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Impact of Technology and School-Based Nutrition Education Programs on Nutrition Knowledge and Behavior during Adolescence--A Systematic Review

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Title: Impact of Technology and School-Based Nutrition Education Programs on Nutrition Knowledge and Behavior during Adolescence--A Systematic Review
Language: English
Authors: Tallon, J. M., Saavedra Dias, R., Costa, A. M. (ORCID 0000-0003-0296-9707), Leitão, J. C., Barros, A., Rodrigues, V., Monteiro, M. J., Almeida, A., Narciso, J., Silva, A. J.
Source: Scandinavian Journal of Educational Research. 2021 65(1):169-180.
Availability: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 12
Publication Date: 2021
Document Type: Journal Articles
Reports - Research
Information Analyses
Descriptors: Influence of Technology, Technology Integration, Electronic Learning, Video Technology, Game Based Learning, Web Based Instruction, Nutrition Instruction, Knowledge Level, School Activities, Program Effectiveness, Intervention, Adolescents, Health Behavior, Eating Habits, Obesity, Dietetics, Educational Research
DOI: 10.1080/00313831.2019.1659408
ISSN: 0031-3831
Abstract: This study aimed to summarize the evidence of the impact of school-based nutrition education programs that incorporate technology on the acquisition of nutrition-related knowledge and behavior change of adolescents. Literature searches were conducted using Cochrane Library, Pubmed, Scopus, Science Direct, and Web of Science databases. Studies published between 2000 and 2018, with adolescents aged from 12 to 18 years, fully available in English, which involved technology-based school interventions, and reported nutrition-related outcomes, were included. Thirteen studies met all the inclusion criteria. Overall, all studies presented positive effects, though these results did not persist. It is feasible to use technology-based approaches in this type of intervention programs, but it is necessary to improve the interventions so that long-lasting results are achieved.
Abstractor: As Provided
Entry Date: 2021
Accession Number: EJ1284833
Database: ERIC
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  Value: <anid>AN0148343820;55b01feb.21;2021Jan29.05:14;v2.2.500</anid> <title id="AN0148343820-1">Impact of Technology and School-Based Nutrition Education Programs on Nutrition Knowledge and Behavior During Adolescence—A Systematic Review </title> <p>This study aimed to summarize the evidence of the impact of school-based nutrition education programs that incorporate technology on the acquisition of nutrition-related knowledge and behavior change of adolescents. Literature searches were conducted using Cochrane Library, Pubmed, Scopus, Science Direct, and Web of Science databases. Studies published between 2000 and 2018, with adolescents aged from 12 to 18 years, fully available in English, which involved technology-based school interventions, and reported nutrition-related outcomes, were included. Thirteen studies met all the inclusion criteria. Overall, all studies presented positive effects, though these results did not persist. It is feasible to use technology-based approaches in this type of intervention programs, but it is necessary to improve the interventions so that long-lasting results are achieved.</p> <p>Keywords: Nutrition education; school programs; technology-based; systematic review</p> <hd id="AN0148343820-2">Introduction</hd> <p>Behavioral patterns established during childhood are often carried over into adulthood. A good example of this are the eating patterns (Hampson, [<reflink idref="bib23" id="ref1">23</reflink>]; Law, [<reflink idref="bib28" id="ref2">28</reflink>]; Mikkilä, Räsänen, Raitakari, Pietinen, & Viikari, [<reflink idref="bib34" id="ref3">34</reflink>]). Over the past decades, the quality of children and adolescents' diet has deteriorated worldwide. Current dietary information indicates that teenagers are not meeting dietary recommendations, especially regarding to fruit and vegetables consumption (Al Ani, Al Subhi, & Bose, [<reflink idref="bib2" id="ref4">2</reflink>]; Guenther, Dodd, Reedy, & Krebs-smith, [<reflink idref="bib20" id="ref5">20</reflink>]; Jones et al., [<reflink idref="bib25" id="ref6">25</reflink>]; Lynch et al., [<reflink idref="bib31" id="ref7">31</reflink>]); furthermore, the consumption of processed food, fat (Braithwaite et al., [<reflink idref="bib6" id="ref8">6</reflink>]), and sugary drinks has increased in a concerning way (Krebs-Smith, Guenther, Subar, Kirkpatrick, & Dodd, [<reflink idref="bib26" id="ref9">26</reflink>]; St-Onge, Keller, & Heymsfield, [<reflink idref="bib44" id="ref10">44</reflink>]; Wang, Bleich, & Gortmaker, [<reflink idref="bib48" id="ref11">48</reflink>]). Poor eating habits are closely correlated with an increase in obesity and overweight. Overweight adolescents have an increased chance of becoming overweight adults (Biro & Wien, [<reflink idref="bib4" id="ref12">4</reflink>]; Lifshitz, [<reflink idref="bib29" id="ref13">29</reflink>]), and many carry with them obesity-related morbidities into adulthood with serious long-life consequences even if the obesity does not persist (Must, Jacques, Dallal, Bajema, & Dietz, [<reflink idref="bib36" id="ref14">36</reflink>]). Therefore, it is imperative to implement interventions in this target population, to stem the growth of this epidemic public health problem. Since most adolescents attend to school on a daily basis, school-based programs represent an ideal setting to enhance healthy eating habits, both in terms of behavior change and nutrition education, and develop skills that allow students to make better decisions towards healthy eating habits and to adopt a healthy lifestyle (Dudley, Cotton, & Peralta, [<reflink idref="bib17" id="ref15">17</reflink>]). The importance of the early learning of nutrition-related knowledge, skills and behaviors, towards future health, has long been recognized (Contento et al., [<reflink idref="bib12" id="ref16">12</reflink>]) and there is evidence that eating patterns are more likely to improve, when changes in the school environment are complemented with classroom nutrition education (Story, Nanney, & Schwartz, [<reflink idref="bib45" id="ref17">45</reflink>]). Some studies reported difficulties in conducting effective nutrition learning activities, since most students show a lack of interest in nutrition- and health-related topics. The use of teaching tools that capture children's attention for these subjects is therefore essential (Kreisel, [<reflink idref="bib27" id="ref18">27</reflink>]). Information and communication technologies (ICTs) allow traditional education methods to be combined with more interactive and engaging methods, making the learning process more appealing; moreover, adolescents have also demonstrated a preference for receiving health information in a digital way, rather than from printed materials (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref19">7</reflink>]). Several interventions using technology to prevent obesity have been tested inside and outside the school environment, and they had a positive influence on healthy behaviors (Di Noia, Contento, & Prochaska, [<reflink idref="bib14" id="ref20">14</reflink>]; Hamel & Robbins, [<reflink idref="bib22" id="ref21">22</reflink>]; Mauriello et al., [<reflink idref="bib33" id="ref22">33</reflink>]; Neville, O'Hara, & Milat, [<reflink idref="bib38" id="ref23">38</reflink>]). With the acceptance and substantial use of computers, smartphones, and internet both inside and outside school among adolescents, it seems that nutrition education would benefit from a technology-based delivery (Ajie & Chapman-Novakofski, [<reflink idref="bib1" id="ref24">1</reflink>]; Räihä, Tossavainen, Enkenberg, & Turunen, [<reflink idref="bib39" id="ref25">39</reflink>]). Some systematic reviews have been conducted to examine the impact of technology-based interventions on childhood and adolescent obesity (Ajie & Chapman-Novakofski, [<reflink idref="bib1" id="ref26">1</reflink>]; Chen & Wilkosz, [<reflink idref="bib9" id="ref27">9</reflink>]; do Amaral e Melo, de Carvalho Silva Vargas, dos Santos Chagas, Toral, & Nugent, [<reflink idref="bib15" id="ref28">15</reflink>]); however, to our knowledge no systematic review has evaluated the impact of technology-based interventions in school settings during adolescence, focusing exclusively on nutrition-related outcomes. Adolescence is a major critical developmental stage, marked by deep physiological, psychological, and social changes (Christie & Viner, [<reflink idref="bib10" id="ref29">10</reflink>]). Since adolescents are becoming more and more independent earlier in life and are seeking to learn competencies to become self-sufficient (Fordyce-Voorham, [<reflink idref="bib18" id="ref30">18</reflink>]), it is important to conduct such review to understand which will be the best approach to deliver the necessary information to adopt a long-term healthy lifestyle. Therefore, this systematic review aimed to summarize the most recent evidence to assess the impact of school-based nutrition education programs, using a technology-based approach on adolescents' nutrition-related knowledge and behavior.</p> <hd id="AN0148343820-3">Methodology</hd> <p>This systematic review was conducted and reported in accordance to the recommendation of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher, Liberati, Tetzlaff, & Altman, [<reflink idref="bib35" id="ref31">35</reflink>]).</p> <hd id="AN0148343820-4">Data Search</hd> <p>The following electronic databases were searched to identify possible relevant articles: Pubmed, Science Direct, Cochrane Library, Web of Science, and SCOPUS. For that, the following combination of keywords and Boolean operators were used: (<emph>nutrition</emph> OR <emph>food literacy</emph> OR <emph>obesity</emph> OR <emph>healthy habits</emph>) AND (<emph>adolescents</emph> OR <emph>youth</emph> OR <emph>teenagers</emph>) AND (<emph>computer-based</emph> OR <emph>ICT</emph> OR <emph>e-learning</emph> OR <emph>videogames</emph> OR <emph>internet</emph> OR <emph>web-based</emph>) AND (<emph>education</emph> OR <emph>school-based</emph> OR <emph>intervention</emph> OR <emph>school program</emph>). In addition, the reference lists of previous systematic reviews on similar topics were searched manually in order to find other relevant publications.</p> <hd id="AN0148343820-5">Selection Criteria</hd> <p>To be eligible for inclusion, the studies needed to be published between 2000 and 2018, be fully available in the English language and include participants aged from 12 to 18 years, independently of participants' gender, ethnic group, anthropometric classification, and socioeconomic status. In addition, articles were required to report a nutrition-related primary outcome (knowledge and/or behavior) and include only school-based interventions that used ICTs. There were no restrictions on study design, study duration, control condition, follow-up period and type of ICT used. Here, ICT refers to all communication technologies, which includes computers, cell phones, the internet, software, social networks, and other multimedia applications and services that enable users to use information in a digital form. Studies were excluded if they did not meet all the inclusion criteria, or if they included subjects out of the age range or with eating disorders/learning disabilities.</p> <hd id="AN0148343820-6">Quality Assessment</hd> <p>The methodological quality of the studies, included in this review, was critically assessed using the Downs & Black scoring system (Downs & Black, [<reflink idref="bib16" id="ref32">16</reflink>]). The checklist consists of 27 items divided into the following subscales: study quality (10 items), external validity (3 items), internal validity (13 items), and power of the study (1 item). The final scores can range from 0 to 32, with higher scores indicating a better methodological quality of the study.</p> <hd id="AN0148343820-7">Results</hd> <p></p> <hd id="AN0148343820-8">Literature Search</hd> <p>Figure 1 describes the searching process. In summary, the databases search retrieved 7,566 articles. The initial screening process reduced the number of articles to 43, and they underwent full-text analysis. Of those, 30 articles did not meet all the inclusion criteria. Thus, 13 publications were included in this systematic review.</p> <p>Graph: Figure 1. Flowchart describing the selection process according to PRISMA guidelines.</p> <hd id="AN0148343820-9">Participants' Characteristics</hd> <p>Participants' age ranged from 12 to 18 years, but only 2 studies included participants older than 16 years (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref33">7</reflink>]; Maes et al., [<reflink idref="bib32" id="ref34">32</reflink>]). The total sample consisted of 11,993 students; the sample size varied across studies ranging from 87 (Yang, Wang, Tsai, & Wang, [<reflink idref="bib49" id="ref35">49</reflink>]) to 6,737 (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref36">7</reflink>]) participants. Most studies included both genders, but two studies enrolled exclusively girls (Rees, Bakhshi, Surujlal-Harry, Stasinopoulos, & Baker, [<reflink idref="bib41" id="ref37">41</reflink>]; Yang et al., [<reflink idref="bib49" id="ref38">49</reflink>]). From the studies that included both genders, most enrolled a higher percentage of female subjects; two studies did not state the gender percentage of its participants (Bech-Larsen & Grønhøj, [<reflink idref="bib3" id="ref39">3</reflink>]; Räihä, Tossavainen, Turunen, Enkenberg, & Kiviniemi, [<reflink idref="bib40" id="ref40">40</reflink>]).</p> <hd id="AN0148343820-10">Studies Characteristics</hd> <p>Six studies were conducted in European countries (Bech-Larsen & Grønhøj, [<reflink idref="bib3" id="ref41">3</reflink>]; Haerens et al., [<reflink idref="bib21" id="ref42">21</reflink>]; Maes et al., [<reflink idref="bib32" id="ref43">32</reflink>]; Räihä et al., [<reflink idref="bib40" id="ref44">40</reflink>]; Rees et al., [<reflink idref="bib41" id="ref45">41</reflink>]; Turnin et al., [<reflink idref="bib46" id="ref46">46</reflink>]), four in the USA (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref47">7</reflink>]; Frenn et al., [<reflink idref="bib19" id="ref48">19</reflink>]; Long & Stevens, [<reflink idref="bib30" id="ref49">30</reflink>]; Mauriello et al., [<reflink idref="bib33" id="ref50">33</reflink>]), two in Asian countries (Chung & Fong, [<reflink idref="bib11" id="ref51">11</reflink>]; Yang et al., [<reflink idref="bib49" id="ref52">49</reflink>]), and one in Canada (Chamberland et al., [<reflink idref="bib8" id="ref53">8</reflink>]). The follow-up period ranged from one month (Frenn et al., [<reflink idref="bib19" id="ref54">19</reflink>]; Long & Stevens, [<reflink idref="bib30" id="ref55">30</reflink>]) to three years (Räihä et al., [<reflink idref="bib40" id="ref56">40</reflink>]). The majority of the studies only had one follow-up after the baseline assessment, with the exception of Maes et al. ([<reflink idref="bib32" id="ref57">32</reflink>]) (two follow-ups assessments), Mauriello et al. ([<reflink idref="bib33" id="ref58">33</reflink>]) (three follow-up assessments), and Chamberland et al. ([<reflink idref="bib8" id="ref59">8</reflink>]) (four follow-up assessments). All studies conducted outcome assessments immediately post-intervention. In addition, two studies conducted follow-up measurements sometime after the intervention ended in order to evaluate the maintenance of results (Chamberland et al., [<reflink idref="bib8" id="ref60">8</reflink>]; Mauriello et al., [<reflink idref="bib33" id="ref61">33</reflink>]). Both studies showed that the improvements achieved during the intervention were almost undetectable at the last measurement. A detailed characterization of the studies included is presented in Table 1.</p> <p>Table 1. Characteristics of the Studies Included in the Review.</p> <p> <ephtml> <table><thead valign="bottom"><tr><td>Authors, Year (Country)</td><td>Sample</td><td>Study description</td><td>Follow-up</td><td>Control</td><td>Significant results</td><td>Quality score</td></tr></thead><tbody><tr><td>Long and Stevens (<xref ref-type="bibr" rid="bibr30">2004</xref>) (USA)</td><td><italic>n</italic> = 121 Age: 12–16 Gender: mixed</td><td>Web-based game (5 hr) and traditional instruction about nutrition education</td><td>Baseline 1 month</td><td>Regular nutrition education</td><td>Nutrition knowledge increased; Healthier usual food choices; No significant change in eating behavior</td><td>15/32</td></tr><tr><td>Frenn et al. (<xref ref-type="bibr" rid="bibr19">2005</xref>) (USA)</td><td><italic>n</italic> = 89 Age: 12–14 Gender: mixed</td><td>Video sessions (8 × 2–3 min) focusing on the increase of physical activity and the reduction of dietary fat consumption followed by individual tailored feedback via e-mail</td><td>Baseline 1 month</td><td>Regular science classes</td><td>Decrease of fat intake on students participating in more than half of the sessions; Increase of physical activity</td><td>19/32</td></tr><tr><td>Casazza and Ciccazzo (<xref ref-type="bibr" rid="bibr7">2007</xref>) (USA)</td><td><italic>n</italic> = 6,737 Age: 13–18 Gender: mixed</td><td>Assessment of the effect of individual instruction using an interactive CD-ROM (5 × 45 min) comparing to traditional education</td><td>Baseline 12 weeks</td><td>No intervention</td><td>Increased nutrition knowledge: both in traditional and CBI-based (no difference); Positive changes in dietary behavior: decreased fat intake and meals skipped; Increased physical activity in CBI</td><td>17/32</td></tr><tr><td>Haerens et al. (<xref ref-type="bibr" rid="bibr21">2007</xref>) (Belgium)</td><td><italic>n</italic> = 304 Age: 13.2 ± 0.5 Gender: mixed</td><td>Computer-tailored dietary fat intake intervention, provided as an interactive CD-ROM (50 min): introduction, diagnostic and tailored-message feedback</td><td>Baseline 3 months</td><td>No intervention</td><td>Decrease of fat intake in intervention groups who read the messages</td><td>19/32</td></tr><tr><td>Mauriello et al. (<xref ref-type="bibr" rid="bibr33">2010</xref>) (USA)</td><td><italic>n</italic> = 823 Age: 15.97 Gender: female</td><td>Computer-tailored intervention feedback (3 × 30 min) based on individuals' self-reported intake of target foods</td><td>Baseline 2 months 6 months 12 months</td><td>Generic leaflet based on the National Guidelines</td><td>Increase in brown bread consumption; No change observed in other parameters</td><td>20/32</td></tr><tr><td>Rees et al. (<xref ref-type="bibr" rid="bibr41">2010</xref>) (UK)</td><td><italic>n</italic> = 1,128 Age: 12–16 Gender: mixed</td><td>Computer-tailored intervention feedback, based on individuals' self-reported intake of target foods (1 session)</td><td>Baseline 3 months</td><td>No intervention, only questionnaires fulfillment for comparison</td><td>Positive change in fruit and vegetables intake and physical activity No change in sedentary behavior</td><td>20/32</td></tr><tr><td>Maes et al. (<xref ref-type="bibr" rid="bibr32">2011</xref>) (Austria, Belgium, Sweden, Greece, Germany)</td><td><italic>n</italic> = 1,298 Age: 12–17 Gender: mixed</td><td>Assess the feasibility and impact of an Internet-based computer-tailored nutrition intervention (2 sessions)</td><td>Baseline 1 month 3 months</td><td>Generic standard advice in text format covering similar topics</td><td>Decrease of fat intake; No significant change in other nutrients intake</td><td>19/32</td></tr><tr><td>Räihä et al. (<xref ref-type="bibr" rid="bibr40">2012</xref>) (Finland)</td><td><italic>n</italic> = 167 Grade: 7th–9th Gender: mixed</td><td>ICT-learning environment in a new scholar program based on nutrition education</td><td>Baseline 3 years</td><td>No intervention</td><td>General nutrition knowledge and the consumption of healthy foods increased; No change in the number of daily meals</td><td>16/32</td></tr><tr><td>Bech-Larsen and Grønhøj (<xref ref-type="bibr" rid="bibr3">2013</xref>) (Denmark)</td><td><italic>n</italic> = 256 Age: 12 Gender: mixed</td><td>SMS-based diary and feedback system nutrition education provided by a dietician (2 × 45 min)</td><td>Baseline 15 weeks</td><td>Nutrition education only</td><td>Higher frequency of fruits and vegetables intake only for those with a low pre-intervention intake in the intervention group</td><td>16/32</td></tr><tr><td>Yang et al. (<xref ref-type="bibr" rid="bibr49">2015</xref>) (Taiwan)</td><td><italic>n</italic> = 87 Age: 15–16 Gender: female</td><td>Study formed by two intervention groups (E1 and E2) Use of a Diet Assessment System for self-monitoring and metacognitive strategies;—The Diet Assessment System was also used as an online team-based competitive game</td><td>Baseline 8 weeks</td><td>Traditional lecture-based instruction plus motivational elements (video clips related to healthy eating)</td><td>E1 didn't show significant changes in food consumption E2 (game-based) showed an increase in every food group, approaching an average of 100% of recommended daily intake</td><td>19/32</td></tr><tr><td>Turnin et al. (<xref ref-type="bibr" rid="bibr46">2016</xref>) (France)</td><td><italic>n</italic> = 580 Age: 13.3 ± 1.0 Gender: mixed</td><td>Register food choice from the available ones in a kiosk</td><td>Baseline 6 months</td><td>No control</td><td>Students chose dairy, fruit, vegetables and starchy foods more often Reduced choice of cheese and dessert BMI decreased in two schools: A and C</td><td>16/32</td></tr><tr><td>Chamberland et al. (<xref ref-type="bibr" rid="bibr8">2017</xref>) (Canada)</td><td><italic>n</italic> = 282 Age: 13–14 Gender: mixed</td><td>The intervention consisted in the recording of the intake of specific food groups, by setting individual and team goals, and providing feedback</td><td>Baseline 3 weeks 5 weeks 9 weeks 17 weeks</td><td>Not exposed to Nutriathlon app, just a clear website to record their food consumption</td><td>Increased fruit and vegetables and milk and alternatives intake Positive results lost 10 weeks after the end of the intervention</td><td>19/32</td></tr><tr><td>Chung and Fong (<xref ref-type="bibr" rid="bibr11">2018</xref>) (China)</td><td><italic>n</italic> = 95 Age: n/d Grade: 7th–9th Gender: mixed</td><td>Traditional lessons daily food report with NeL + nutrient report and behavioral feedback</td><td>Baseline 12 weeks</td><td>Access to NeL but no feedback provided</td><td>Significant dietary improvement Increased nutrition knowledge related to food choices and dietary recommendations No change observed related to food sources and diet-disease relationship</td><td>13/32</td></tr></tbody></table> </ephtml> </p> <p>Note: CBI—Computer-based intervention; NeL—Nutrition education delivery through e-learning.</p> <hd id="AN0148343820-11">Intervention</hd> <p>Two interventions adopted computer games (Long & Stevens, [<reflink idref="bib30" id="ref62">30</reflink>]; Yang et al., [<reflink idref="bib49" id="ref63">49</reflink>]), six used computer software that generated tailored feedback (Chamberland et al., [<reflink idref="bib8" id="ref64">8</reflink>]; Frenn et al., [<reflink idref="bib19" id="ref65">19</reflink>]; Maes et al., [<reflink idref="bib32" id="ref66">32</reflink>]; Mauriello et al., [<reflink idref="bib33" id="ref67">33</reflink>]; Rees et al., [<reflink idref="bib41" id="ref68">41</reflink>]; Turnin et al., [<reflink idref="bib46" id="ref69">46</reflink>]), two used an interactive CD-ROM (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref70">7</reflink>]; Haerens et al., [<reflink idref="bib21" id="ref71">21</reflink>]), two adopted a web-based learning system (Chung & Fong, [<reflink idref="bib11" id="ref72">11</reflink>]; Räihä et al., [<reflink idref="bib40" id="ref73">40</reflink>]), and one used text messages (Bech-Larsen & Grønhøj, [<reflink idref="bib3" id="ref74">3</reflink>]). The major approach used in the interventions focused on nutrition education, either through classroom sessions, or tailored feedback, or customized videos or games. However, some of the interventions combined it with other strategies, such as family involvement (Chamberland et al., [<reflink idref="bib8" id="ref75">8</reflink>]; Räihä et al., [<reflink idref="bib40" id="ref76">40</reflink>]) and monetary motivations (Räihä et al., [<reflink idref="bib40" id="ref77">40</reflink>]). The length of the interventions and frequency of exposure varied widely. Some studies reported non-continuous interventions: in two studies there was only one exposure (Haerens et al., [<reflink idref="bib21" id="ref78">21</reflink>]; Rees et al., [<reflink idref="bib41" id="ref79">41</reflink>]), one study consisted in a two-times exposure (Maes et al., [<reflink idref="bib32" id="ref80">32</reflink>]), and one study comprised three individual exposures (Mauriello et al., [<reflink idref="bib33" id="ref81">33</reflink>]). Other studies described more frequent interactions, with one reporting a registration twice a day (Chamberland et al., [<reflink idref="bib8" id="ref82">8</reflink>]), one involving daily report during the intervention period (Turnin et al., [<reflink idref="bib46" id="ref83">46</reflink>]), and other relating weekly feedback (Bech-Larsen & Grønhøj, [<reflink idref="bib3" id="ref84">3</reflink>]), whereas other interventions had more extensive programs (Räihä et al., [<reflink idref="bib40" id="ref85">40</reflink>]; Yang et al., [<reflink idref="bib49" id="ref86">49</reflink>]). There were also studies that did not set a specific time of exposure to the intervention, but rather defined a number of lessons to be completed during an established time period (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref87">7</reflink>]; Chung & Fong, [<reflink idref="bib11" id="ref88">11</reflink>]; Frenn et al., [<reflink idref="bib19" id="ref89">19</reflink>]; Long & Stevens, [<reflink idref="bib30" id="ref90">30</reflink>]). In summary, all of the analyzed studies were computer-mediated, in the form of a program, a game, a website or an e-mail, except for a single one which used a mobile phone (Bech-Larsen & Grønhøj, [<reflink idref="bib3" id="ref91">3</reflink>]).</p> <hd id="AN0148343820-12">Main Outcomes</hd> <p>All the studies reported at least one positive change towards the acquisition of healthier habits, whether it was the increase in the consumption of fruits, vegetables and other healthy foods, or the decreased intake of unhealthy foods. The only exception was the one performed by Long and Stevens ([<reflink idref="bib30" id="ref92">30</reflink>]) that found no differences in the eating behavior related to fruit, vegetables and fat consumption between the intervention and the control groups.</p> <p>A lower fat intake was reported by Frenn et al. ([<reflink idref="bib19" id="ref93">19</reflink>]) and Haerens et al. ([<reflink idref="bib21" id="ref94">21</reflink>]), whose interventions similarly focus on the reduction of the intake of foods with high fat content. Maes et al. ([<reflink idref="bib32" id="ref95">32</reflink>]) found a similar result regarding fat consumption, although this effect was only noticeable after three months in overweight students.</p> <p>Four studies (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref96">7</reflink>]; Chung & Fong, [<reflink idref="bib11" id="ref97">11</reflink>]; Long & Stevens, [<reflink idref="bib30" id="ref98">30</reflink>]; Räihä et al., [<reflink idref="bib40" id="ref99">40</reflink>]) evaluated the nutrition knowledge gain, and the results obtained were contradictory. Long and Stevens ([<reflink idref="bib30" id="ref100">30</reflink>]) showed that the intervention group had an increase in nutrition knowledge, though these results were not reflected in their food choices. On the other hand, the results obtained by Casazza and Ciccazzo ([<reflink idref="bib7" id="ref101">7</reflink>]), Räihä et al. ([<reflink idref="bib40" id="ref102">40</reflink>]), Chung and Fong ([<reflink idref="bib11" id="ref103">11</reflink>]) revealed an increase in basic nutrition knowledge which was reflected in the students' food choices. It is important to mention that the study conducted by Long and Stevens ([<reflink idref="bib30" id="ref104">30</reflink>]) only lasted one month while the others had longer intervention periods, a fact that could have influenced this outcome. Despite of that, the importance of education in the promotion of healthier habits should not be underestimated.</p> <p>The study performed by Casazza and Ciccazzo ([<reflink idref="bib7" id="ref105">7</reflink>]) was the only study that compared traditional versus computer-based education and reported no differences regarding nutrition knowledge acquisition; the computer-based intervention was more effective in changing healthy behaviors, however, both interventions demonstrated positive effects. These results provide an interesting perspective since they highlight that education can be more important than the approach used to deliver it.</p> <p>Results found by Bech-Larsen and Grønhøj ([<reflink idref="bib3" id="ref106">3</reflink>]) suggest a relation between the possible dietary changes and the baseline dietary patterns of participants. Yang et al. ([<reflink idref="bib49" id="ref107">49</reflink>]) reported that a group-based intervention can result better rather than a more individualized one. Both results highlight the importance of developing customized interventions, based on a previous analysis of the participants, in order to achieve better and broader results.</p> <hd id="AN0148343820-13">Discussion</hd> <p>Overall, all studies reported here showed some positive results suggesting that it is feasible to use technology-based programs to provide nutrition education and promote dietary changes. In addition, adolescents find these approaches more attractive and enjoyable than the traditional ones (Casazza & Ciccazzo, [<reflink idref="bib7" id="ref108">7</reflink>]; Haerens et al., [<reflink idref="bib21" id="ref109">21</reflink>]; Long & Stevens, [<reflink idref="bib30" id="ref110">30</reflink>]). Nonetheless, the large heterogeneity of the interventions included in this review, with some using solely technology and others incorporating technology in a broader program, makes it difficult to separate the effects of technology from other components used in the interventions, and to determine to what extent the technology applied contributed to the positive outcomes. Furthermore, the diversity of measures and reporting methods used make it difficult to compare results across studies and conclude which one was the most effective. However, it is necessary to consider that some variability and flexibility are expected in these interventions, so that they can address different social contexts, values and interests, especially during adolescence. In fact, studies in this research field recognize adolescents' high receptivity to the use of ICTs, as it allows combining students' interests with innovative teaching methodologies that are more motivating, and help to develop reasoning and stimulate knowledge itself through the research process.</p> <p>The two studies that conducted follow-up measurements sometime after the end of the intervention concluded that the improvements achieved had almost returned to the initial levels (Chamberland et al., [<reflink idref="bib8" id="ref111">8</reflink>]; Mauriello et al., [<reflink idref="bib33" id="ref112">33</reflink>]). Thus, it is possible that on the other interventions the positive outcomes did not persist as well, although it remains uncertain. Therefore, it is important to include longer-term follow-ups in future trials. These findings are consistent with the ones achieved in other studies concerning similar topics (Hamel & Robbins, [<reflink idref="bib22" id="ref113">22</reflink>]), and therefore attest to the difficulty of modifying dietary behaviors.</p> <p>The unsustainability of the improvements achieved during the interventions may be due to several explanations. One is the length and frequency of the interventions. Research studies have demonstrated that people with solid habits are less receptive to information about alternative behavioral options. Eating patterns are established by habits that are a consequence of repetitive behavior (Riet, Sijtsema, Dagevos, & De Bruijn, [<reflink idref="bib42" id="ref114">42</reflink>]), and habits are less susceptible to change, since people frequently have an illusory perception of what motivates their actions (Neal, Wood, Labrecque, & Lally, [<reflink idref="bib37" id="ref115">37</reflink>]). Hence, it may suggest that the interventions were neither long nor repetitive enough in order to motivate and create a new habit within the participants, making it easier to forget about the healthier recommendations as soon as the program ends. Moreover, interventions focused on habits change are more successful when using multi-target strategies that focus on the specific triggers of the habitual behavior and anticipate the possible negative consequences of this change (Bouton, [<reflink idref="bib5" id="ref116">5</reflink>]; Neal et al., [<reflink idref="bib37" id="ref117">37</reflink>]). A possible further explanation may be the absence of parental involvement in all of studies except one, as parents commonly play a central role in food decisions. However, the impact of parents' participation in this type of programs is yet to be clarified; there are studies that suggested that better outcomes are achieved with direct parental involvement (Hingle, O'Connor, Dave, & Baranowski, [<reflink idref="bib24" id="ref118">24</reflink>]), and, in contrast, others found that parental involvement did not reflect significant improvements when compared to other factors (Stice, Shaw, & Marti, [<reflink idref="bib43" id="ref119">43</reflink>]). Still, there are few studies evaluating this parental relation within technology-based interventions, so it is not clear if this is an important feature to increase the success of the programs. In addition to that, dietary intake was always assessed based on self-report, which can cause some bias, as adolescents do not always report accurate food quantities (Walker, Ardouin, & Burrows, [<reflink idref="bib47" id="ref120">47</reflink>]), and often misunderstand what they are eating especially concerning to fat and sugar intakes, leading them to think that the intervention is not suitable for them. Thus, they do not even make an effort to achieve the intervention goals.</p> <p>The study performed by Long and Stevens ([<reflink idref="bib30" id="ref121">30</reflink>]) demonstrated that the increase in nutrition knowledge had no relation with dietary intake, suggesting that interventions that are merely focused on nutrition knowledge itself are not effective. Previous studies have shown that adolescents often demonstrate good knowledge about healthy eating, but despite this they do not meet the dietary recommendations, and consume plenty of unhealthy food (Croll, Neumark-Sztainer, & Story, [<reflink idref="bib13" id="ref122">13</reflink>]). This corroborates the demand for the development of better programs that connect nutrition knowledge, practical skills and self-efficacy, and stronger policies about food marketing strategies, which highly influence people's choices.</p> <p>The methodological quality of the studies is moderate (mean score: 17.5 ± 2.18). Most of the studies had poor classification scores in the categories of internal validity, especially regarding to blinding, adjustment for confounding and accounting for drop-out rates. Additionally, they also performed poorly in the power category. Some of the studies did not satisfy the criteria assessed in the checklist used, and therefore had worse scores, because the information was not included. Consequently, in some cases, it is difficult to draw conclusions about the potential of the interventions. These findings also corroborate the need to improve the study design used in this type of interventions, which will surely benefit future interventions.</p> <hd id="AN0148343820-14">Study Limitations</hd> <p>Only one researcher examined and selected the studies, which may have caused some bias. Ideally, at least two researchers should have independently worked on this review. Only articles that were published in English were included, which is another limitation. There are limited studies available that test the effectiveness of technology-based interventions in this particular age range. In most studies included in this review, the majority of the participants were females, which can cause gender bias; future studies should make an effort to include similar percentages of both genders. Despite these limitations, the results of this systematic review provide a resume of the current research done in this field and can be helpful to identify different directions for future studies.</p> <hd id="AN0148343820-15">Conclusions and Future Directions</hd> <p>School-based nutrition interventions using technology may provide a practical, attractive, and cost-effective strategy to improve nutrition knowledge and eating behaviors. Technologies can be easily adapted to self-administered interventions and used to provide tailored advice to meet the participants' needs and preferences. The positive results make it evident that it is possible to motivate adolescents and capture their attention into nutrition issues. Nevertheless, future interventions might benefit from a thorough analysis of the target population in order to develop tailored interventions according to the adolescents' preferences and needs. The heterogeneity of studies makes it difficult to draw conclusions about the effectiveness of the interventions. However, we hypothesized that longer and tailored interventions, ideally included in the official education curricula, which combine a theoretical component with practical skills training, can improve nutrition and develop life-longing behaviors.</p> <hd id="AN0148343820-16">Disclosure Statement</hd> <p>No potential conflict of interest was reported by the authors.</p> <ref id="AN0148343820-17"> <title> References </title> <blist> <bibl id="bib1" idref="ref24" type="bt">1</bibl> <bibtext> Ajie, W. N., & Chapman-Novakofski, K. M. (2014). Impact of computer-mediated, obesity-related nutrition education interventions for adolescents: A systematic review. 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PubType: Academic Journal
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Items – Name: Title
  Label: Title
  Group: Ti
  Data: Impact of Technology and School-Based Nutrition Education Programs on Nutrition Knowledge and Behavior during Adolescence--A Systematic Review
– Name: Language
  Label: Language
  Group: Lang
  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Tallon%2C+J%2E+M%2E%22">Tallon, J. M.</searchLink><br /><searchLink fieldCode="AR" term="%22Saavedra+Dias%2C+R%2E%22">Saavedra Dias, R.</searchLink><br /><searchLink fieldCode="AR" term="%22Costa%2C+A%2E+M%2E%22">Costa, A. M.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0003-0296-9707">0000-0003-0296-9707</externalLink>)<br /><searchLink fieldCode="AR" term="%22Leitão%2C+J%2E+C%2E%22">Leitão, J. C.</searchLink><br /><searchLink fieldCode="AR" term="%22Barros%2C+A%2E%22">Barros, A.</searchLink><br /><searchLink fieldCode="AR" term="%22Rodrigues%2C+V%2E%22">Rodrigues, V.</searchLink><br /><searchLink fieldCode="AR" term="%22Monteiro%2C+M%2E+J%2E%22">Monteiro, M. J.</searchLink><br /><searchLink fieldCode="AR" term="%22Almeida%2C+A%2E%22">Almeida, A.</searchLink><br /><searchLink fieldCode="AR" term="%22Narciso%2C+J%2E%22">Narciso, J.</searchLink><br /><searchLink fieldCode="AR" term="%22Silva%2C+A%2E+J%2E%22">Silva, A. J.</searchLink>
– Name: TitleSource
  Label: Source
  Group: Src
  Data: <searchLink fieldCode="SO" term="%22Scandinavian+Journal+of+Educational+Research%22"><i>Scandinavian Journal of Educational Research</i></searchLink>. 2021 65(1):169-180.
– Name: Avail
  Label: Availability
  Group: Avail
  Data: Routledge. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
– Name: PeerReviewed
  Label: Peer Reviewed
  Group: SrcInfo
  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 12
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2021
– Name: TypeDocument
  Label: Document Type
  Group: TypDoc
  Data: Journal Articles<br />Reports - Research<br />Information Analyses
– Name: Subject
  Label: Descriptors
  Group: Su
  Data: <searchLink fieldCode="DE" term="%22Influence+of+Technology%22">Influence of Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Technology+Integration%22">Technology Integration</searchLink><br /><searchLink fieldCode="DE" term="%22Electronic+Learning%22">Electronic Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Video+Technology%22">Video Technology</searchLink><br /><searchLink fieldCode="DE" term="%22Game+Based+Learning%22">Game Based Learning</searchLink><br /><searchLink fieldCode="DE" term="%22Web+Based+Instruction%22">Web Based Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Nutrition+Instruction%22">Nutrition Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Knowledge+Level%22">Knowledge Level</searchLink><br /><searchLink fieldCode="DE" term="%22School+Activities%22">School Activities</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Intervention%22">Intervention</searchLink><br /><searchLink fieldCode="DE" term="%22Adolescents%22">Adolescents</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Behavior%22">Health Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Eating+Habits%22">Eating Habits</searchLink><br /><searchLink fieldCode="DE" term="%22Obesity%22">Obesity</searchLink><br /><searchLink fieldCode="DE" term="%22Dietetics%22">Dietetics</searchLink><br /><searchLink fieldCode="DE" term="%22Educational+Research%22">Educational Research</searchLink>
– Name: DOI
  Label: DOI
  Group: ID
  Data: 10.1080/00313831.2019.1659408
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 0031-3831
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: This study aimed to summarize the evidence of the impact of school-based nutrition education programs that incorporate technology on the acquisition of nutrition-related knowledge and behavior change of adolescents. Literature searches were conducted using Cochrane Library, Pubmed, Scopus, Science Direct, and Web of Science databases. Studies published between 2000 and 2018, with adolescents aged from 12 to 18 years, fully available in English, which involved technology-based school interventions, and reported nutrition-related outcomes, were included. Thirteen studies met all the inclusion criteria. Overall, all studies presented positive effects, though these results did not persist. It is feasible to use technology-based approaches in this type of intervention programs, but it is necessary to improve the interventions so that long-lasting results are achieved.
– Name: AbstractInfo
  Label: Abstractor
  Group: Ab
  Data: As Provided
– Name: DateEntry
  Label: Entry Date
  Group: Date
  Data: 2021
– Name: AN
  Label: Accession Number
  Group: ID
  Data: EJ1284833
PLink https://search.ebscohost.com/login.aspx?direct=true&site=eds-live&db=eric&AN=EJ1284833
RecordInfo BibRecord:
  BibEntity:
    Identifiers:
      – Type: doi
        Value: 10.1080/00313831.2019.1659408
    Languages:
      – Text: English
    PhysicalDescription:
      Pagination:
        PageCount: 12
        StartPage: 169
    Subjects:
      – SubjectFull: Influence of Technology
        Type: general
      – SubjectFull: Technology Integration
        Type: general
      – SubjectFull: Electronic Learning
        Type: general
      – SubjectFull: Video Technology
        Type: general
      – SubjectFull: Game Based Learning
        Type: general
      – SubjectFull: Web Based Instruction
        Type: general
      – SubjectFull: Nutrition Instruction
        Type: general
      – SubjectFull: Knowledge Level
        Type: general
      – SubjectFull: School Activities
        Type: general
      – SubjectFull: Program Effectiveness
        Type: general
      – SubjectFull: Intervention
        Type: general
      – SubjectFull: Adolescents
        Type: general
      – SubjectFull: Health Behavior
        Type: general
      – SubjectFull: Eating Habits
        Type: general
      – SubjectFull: Obesity
        Type: general
      – SubjectFull: Dietetics
        Type: general
      – SubjectFull: Educational Research
        Type: general
    Titles:
      – TitleFull: Impact of Technology and School-Based Nutrition Education Programs on Nutrition Knowledge and Behavior during Adolescence--A Systematic Review
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