Digital Intervention Reduces Early Childhood Obesity Risk in Diverse Populations

Incorporating a digital intervention into health behavior counseling improved growth trajectories and reduced obesity risk over the first 24 months among children of racially and ethnically diverse backgrounds vs health behavior counseling alone, according to a study published in JAMA.¹

Childhood obesity is highly prevalent in the US, with significant health disparities by race, ethnicity, and socioeconomic status.² The researchers noted that these disparities emerge in early childhood, suggesting the need for early intervention strategies.¹ Digital interventions are considered well-suited for reducing health disparities in childhood obesity, but those designed to prevent obesity in the first 2 years of life have been largely unsuccessful.

For example, Greenlight, a health literacy–informed, primary care–based intervention, improved infant weight-for-length trajectories through 18 months of age, but these improvements were not sustained through 24 months.³ Consequently, the researchers conducted the Greenlight Plus Trial to analyze the effectiveness of adding a digital childhood obesity prevention intervention to health behavior counseling delivered by pediatric primary care clinicians.¹

They predicted that children randomized to receive the digital intervention plus health behavior counseling would have healthier weight-for-length trajectories over the first 24 months of life, along with lower incidence of overweight and/or obesity, than those randomized to receive health behavior counseling alone.

Combining a digital intervention with health behavior counseling improved weight trajectories and lowered obesity risk in racially and ethnically diverse children over 24 months. | Image Credit: Farknot Architect - stock.adobe.com

Patients were enrolled shortly after birth at 6 medical centers: Duke University, Stanford University, University of Miami, New York University Grossman School of Medicine/Bellevue Hospital Center, University of North Carolina at Chapel Hill, and Vanderbilt University Medical Center. The study was conducted in clinics affiliated with each medical center, including 3 staffed by pediatricians and advanced practice health professionals and 7 staffed by medical residents.

The researchers used extensive eligibility criteria when enrolling parent-child pairs. For parents, this included being 18 years or older, having English or Spanish as their preferred language, and owning a smartphone with access to data services. Conversely, the eligibility criteria for children included being born after 34 weeks gestation at a weight greater than 1500 g. Study enrollment occurred between October 2019 and January 2022, with follow-up through January 2024.

After enrollment, randomization to either the clinic-only group or the clinic + digital intervention group was stratified by medical center, baseline health literacy level, and parent language. Principal investigators, outcome assessors, and study directors were blinded to all randomization assignments.

Families in the clinic-only group received health behavior counseling from pediatric primary care clinicians; clinicians used health literacy–informed booklets to promote healthy behaviors at well-child visits. Conversely, families in the clinic + digital intervention group received health behavior counseling in addition to health literacy–informed, individually tailored, responsive text messages and a web-based dashboard to support health behavior goals.

Overall, the primary outcome was child weight-for-length trajectory over 24 months. Secondary outcomes included body mass index (BMI) z score, weight-for-length z score, and the percentage of children overweight or obese.

Of 3224 parent-child pairs assessed, the researchers determined 900 as eligible. They randomized 449 pairs to the clinic + digital intervention group and 451 to the clinic-only group.

Among the children included, 405 (45.0%) were Hispanic, 185 (20.6%) were non-Hispanic White, 143 (15.9%) were non-Hispanic Black, and 165 (18.3%) identified as other or multiple races and ethnicities. At 24 months, same-day weight and length measures were available for 385 (85.7%) children in the clinic + digital intervention group and 392 (86.9%) in the clinic-only group.

Conversely, among the parents, 587 (65.2%) opted to receive the intervention in English, while 313 (34.8%) opted for Spanish. Additionally, 141 (15.6%) reported household food insecurity, and 500 (55.6%) had limited health literacy.

The researchers found that, at 24 months, the mean (SD) weight-for-length was 14.8 (1.6) kg/m in the clinic + digital intervention group and 15.1 (1.9) kg/m in the clinic-only group. Therefore, the clinic + digital intervention group had a lower mean weight-for-length trajectory at 24 months, with an estimated reduction of 0.33 kg/m (95% CI, 0.09-0.57).

Also, between groups, there was an adjusted mean difference of –0.19 (95% CI, –0.37 to 0.57) at 24 months for weight-for-length and BMI z scores. Based on the CDC BMI criteria (BMI ≥85th percentile), the number of children considered overweight or obese at 24 months was not statistically different between the clinical + digital intervention (23.2%) and clinic-only (24.5%) groups (adjusted risk ratio [aRR], 0.91; 95% CI, 0.70-1.17).

However, the incidence of child obesity (BMI ≥95th percentile) at 24 months was significantly lower in the clinic + digital intervention group (7.4%) compared with the clinic-only group (12.7%; aRR, 0.56; 95% CI, 0.36-0.88). Consequently, the researchers concluded that the text messaging and web-based intervention improved child weight-for-length trajectory from baseline to 24 months.

The researchers acknowledged their study’s limitations, including that some US population groups were underrepresented or not represented at all and that patients who did not prefer to speak Spanish or English were excluded from the study. Despite their limitations, they expressed confidence in their findings and suggested areas for further research.

“The substantial reduction in risk of childhood obesity observed in this study could have significant population-level impact if implemented at scale, suggesting that broader implementation studies are warranted,” the authors concluded.

References

1. Heerman WJ, Rothman RL, Sanders LM, et al. A digital health behavior intervention to prevent childhood obesity: the Greenlight Plus randomized clinical trial. JAMA. Published online November 3, 2024. doi:10.1001/jama.2024.22362
2. Hu K, Staiano AE. Trends in obesity prevalence among children and adolescents aged 2 to 19 years in the US from 2011 to 2020. JAMA Pediatr. 2022;176(10):1037–1039. doi:10.1001/jamapediatrics.2022.2052
3. Sanders LM, Perrin EM, Yin HS, et al. A health-literacy intervention for early childhood obesity prevention: a cluster-randomized controlled trial. Pediatrics. 2021;147(5):e2020049866. doi:10.1542/peds.2020-049866