness of interventions in weight status, becoming a difficult variable to change in children¹⁶.

Some studies showed significant results for children with overweight or obesity, this is consistent with previous results that mention interventions can be more effective as treatment of childhood obesity¹⁴. In addition, it was reported that interventions show greater effects in weight loss compared to prevention in children¹³.

For studies with exclusively ICT-T, the intervention that used a smartphone app had mixed effects with significant results to reduce intake of sweetened beverage intake (p=0.049) at follow-up. Besides, children had 99% higher odds of increasing the composite score (OR: 1.99; 95%CI [1.20, 3.30]; p=0.008) and the effect was more pronounced for children with higher FMI. This is related to a recent systematic review, which mentions that website and app-based interventions can be effective for improving children's dietary intake and nutrition knowledge and can achieve small to moderate changes in nutrient-poor foods and drinks¹⁷. In addition, another study that tested the efficacy of a smartphone-delivered intervention to reduce parent provision of sugar-sweetened beverages among preschool children, showed that children had a greater reduction for consumption of SSB, even mothers in the IG had a significant weight loss²⁸.

In contrast, two studies used exclusively TA. One study showed positive effects only for CHD (e.g., SSB intake). This result is related to a previous systematic review where successful strategies to reduce consumption of SSB had provision of written educational materials such as those used in the study included in this review²⁹. The other study showed negative effects for CHD and CBMI. It is worth mentioning that this study had a daycare setting, and in a previous systematic review focused on childcare, less than half of included studies had a significant difference in BMI, BMI-Z score, waist circumference or body fat³⁰. An important characteristic of this study included, is that it gave general information for healthy meals or PA to parents, and this has been previously described as a barrier to obesity prevention in childcare settings instead of being a facilitator, because some parents did nothing for their children to eat healthier when only received information³¹.

There were some limitations to this systematic review. Only studies written in English and Spanish were included, therefore, studies written in different languages that could increase the quantity and quality of the evidence reviewed were excluded. Moreover, studies were constrained to be available in open access, thus, some studies that seemed accomplished inclusion criteria, nevertheless had a cost to be full text read were excluded. Furthermore, all studies included different settings where its characteristics around healthy diet or BMI could condition outcomes. Similarly, its heterogeneity constrains an exact comparison. Finally, according to the methodological quality of the studies included, results and conclusions of this systematic review must be considered with caution.

On the other hand, to our knowledge, is the most recent evidence of comparison ICT-T and TA, where most of the studies had mixed effects and due to the heterogeneity of the studies, seemed difficult to exactly determine which factors were successful. However, differentiating characteristics were identified in the study with positive effects and should be considered for future interventions. In addition, this review showed that although studies had recent publication dates, there were few with ICT-T. In other words, there is a need to increase the use of ICT, as it is recognized that ICT are essential for achieving the Sustainable Development Goals and are innovative forms to address health needs⁹.

Furthermore, the results increase the evidence that interventions can be more effective in reducing consumption of not recommended food groups than increasing intake of recommended food groups, as well as are more likely to have effect on children with overweight or obesity. Additionally, interventionists did not evaluate the knowledge acquired through educational components. Therefore, it should be considered and assessed the role of parent's knowledge in children's nutritional status.

CONCLUSIONS

In conclusion, interventions first, seemed more effective as treatment than prevention for preschoolers with overweight or obesity, second, had better results with daily implementation and home settings, and third, showed being successful with a defined dose of the intervention. Similarly, although most used mixed tools, there were few which implemented new methods through ICT-T.