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Electronic health (eHealth) obesity programs offer benefits to traditionally delivered programs and have shown promise in improving obesity-related behaviors in children.
This study aimed to assess the efficacy of a parent-focused, internet-based healthy lifestyle program for preschool-aged children, who are overweight or at or above the fiftieth percentile for body mass index (BMI) for their age and sex, on child BMI, obesity-related behaviors, parent modeling, and parent self-efficacy.
The
A total of 86 dyads were recruited, with 42 randomized to the intervention group and 44 to the comparison group. Moreover, 78 dyads attended the 3- and 6-month follow-ups, with 7 lost to follow-up and 1 withdrawing. Mean child age was 3.46 years and 91% (78/86) were in the healthy weight range. Overall, 69% (29/42) of participants completed at least 5 of the 6 modules. Intention-to-treat analyses found no significant outcomes for change in BMI between groups. Compared with children in the comparison group, those in the intervention group showed a reduced frequency of discretionary food intake (estimate −1.36, 95% CI −2.27 to −0.45;
The trial demonstrated that a parent-focused eHealth childhood obesity prevention program can provide support to improve dietary-related practices and self-efficacy but was not successful in reducing BMI. The target sample size was not achieved, which would have affected statistical power.
Australian New Zealand Clinical Trials Registry ANZCTR12616000119493; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370030 (Archived by WebCite at http://www.webcitation.org/74Se4S7ZZ).
The World Health Organization (WHO) has described childhood obesity as one of the most significant public health issues [
Targeted interventions have the potential to alter the trajectory of childhood overweight and obesity continuing into adulthood, and interventions that involve parents are the most successful [
Overweight and obesity interventions, which use an electronic health (eHealth) delivery method, offer many advantages compared with traditional delivery methods, particularly around convenience and accessibility. Most interventions using eHealth delivery methods have been conducted in older children and have not involved parents [
This paper reports the outcomes of a randomized controlled trial (RCT) evaluating the efficacy of a parent-focused, internet-based program in facilitating behavior change in preschool-aged children who are overweight or at risk of becoming overweight. We hypothesized that children in the intervention group would achieve significantly greater reductions in BMI compared with those in the comparison group at 6-month follow-up. It was also hypothesized that the intervention group would achieve significantly greater improvements in child dietary intake, physical activity, screen time, sleep, child feeding, and parent self-efficacy and role modeling.
The protocol for this study has been published [
The Consolidated Standards of Reporting Trials statement was used to guide the reporting of this study [
Potential participants were informed about the study through flyers distributed at early childhood education and care centers, general practices/primary health care centers, early childhood health centers, playgroups, and local sporting groups. Flyers were also displayed on community notice boards (eg, libraries, shopping centers, children’s activity centers), and articles were placed in the University of Wollongong and Local Health District newsletters and posted on Facebook. Media releases were also sent to local media outlets.
As the focus of the program was prevention of childhood obesity, healthy weight children as well as overweight children were included in the sample. Participants were eligible if they had access to the internet, if their child was 2 to 5 years old (and not yet attending school), and was at or above the WHO fiftieth percentile for BMI for their age and sex [
Child participants were excluded if they were taking medications or had a medical condition with the potential to affect weight or restrict age-appropriate play. Children with conditions that required the restriction of certain foods (eg, celiac disease or food allergies) were deemed eligible to participate, but parents were informed that parts of the program would not be completely appropriate and that they would need to make some adaptations to the material provided to match their child’s individual dietary/health needs.
Informed written consent was provided by the parents/guardians after reading a participant information sheet. Provisional eligibility was determined through contact with participants via phone or email and was confirmed at the face-to-face baseline data collection visit when the child’s height and weight were measured to confirm if the child’s BMI was at or above the WHO fiftieth percentile for age and sex. Participants below the fiftieth percentile were excluded.
Participants were randomized into the intervention or comparison group following the collection of baseline measures. Randomization was performed in a 1:1 ratio using a computerized random number generator. A data manager with no other involvement in the study conducted the randomization. The researcher responsible for implementing the intervention was the only person who was informed about group allocation. At the follow-up data collection time points, height and weight measurements were taken by trained data collectors blinded to group allocation.
Participants randomized to the intervention group were provided with an individual log-in to access the
Participants continued to receive emails fortnightly at the end of the program until the 6-month follow-up. Infographics summarizing the key points from each of the modules were provided in these emails, and participants were also encouraged to log back into the website to revise the material and review their progress with their goals.
Participants randomized to the comparison group received fortnightly emails, which contained links to the
Measurements were taken at baseline and 3 and 6 months post baseline. Participant measures were collected at the University of Wollongong, in the participant’s home, or in a community setting. Questionnaires were completed by the parents on an iPad during these sessions, which took approximately 30 to 45 min. Demographic information was also collected from parents at the baseline data collection point. Participants in the intervention group were asked to complete a process evaluation questionnaire at the end of the Web-based program, which assessed user acceptability of the program content, length, goal setting, Facebook discussion group, and the modality used.
Child height and weight were measured using a standardized method [
Dietary intake was assessed using both a parent-reported food questionnaire (modified from the Eating and Physical Activity Questionnaire) [
Physical activity intensity and duration were measured using an ActiGraph GT3X+ accelerometer (ActiGraph Corporation, Pensacola, FL), which was worn on an elasticized belt around the child’s waist for 7 days. Accelerometer data were analyzed in ActiLife version 6 (ActiGraph Corporation, Pensacola, FL). A sampling frequency of 30 Hz was used, with the files then reintegrated into 15-second epochs. Nonwear time was defined as 20 min or more of 0 counts. Accelerometer data used for the physical activity analysis were considered valid based on wear time of at least 6 hours per day on 3 days, which has been found to be reliable in previous research [
Sleep habits were assessed using 4 questions assessing sleep latency, sleep reluctance, difficulty sleeping, and difficulty falling to sleep in own bed based on questions from the Children’s Sleep Habits Questionnaire [
Parent-reported questionnaires were used to assess child feeding (from the Child Feeding Questionnaire predefined subscales of “restriction” and “pressure to eat” [
On the basis of the results of the pilot study [
Differences in changes over time between the intervention and comparison groups were assessed for each outcome. Linear mixed models were used to determine differences between groups over time (baseline, 3 months, and 6 months) with adjustment for potential covariates. Intention-to-treat (ITT) principles were used for parametric data, with all participants analyzed in the group to which they were randomized regardless of whether they attended all data collection time points or completed the intervention. Covariates included baseline values, age, and cohort. Due to nonparametric distributions for some variables, Freidman tests and Wilcoxon signed rank tests were used followed by Mann-Whitney tests to analyze nonparametric data using completed cases. Generalized estimating equations were considered; however, the analyses would not converge.
Post hoc analysis of covariance (ANCOVA) analyses were used to detect changes between groups at individual time points, which included the baseline value, age, and cohort as covariates. Within-group changes were analyzed using repeated measures analysis of variance (ANOVA), which included age and cohort as covariates. These were complete case analyses. Analyses were performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp, Armonk, NY, USA).
CONSORT flow diagram for
Participant completion of
The baseline characteristics of participants are displayed in
The posthoc ANCOVA analyses results (displayed in
Baseline characteristics of participants.
Variable | Comparison group (n=44) | Intervention group (n=42) | All (n=86) | |
Male | 19 (43) | 24 (57) | 43 (50) | |
Female | 25 (57) | 18 (43) | 43 (50) | |
Child age (months), mean (SD) | 43 (12.26) | 40 (9.65) | 42 (11.05) | |
Child age (years), mean (SD) | 3.55 (1.02) | 3.36 (0.80) | 3.46 (0.92) | |
Child body mass index (BMI), mean (SD) | 16.72 (0.92) | 17.28 (1.44) | 17.01 (1.24) | |
Healthy weight | 38 (86) | 40 (95) | 78 (91) | |
Overweight | 5 (11) | 2 (5) | 7 (8) | |
Obese | 1 (2) | 0 (0) | 1 (1) | |
Median BMI percentile range | 85 to ≤95 | 75 to ≤85 | 75 to ≤85 | |
Aboriginal | 4 (9) | 1 (2) | 5 (6) | |
Torres Strait Islander | 0 (0) | 0 (0) | 0 (0) | |
No | 39 (89) | 40 (95) | 79 (92) | |
Not answered | 1 (2) | 1 (2) | 2 (2) | |
Male | 1 (2) | 2 (5) | 3 (3) | |
Female | 43 (98) | 40 (95) | 83 (97) | |
Participating parent’s age, mean (SD) | 34.91 (4.68) | 35.45 (4.95) | 35.17 (4.80) | |
Not university qualified | 22 (50) | 8 (19) | 30 (35) | |
University qualified | 22 (50) | 32 (76) | 54 (63) | |
Currently studying | 0 (0) | 2 (5) | 2 (2) | |
<$580/week | 23 (52) | 20 (48) | 43 (50) | |
$580-$1240/week | 15 (34) | 16 (38) | 31 (36) | |
>$1240/week | 6 (14) | 6 (14) | 12 (14) | |
BMI of participating parent, mean (SD) | 27.38 (21.61) | 24.81 (4.64) | 26.08 (5.97) | |
Underweight | 1 (2) | 1 (2) | 2 (2) | |
Healthy weight | 15 (34) | 26 (62) | 42 (49) | |
Overweight | 13 (30) | 9 (21) | 22 (26) | |
Obese | 11 (25) | 6 (14) | 17 (20) | |
Not answered | 3 (7) | 0 (0) | 3 (3) | |
Aboriginal | 2 (4.55) | 1 (2.38) | 3 (3.49) | |
No | 41 (88.64) | 40 (95.24) | 81 (94.19) | |
Not answered | 1 (2.27) | 1 (2.38) | 2 (2.33) | |
Biological mother | 41 (93) | 39 (93) | 80 (93) | |
Biological father | 2 (5) | 2 (5) | 4 (5) | |
Other | 1 (2) | 1 (2) | 2 (2) | |
Single/divorced/separated/widowed | 10 (23) | 3 (7) | 13 (15) | |
Married/with partner | 34 (77) | 39 (93) | 73 (85) | |
BMI of other parent, mean (SD) | 27.61 (4.51) | 28.24 (6.72) | 27.95 (5.76) | |
Underweight | 0 (0) | 0 (0) | 0 (0) | |
Healthy weight | 9 (20) | 15 (36) | 24 (28) | |
Overweight | 13 (30) | 9 (21) | 22 (26) | |
Obese | 9 (20) | 11 (26) | 20 (23) | |
No answer/not applicable | 13 (30) | 7 (17) | 19 (22) | |
<$580/week | 6 (14) | 5 (12) | 11 (13) | |
$580-$1240/week | 20 (45) | 19 (45) | 39 (45) | |
>$1240/week | 9 (20) | 15 (36) | 24 (28) | |
No answer/not applicable | 9 (20) | 3 (7) | 12 (14) | |
English | 40 (91) | 37 (88) | 77 (90) | |
Other | 4 (9) | 5 (12) | 9 (10) | |
Early childhood education center | 18 (41) | 16 (38) | 34 (40) | |
Flyer | 5 (11) | 7 (17) | 12 (14) | |
Early childhood nurse/center | 2 (5) | 5 (12) | 7 (8) | |
0 (0) | 4 (10) | 4 (5) | ||
School newsletter | 2 (5) | 1 (2) | 3 (3) | |
Media (print, television, and radio) | 2 (5) | 1 (2) | 3 (3) | |
Social media | 5 (11) | 4 (10) | 9 (10) | |
Playgroup | 3 (7) | 0 (0) | 3 (3) | |
Other | 7 (16) | 4 (10) | 11 (13) |
aWorld Health Organization definition [
Mean (SD) values for primary and secondary outcomes at each time point.
Variable | Baseline, mean (SD) | 3 months, mean (SD) | 6 months, mean (SD) | ||||
Comparison (n=44) | Intervention (n=42) | Comparison (n=40) | Intervention (n=38) | Comparison (n=40) | Intervention (n=38) | ||
Body mass index (BMI) | 17.28 (1.44) | 16.72 (0.92) | 16.99 (1.25) | 16.46 (0.80) | 16.87 (1.24) | 16.51 (0.75) | |
Median BMI percentile range | 85 to ≤95 | 75 to ≤85 | 85 to ≤95 | 75 to ≤85 | 85 to ≤95 | 75 to ≤85 | |
kJ/kg of body weighta | 330.43 (125.08) | 343.64 (112.01) | 296.24 (114.64) | 303.75 (120.15) | 296.20 (82.05) | 327.60 (104.06)b | |
Percentage of kJ from sugara | 22.24 (6.75 | 20.14 (7.01) | 21.15 (7.30) | 20.83 (6.02) | 19.29 (7.01) | 19.54 (6.95)b | |
Percentage of kJ from saturated fata | 12.52 (4.77) | 11.74 (3.95) | 11.58 (3.84) | 11.37 (3.91) | 12.50 (3.74) | 11.00 (3.90)b | |
Servings of fruitc | 2.91 (1.03) | 2.52 (0.92) | 2.95 (0.96) | 2.47 (0.83) | 2.88 (1.04) | 2.53 (0.86) | |
Servings of vegetablesc | 2.34 (1.08) | 2.62 (1.27) | 2.53 (1.22) | 2.84 (1.22) | 2.65 (1.05) | 2.97 (1.28) | |
Discretionary food frequency scored | 11.73 (2.86) | 11.21 (3.82) | 11.60 (2.73) | 9.82 (3.21) | 11.90 (2.29) | 10.40 (3.22) | |
Nutrition self-efficacye | 7.94 (1.13) | 8.19 (1.36) | 8.28 (1.19) | 8.69 (0.97) | 8.30 (1.22) | 8.89 (0.89) | |
Child feeding–restrictionf | 3.60 (0.92) | 3.630 (0.78) | 3.73 (0.84) | 3.69 (0.75) | 3.58 (0.89) | 3.66 (0.79) | |
Child feeding–pressuref | 2.34 (0.98) | 2.52 (0.99) | 2.34 (1.09) | 2.17 (1.08) | 2.43 (1.04) | 2.14 (0.99) | |
Parent modelingg | 3.95 (0.76) | 3.98 (0.79) | 3.93 (0.85) | 4.18 (0.55) | 4.16 (0.73) | 4.36 (0.54) | |
Sleep reluctanceh | 3.00 (1.24) | 2.36 (1.06) | 2.65 (1.00) | 2.13 (0.99) | 2.68 (0.97) | 2.24 (1.14)b | |
Duration (hours)i | 9.59 (0.93) | 9.85 (0.78) | 9.74 (0.72) | 9.91 (0.62) | 9.78 (0.96) | 9.54 (0.64) | |
Latency (minutes)i | 19.92 (16.55) | 20.98 (14.41) | 19.97 (18.05) | 16.44 (11.91) | 22.19 (11.85) | 25.00 (18.03) | |
Week day (hours)j | 2.52 (2.55) | 2.82 (3.87) | 1.37 (1.06) | 1.73 (2.47) | 2.20 (2.91) | 1.26 (0.99) | |
Weekend day (hours)j | 2.94 (1.98) | 3.15 (2.95) | 2.31 (1.56) | 1.84 (1.43) | 2.68 (2.33) | 2.04 (1.39) | |
Sedentary timei | 46.28 (7.98) | 47.44 (11.09) | 48.28 (7.87) | 49.17 (4.03) | 46.45 (6.21) | 49.47 (5.56) | |
Light, moderate, and vigorous physical activityi | 27.74 (7.40) | 25.82 (6.24) | 26.18 (6.16) | 25.61 (4.38) | 27.73 (5.42) | 25.44 (4.93) | |
Moderate-to-vigorous physical activityi | 13.88 (5.04) | 12.02 (3.60) | 13.56 (4.43) | 12.91 (3.70) | 14.38 (4.11) | 13.01 (3.77) |
aCalculated from 24-hour diet recall using Easy Diet Diary/Foodworks.
bn=37.
cFrom food questionnaire.
dScored from food questionnaire questions on frequency of intake of takeaway or fast food; sugary cereals; potato chips or other salty foods; sweets; and cakes, doughnuts, sweet cookies, or muffins. Responses of never or rarely, 1 to 3 times per month, 1 to 2 times per week, 3 to 4 times per week, 5 to 6 times per week, once per day, and 2 or more times per day were coded as 1 to 6, respectively, and summed to obtain a discretionary food score.
eSelf-efficacy questionnaire.
fChild-feeding questionnaire.
gParent modeling questionnaire.
hFrom sleep questionnaire.
iAccelerometer measures.
jFrom screen time questionnaire.
Results of intention-to-treat analyses for primary and secondary outcomes; linear mixed model group × time interaction (random intercept and compound symmetry covariance structure). Age, cohort, and baseline values included as covariates in the model (n=86).
Variable | Estimate | 95% CI | |
Body mass index | −0.11 | −0.34 to 0.12 | .35 |
kJ/kg of body weightb | 10.89 | −29.94 to 51.73 | .60 |
Percentage of kJ from sugarb | −0.09 | −2.44 to 2.25 | .94 |
Percentage of kJ from saturated fatb | −0.61 | −3.09 to 1.87 | .63 |
Servings of fruitc | −0.24 | −0.58 to 0.10 | .17 |
Servings of vegetablesc | 0.17 | −0.15 to 0.49 | .24 |
Discretionary food frequency scored | −1.36 | −2.27 to −0.45 | <.01 |
Nutrition self-efficacye | 0.43 | 0.10 to 0.76 | |
Child feeding–restrictiong | 0.04 | −0.21 to 0.29 | .76 |
Child feeding–pressureg | −0.30 | −0.61 to −0.00 | |
Parent modelingh | 0.21 | −0.02 to 0.44 | .08 |
Sleep duration (hours)i | −0.22 | −0.57 to 0.13 | .21 |
Sleep latency (minutes)i | −0.25 | −0.79 to 0.74 | .95 |
Sleep reluctancej | −0.36 | −0.77 to 0.06 | .09 |
Screen time–week day (hours)k | −0.20 | −0.87 to 0.47 | .56 |
Screen time–weekend day (hours)k | −0.40 | −0.90 to 0.10 | .11 |
Percentage sedentary timei | 0.84 | −1.60 to −3.27 | .49 |
Percentage light, moderate, and vigorous intensity physical activityi,k | −0.99 | −2.20 to 2.01 | .93 |
Percentage moderate-to-vigorous intensity physical activityi | 0.54 | −0.94 to 2.01 | .47 |
aSignificant at
bCalculated from 24-hour diet recall using Easy Diet Diary/Foodworks.
cFrom Food Questionnaire.
dScored from food questionnaire questions on the frequency of intake of takeaway or fast food; sugary cereals; potato chips or other salty foods; sweets; and cakes, doughnuts, sweet cookies, or muffins. Responses of never or rarely, 1 to 3 times per month, 1 to 2 times per week, 3 to 4 times per week, 5 to 6 times per week, once per day, and 2 or more times per day were coded as 1 to 6, respectively, and summed to obtain a discretionary food score.
eSelf-efficacy questionnaire.
fItalicized text: statistically significant result.
gChild feeding questionnaire.
hParent modeling questionnaire.
iAccelerometer measures.
jFrom sleep questionnaire.
kFrom screen time questionnaire.
Adjusted mean differences (and 95% CI) for primary and secondary outcomes at 3 months (complete case analyses). Analysis of covariance (ANCOVA) analyses, with baseline value, age, and cohort as covariates (n=78).
Variable | Intervention comparison, adjusted mean difference (95% CI) | |
Body mass index | −0.23 (−0.50 to 0.04) | .09 |
kJ/kg of body weightb | −0.57 (−57.71 to 46.26) | .83 |
Percentage of kJ from sugarb | −0.23 (−3.29 to 2.83) | .88 |
Percentage of kJ from saturated fatb | −0.15 (−1.94 to 1.63) | .87 |
Servings of fruitc | −0.31 (−0.69 to 0.07) | .11 |
Servings of vegetablesc | 0.19 (−0.23 to 0.60) | .37 |
Frequency discretionary foodsd | −1.45 (−2.47 to −0.43) | .01 |
Nutrition self-efficacye | 0.33 (−0.03 to 0.69) | .07 |
Child feeding–restrictionf | 0.01 (−0.28 to 0.29) | .96 |
Child feeding–pressuref | −0.27 (−0.61 to 0.07) | .12 |
Parent modelingg | 0.24 (0.06 to 0.53) | .12 |
Sleep durationh | 0.04 (−0.35 to 0.43) | .84 |
Sleep latencyh | −4.46 (−13.91 to 4.98) | .35 |
Sleep reluctancei | −0.36 (−0.82 to 0.09) | .11 |
Screen time–weekdayj | 0.45 (−0.36 to 1.27) | .27 |
Screen time–weekendj | −0.30 (−0.86 to 0.26) | .29 |
Percentage sedentary timeh | 0.14 (−2.76 to 3.04) | .92 |
Percentage light, moderate, and vigorous intensity physical activityh | 0.92 (−1.60 to 3.44) | .47 |
Percentage moderate-to-vigorous intensity physical activityh | 1.10 (−0.65 to 2.84) | .21 |
aSignificant at
bCalculated from 24-hour diet recall using Easy Diet Diary/Foodworks.
cFrom food questionnaire.
dScored from food questionnaire questions on frequency of intake of takeaway or fast food; sugary cereals; potato chips or other salty foods; sweets; and cakes, doughnuts, sweet cookies, or muffins. Responses of never or rarely, 1 to 3 times per month, 1 to 2 times per week, 3 to 4 times per week, 5 to 6 times per week, once per day, and 2 or more times per day were coded as 1-6, respectively, and summed to obtain a discretionary food score.
eSelf-efficacy questionnaire.
fChild feeding questionnaire.
gParent modeling questionnaire.
hAccelerometer measures.
iFrom sleep questionnaire.
jFrom screen time questionnaire.
Adjusted mean differences (and 95% CI) for primary and secondary outcomes at 6 months (complete case analyses). Analysis of covariance (ANCOVA) analyses, with baseline value, age, and cohort as covariates (n=78).
Variable | Intervention comparison, adjusted mean difference (95% CI) | |
Body mass index | 0.01 (−0.27 to −0.29) | .95 |
kJ/kg of body weightb | 24.80 (−17.75 to 67.35) | .25 |
Percentage of kJ from sugarb | 0.05 (−3.18 to 3.29) | .97 |
Percentage of kJ from saturated fatb | −1.41 (−3.19 to 0.37) | .12 |
Servings of fruitc | −0.17 (−0.57 to 0.23) | .39 |
Servings of vegetablesc | 0.16 (−0.24 to 0.56) | .44 |
Frequency discretionary foodsd | −1.30 (−2.34 to −0.26) | .02 |
Nutrition self-efficacye | 0.53 (0.13 to 0.93) | .01 |
Child feeding–restrictionf | 0.10 (−0.18 to 0.37) | .48 |
Child feeding–pressuref | −0.35 (−0.68 to −0.02) | .04 |
Parent modelingg | 0.18 (−0.05 to 0.41) | .12 |
Sleep durationh | −0.55 (−1.01 to −0.03) | .04 |
Sleep latencyh | 6.00 (−4.09 to 16.09) | .24 |
Sleep reluctancei | −0.33 (−0.82 to 0.15) | .18 |
Screen time–weekdayj | −0.84 (−1.76 to 0.07) | .07 |
Screen time–weekendj | −0.49 (−1.14 to 0.15) | .13 |
Percentage sedentary timek | 1.590 (−1.415 to 4.60) | .29 |
Percentage light, moderate, and vigorous intensity physical activityh | −1.106 (−3.601 to 1.40) | .38 |
Percentage moderate-to-vigorous intensity physical activityh | −1.110 (−1.912 to 1.69) | .90 |
aSignificant at
bCalculated from 24-hour diet recall using Easy Diet Diary/Foodworks.
cFrom food questionnaire.
dScored from food questionnaire questions on frequency of intake of takeaway or fast food; sugary cereals; potato chips or other salty foods; sweets; and cakes, doughnuts, sweet cookies, or muffins. Responses of never or rarely, 1 to 3 times per month, 1 to 2 times per week, 3 to 4 times per week, 5 to 6 times per week, once per day, and 2 or more times per day were coded as 1-6, respectively, and summed to obtain a discretionary food score.
eSelf-efficacy questionnaire.
fChild feeding questionnaire.
gParent modeling questionnaire.
hAccelerometer measures.
iFrom sleep questionnaire.
jFrom screen time questionnaire.
Question | Strongly agree, n (%) | Agree, n (%) | Neutral, n (%) | Disagree, n (%) | Strongly disagree, n (%) | Not applicable, n (%) |
The program content was interesting | 21 (55) | 15 (39) | 2 (5) | 0 (0) | 0 (0) | 0 (0) |
The program content was easy to understand | 28 (74) | 10 (26) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
The program content was relevant | 22 (58) | 15 (39) | 1 (3) | 0 (0) | 0 (0) | 0 (0) |
The length of the program was appropriate | 15 (39) | 18 (47) | 2 (5) | 3 (8) | 0 (0) | 0 (0) |
One module every 2 weeks was appropriate | 11 (29) | 23 (61) | 4 (11) | 0 (0) | 0 (0) | 0 (0) |
The tips and tricks for parents was helpful | 20 (53) | 17 (45) | 1 (3) | 0 (0) | 0 (0) | 0 (0) |
The information about meals was helpful | 22 (58) | 13 (34) | 2 (5) | 1 (3) | 0 (0) | 0 (0) |
There was enough information in the module about meals | 14 (37) | 20 (53) | 0 (0) | 4 (11) | 0 (0) | 0 (0) |
The information on snacks and drinks was helpful | 21 (55) | 15 (39) | 1 (3) | 1 (3) | 0 (0) | 0 (0) |
There was enough information in the module about snacks and drinks | 15 (39) | 19 (50) | 2 (5) | 2 (5) | 0 (0) | 0 (0) |
The information about physical activity was helpful | 20 (53) | 16 (42) | 2 (5) | 0 (0) | 0 (0) | 0 (0) |
There was enough information in the module about physical activity | 19 (50) | 17 (45) | 2 (5) | 0 (0) | 0 (0) | 0 (0) |
The information on screen time was helpful | 20 (53) | 13 (34) | 4 (11) | 1 (3) | 0 (0) | 0 (0) |
There was enough information in the module about screen time | 14 (37) | 20 (53) | 4 (11) | 0 (0) | 0 (0) | 0 (0) |
The information about sleep was helpful | 11 (29) | 19 (50) | 6 (16) | 0 (0) | 1 (3) | 1 (3) |
There was enough information about sleep | 8 (21) | 24 (63) | 4 (11) | 0 (0) | 1 (3) | 1 (3) |
The goal setting was helpful | 12 (32) | 18 (47) | 7 (18) | 1 (3) | 0 (0) | 0 (0) |
The number of goals set was appropriate | 12 (32) | 18 (47) | 7 (18) | 0 (0) | 1 (3) | 0 (0) |
The health consultants were helpful and knowledgeable | 20 (53) | 15 (39) | 1 (3) | 1 (3) | 0 (0) | 1 (3) |
The time the health consultants responded in was appropriate | 21 (55) | 16 (42) | 0 (0) | 0 (0) | 0 (0) | 1 (3) |
The online delivery mode was suitable | 19 (50) | 18 (47) | 1 (3) | 0 (0) | 0 (0) | 0 (0) |
The Facebook group component was useful | 3 (8) | 12 (32) | 18 (47) | 4 (11) | 1 (3) | 0 (0) |
Overall, 38 participants from the intervention group (38/42, 90%) completed the process evaluation questionnaire. The results are displayed in
In this RCT, we found no significant difference in the BMI change between the 2 groups at 6 months post baseline. There were no significant differences in physical activity, screen time, or sleep outcomes between groups. The intervention did, however, demonstrate some positive group-by-time outcomes in relation to dietary intake, child feeding, and nutrition parent self-efficacy. To the best of our knowledge,
Our null finding regarding BMI change at 6 months aligns with similar eHealth obesity prevention studies conducted in young [
Other eHealth parent-focused studies have demonstrated similar improvements in dietary outcomes, such as energy dense food consumption [
Our null findings in regard to kJ/kg body weight and kJ from sugar and saturated fat were perhaps due to the fact that (due to resource constraints) the 24-hour recall was administered on 1 single weekday at each time point and was not sufficient to capture regular and weekend consumption patterns. It is also possible that the intervention effects on each of the obesity-related behaviors could have been diluted due to the multi-behavior focus and breadth of the content covered compared with previous studies that have focused on fewer behaviors.
Similar eHealth parent-focused studies in a range of age groups have shown mixed physical activity outcomes [
There was a significant group-by-time interaction for nutrition parent self-efficacy but no significant differences between the intervention and comparison groups for parent self-efficacy in relation to physical activity, screen time, or sleep. The reason why positive outcomes were achieved for nutrition parent self-efficacy and not for the other behaviors is unclear, but it may be due to the higher proportion of program time dedicated to healthy eating and nutrition (2 modules compared with only 1 module for the other behaviors) and the larger number of videos, providing a greater opportunity for vicarious learning.
It is established that parent self-efficacy is crucial for implementing obesity-related behavior change in children [
There was a significant group-by-time interaction for “pressure-to-eat” child feeding practices, but there was no significant difference between groups for “restriction” of child-feeding practices. Despite the body of evidence regarding child feeding practices and risk of overweight and obesity, there are limited studies that have used child feeding as an outcome measure. No other eHealth study to the best of our knowledge has assessed child feeding practices; hence, the outcomes of this study will be compared with traditionally delivered programs in preschool-aged children. Similar to this study, a significant improvement in “pressure-to-eat” child feeding practices was reported in a group that received a regular newsletter (compared with a group that received a single booklet), but no significant changes in other child-feeding practices were reported in a study of mothers of African American preschool-aged children [
Research clearly demonstrates the need to intervene early to establish healthy behaviors [
A cost-effectiveness analysis was not within the scope of this study. Although it is generally perceived that eHealth interventions are more cost-effective than traditionally delivered programs, more research is needed [
Recruitment for this study was challenging, despite the expansion of the recruitment area and extension of the recruitment period, and we are not able to determine with certainty the factors involved in the lower than anticipated sample size without further investigation. Further work is required to explore optimal avenues to access at-risk and hard-to-reach populations. The program was marketed as a “healthy lifestyle program” and appeared to be more successful in recruiting parents of children in the healthy weight range than overweight or obese ranges. Parental awareness of their child’s weight status may have been a factor in the low enrollment rates in the overweight and obese ranges. Previous research has found that the majority of parents do not recognize that their child is overweight [
This study used a randomized controlled design, applying a backwards intervention mapping exercise to align the intervention with social cognitive theory [
There are several limitations of this study. Although it was intentional to include healthy weight children in this study, there were a higher than anticipated proportion of children (over 90%, 78/86) in the healthy weight range. Therefore, the effect on BMI may have been diluted. Due to the small number of children in the overweight and obese ranges, it was not possible to conduct a subanalysis of these participants. Statistical power would have been affected by the fact that the target sample size was not achieved despite measures to enhance participant recruitment, including expanding the recruitment area and extending the recruitment period. It is also possible that a longer follow-up period may have been required to demonstrate differences in BMI change between groups. As there were multiple outcomes assessed, there is a risk that there may have been a type 1 error. Questionnaire-based measures and the 24-hour recall used for secondary outcomes, involving self-reporting of data, were used, and therefore, it may have been possible that parents misreported this information (either intentionally or unintentionally) and such misreporting would probably have occurred in both groups. This is a familiar challenge to researchers assessing behavioral outcomes [
In conclusion,
CONSORT‐EHEALTH checklist (V 1.6.1).
analysis of covariance
analysis of variance
body mass index
electronic health
intention-to-treat
randomized controlled trial
World Health Organization
The authors would like to thank the data collectors who assisted with this study and Penny Cross for her assistance with data management and randomization. The authors would also like to thank the parents and carers and children who participated in the study and the individuals and organizations who disseminated information about the study to families. This research has been conducted with the support of the Australian Government Research Training Program Scholarship. The study was also supported by funding from the Telstra Foundation and Australian Health Management. The funding body was not involved in the design, data collection, analysis, interpretation, or writing.
The University of Wollongong developed the