'Not to Be Harsh but Try Less to Relate to 'the Teens' and You'll Relate to Them More': Co-Designing Obesity Prevention Text Messages with Adolescents

The Development of a Text Messaging Platform to Enhance a Youth Diabetes Prevention Program: Observational Process Study

BACKGROUND

Approximately 1 in 5 adolescents in the United States has prediabetes, and racially and ethnically minoritized youths are disproportionately impacted. Unfortunately, there are few effective youth diabetes prevention programs, and in-person interventions are challenging because of barriers to access and engagement.

OBJECTIVE

We aimed to develop and assess the preliminary feasibility and acceptability of a youth-informed SMS text messaging platform to provide additional support and motivation to adolescents with prediabetes participating in a diabetes prevention workshop in East Harlem, New York City, New York, United States. We collaborated with our youth action board and a technology partner (mPulse Mobile) to develop and pilot-test the novel interactive platform.

METHODS

The technology subcommittee of our community action board (comprising youths and young adults) used the results from focus groups that we had previously conducted with youths from our community to develop 5 message types focused on healthy eating and active living: goal setting, behavior tracking, individually tailored guidance, motivational messages, and photo diary. We used an iterative process to develop and pilot the program with our internal study team, including youths from our community action board and mPulse Mobile developers. We then conducted a pilot of the 12-week SMS text messaging program with 13 youths with prediabetes.

RESULTS

Participants (aged 15-21 years; 10/13, 77% female; 3/10, 23% Black and 10/13, 77% Hispanic or Latinx) received an average of 2 automated messages per day. The system correctly sent 84% (2231/2656) of the messages at the time intended; the remaining 16% (425/2656) of the messages were either sent at the incorrect time, or the system did not recognize a participant response to provide the appropriate reply. The level of engagement with the program ranged from 1 (little to no response) to 5 (highly responsive) based on how frequently participants responded to the interactive (2-way) messages. Highly responsive participants (6/13, 46%) responded >75% (1154/1538) of the time to interactive messages sent over 12 weeks, and 69% (9/13) of the participants were still engaged with the program at week 12. During a focus group conducted after program completion, the participants remarked that the message frequency was appropriate, and those who had participated in our in-person workshops reflected that the messages were reminiscent of the workshop content. Participants rated goal setting, behavior tracking, and tailored messages most highly and informed planned adaptations to the platform. Participants described the program as: "interactive, informative, enjoyable, very convenient, reliable, motivational, productive, and reflective."

CONCLUSIONS

We partnered with youths in the initial content development and pilot testing of a novel SMS text messaging platform to support diabetes prevention. This study is unique in the triple partnership we formed among researchers, technology experts, and diverse youths to develop a mobile health platform to address diabetes-related disparities.

Interventions to prevent obesity in children aged 12 to 18 years old

BACKGROUND

Prevention of obesity in adolescents is an international public health priority. The prevalence of overweight and obesity is over 25% in North and South America, Australia, most of Europe, and the Gulf region. Interventions that aim to prevent obesity involve strategies that promote healthy diets or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective, and numerous new studies have been published over the last five years since the previous version of this Cochrane Review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in adolescents by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in adolescents (mean age 12 years and above but less than 19 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were BMI, zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 74 studies (83,407 participants); 54 studies (46,358 participants) were included in meta-analyses. Sixty studies were based in high-income countries. The main setting for intervention delivery was schools (57 studies), followed by home (nine studies), the community (five studies) and a primary care setting (three studies). Fifty-one interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over 28 months. Sixty-two studies declared non-industry funding; five were funded in part by industry. Dietary interventions versus control The evidence is very uncertain about the effects of dietary interventions on body mass index (BMI) at short-term follow-up (mean difference (MD) -0.18, 95% confidence interval (CI) -0.41 to 0.06; 3 studies, 605 participants), medium-term follow-up (MD -0.65, 95% CI -1.18 to -0.11; 3 studies, 900 participants), and standardised BMI (zBMI) at long-term follow-up (MD -0.14, 95% CI -0.38 to 0.10; 2 studies, 1089 participants); all very low-certainty evidence. Compared with control, dietary interventions may have little to no effect on BMI at long-term follow-up (MD -0.30, 95% CI -1.67 to 1.07; 1 study, 44 participants); zBMI at short-term (MD -0.06, 95% CI -0.12 to 0.01; 5 studies, 3154 participants); and zBMI at medium-term (MD 0.02, 95% CI -0.17 to 0.21; 1 study, 112 participants) follow-up; all low-certainty evidence. Dietary interventions may have little to no effect on serious adverse events (two studies, 377 participants; low-certainty evidence). Activity interventions versus control Compared with control, activity interventions do not reduce BMI at short-term follow-up (MD -0.64, 95% CI -1.86 to 0.58; 6 studies, 1780 participants; low-certainty evidence) and probably do not reduce zBMI at medium- (MD 0, 95% CI -0.04 to 0.05; 6 studies, 5335 participants) or long-term (MD -0.05, 95% CI -0.12 to 0.02; 1 study, 985 participants) follow-up; both moderate-certainty evidence. Activity interventions do not reduce zBMI at short-term follow-up (MD 0.02, 95% CI -0.01 to 0.05; 7 studies, 4718 participants; high-certainty evidence), but may reduce BMI slightly at medium-term (MD -0.32, 95% CI -0.53 to -0.11; 3 studies, 2143 participants) and long-term (MD -0.28, 95% CI -0.51 to -0.05; 1 study, 985 participants) follow-up; both low-certainty evidence. Seven studies (5428 participants; low-certainty evidence) reported data on serious adverse events: two reported injuries relating to the exercise component of the intervention and five reported no effect of intervention on reported serious adverse events. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, do not reduce BMI at short-term follow-up (MD 0.03, 95% CI -0.07 to 0.13; 11 studies, 3429 participants; high-certainty evidence), and probably do not reduce BMI at medium-term (MD 0.01, 95% CI -0.09 to 0.11; 8 studies, 5612 participants; moderate-certainty evidence) or long-term (MD 0.06, 95% CI -0.04 to 0.16; 6 studies, 8736 participants; moderate-certainty evidence) follow-up. They may have little to no effect on zBMI in the short term, but the evidence is very uncertain (MD -0.09, 95% CI -0.2 to 0.02; 3 studies, 515 participants; very low-certainty evidence), and they may not reduce zBMI at medium-term (MD -0.05, 95% CI -0.1 to 0.01; 6 studies, 3511 participants; low-certainty evidence) or long-term (MD -0.02, 95% CI -0.05 to 0.01; 7 studies, 8430 participants; low-certainty evidence) follow-up. Four studies (2394 participants) reported data on serious adverse events (very low-certainty evidence): one reported an increase in weight concern in a few adolescents and three reported no effect.

AUTHORS' CONCLUSIONS

The evidence demonstrates that dietary interventions may have little to no effect on obesity in adolescents. There is low-certainty evidence that activity interventions may have a small beneficial effect on BMI at medium- and long-term follow-up. Diet plus activity interventions may result in little to no difference. Importantly, this updated review also suggests that interventions to prevent obesity in this age group may result in little to no difference in serious adverse effects. Limitations of the evidence include inconsistent results across studies, lack of methodological rigour in some studies and small sample sizes. Further research is justified to investigate the effects of diet and activity interventions to prevent childhood obesity in community settings, and in young people with disabilities, since very few ongoing studies are likely to address these. Further randomised trials to address the remaining uncertainty about the effects of diet, activity interventions, or both, to prevent childhood obesity in schools (ideally with zBMI as the measured outcome) would need to have larger samples.

Striking the right balance: co-designing the Health4Me healthy lifestyle digital health intervention with adolescents

BACKGROUND

Adolescents are navigating a period of rapid growth and development within an era of digitalization. Mobile phone ownership among adolescents is nearly ubiquitous, and this provides an opportunity to harness text messaging to promote a healthy lifestyle and reduce chronic disease risk factors. Inclusion of adolescents throughout the design process has been recognized as essential for engagement and future implementation of such interventions. This study aimed to co-design a bank of text messages to promote a healthy lifestyle which are useful, acceptable, and engaging for adolescents aged 12-18 years old.

METHODS

Iterative, mixed-methods design with consumer partnership. Co-design occurred over three stages: text message development, text message review and final refinement and testing. The text message development included literature searches and consumer partnership with an established youth advisory group (n = 16). Participants who gave e-consent participated in text message review. Demographic characteristics were collected, and quantitative surveys were distributed to adolescents (n = up to 50) and health professionals (n = up to 30), who rated text message content for understanding, usefulness and appropriateness (total score out of 15). Final refinement was completed by the research team to edit or remove messages which had low scores and to assess readability and interactivity of the text messages.

RESULTS

The Heath Advisory Panel for Youth at the University of Sydney (HAPYUS) identified the top six lifestyle health issues for young people today in relation to chronic disease prevention, which became the key content areas for the text message bank and drafted new text messages. Following text message development, 218 messages were available for review. Adolescents (n = 18, mean age 16.3 [SD 1.4]) and healthcare professionals (n = 16) reviewed the text messages. On average, all reviewers found that the text messages were easy to understand (mean = 13.4/15) and useful (mean = 12.7/15). Based on scoring and open ended-feedback, 91 text messages were edited and 42 deleted. The final text message bank included 131 text messages. The overall program is suitable for a seventh-grade reading level, and interactive.

CONCLUSIONS

This study describes the process of effectively engaging adolescents to co-design a text message bank intervention, which are useful, acceptable and engaging for an adolescent audience. The effectiveness of the co-designed text message bank is currently being tested in the Health4Me RCT.

An SMS Text Message-Based Type 2 Diabetes Prevention Program for Hispanic Adolescents With Obesity: Qualitative Co-Design Process

BACKGROUND

SMS text message-based interventions are a promising approach for reaching and engaging high-risk youths, such as Hispanic adolescents with obesity, in health promotion and disease prevention opportunities. This is particularly relevant, given that SMS text messaging is widely accessible and available and that adolescents are frequent texters. Including youths in the development of SMS text message content can lead to more acceptable and relevant messaging; however, few studies include this group as cocollaborators.

OBJECTIVE

This study aimed to use a co-design process to inform the development of SMS text messages that promote healthy physical activity (PA) and sleep behaviors among Hispanic adolescents with obesity.

METHODS

The co-design framework uses multiple methods across several phases. Self-determination theory and a literature review of SMS text message-based interventions guided the background and research phases. In the co-design phase, Hispanic adolescents (n=20) completed in-depth interviews to identify barriers and facilitators of PA and sleep, preferences for ways to emphasize key self-determination theory constructs (autonomy, competence, and relatedness), and suggestions for making SMS text message content engaging. In the design and content phase, interview findings were used to develop initial SMS text messages, which were then evaluated in the early evaluation phase by experts (n=6) and adolescents (n=6). Feedback from these panels was integrated into the SMS text message content during refinement.

RESULTS

The background phase revealed that few SMS text message-based interventions have included Hispanic adolescents. Common barriers and facilitators of activity and sleep as well as preferences for ways in which SMS text messages could provide autonomy, competence, and relatedness support were identified in the co-design phase. The youths also wanted feedback about goal attainment. Suggestions to make SMS text messages more engaging included using emojis, GIFs, and media. This information informed an initial bank of SMS text messages (N=116). Expert review indicated that all (116/116, 100%) SMS text messages were age and culturally appropriate; however, some (21/116, 18.1%) did not adequately address youth-identified barriers and facilitators of PA and sleep, whereas others (30/116, 25.9%) were not theoretically adherent. Adolescents reported that SMS text messages were easy to understand (116/116, 100%), provided the support needed for behavior change (103/116, 88.8%), and used mostly acceptable language (84/116, 72.4%). Feedback was used to refine and develop the final bank of 125 unique text messages.

CONCLUSIONS

Using a co-design process, a theoretically grounded, appealing, and relevant bank of SMS text messages promoting healthy PA and sleep behaviors to adolescents was developed. The SMS text messages will be further evaluated in a pilot study to assess feasibility, acceptability, and preliminary efficacy. The co-design process used in this study provides a framework for future studies aimed at developing SMS text message-based strategies among high-risk adolescents.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1016/j.cct.2023.107117.

A National Health and Wellness SMS Text Message Program for Breast Cancer Survivors During COVID-19 (EMPOWER-SMS COVID-19): Mixed Methods Evaluation Using the RE-AIM Framework

BACKGROUND

COVID-19 lockdowns caused widespread closures of supportive care services for breast cancer survivors in Australia. In a randomized controlled trial, our team's lifestyle-focused, evidence-based SMS text message support program (EMPOWER-SMS COVID-19) was found to be acceptable and useful for breast cancer survivors, and it was ready for rapid widespread delivery.

OBJECTIVE

This study aims to evaluate the reach (uptake) of an adapted 3-month lifestyle-focused SMS text message program (EMPOWER-SMS COVID-19) and barriers and enablers to implementation using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

METHODS

A mixed methods pre-post study was conducted to evaluate the EMPOWER-SMS COVID-19 program. The study evaluated the following aspects: (1) reach/representativeness, which refers to the proportion of participant enrollment (ie, number enrolled/number that visited the study website) and demographics (eg, age, sex, ethnicity, time since completing treatment, Index of Relative Socio-economic Advantage and Disadvantage [IRSAD; quintile 1, which refers to most disadvantaged areas, to quintile 5, which refers to least disadvantaged areas, and remoteness); (2) effectiveness, in which participant engagement and acceptability were evaluated using SMS text message reply data and a feedback survey (5-point Likert scale and free-text responses); (3) adoption, which corresponds to the proportion of organizations or health professionals who agreed to promote the program; (4) implementation fidelity and maintenance, which evaluated SMS text message delivery data, opt-outs, costs, and adaptations. Quantitative data were summarized using means and SDs or frequencies and percentages, while qualitative data were analyzed thematically.

RESULTS

With regard to the reach/representativeness of the program, 841/1340 (62.8%) participants enrolled and provided electronic consent. Participants had a mean age of 58.8 (SD 9.8; range 30-87) years. According to the data collected, most participants identified as female (837/840, 99.6%) and White (736/840, 87.6%) and nearly half (418/841, 49.7%) finished treatment ≤18 months ago. Most resided in major cities (574/838, 68.5%) and 30% (251/838) in IRSAD quintile 1 or 2. In terms of effectiveness, 852 replies were received from 511 unique participants (median 1; range 1-26). The most common replies were participants stating how they heard about the program (467/852, 54.8%) or "thank you" (131/852, 15.4%). None of the replies contained urgent safety concerns. Among participants who provided feedback (449/841, 53.4%), most "(strongly) agreed" the SMS text messages were easy to understand (445/448, 99.3%), useful (373/440, 84.8%), helped participants feel supported (388/448, 86.6%), and motivated participants to be physically active (312/445, 70.1%) and eat healthier (313/457, 68.5%). Free-text responses revealed 5 factors influencing engagement: (1) feeling supported and less alone, (2) motivation and reassurance for health self-management, (3) the variety of information, (4) weblinks to information and resources, and (5) the option to save the SMS text messages. Concerning adoption, 50% (18/36) of organizations/health professionals agreed to promote the program. With regard to implementation/maintenance, SMS text messages were delivered as planned (97.43% [41,257/42,344] of SMS text messages were successfully delivered) with minimal opt-outs (62/838, 7.4%) and low cost (Aus $15.40/participant; Aus $1=US $0.67). No adaptations were made during the intervention period. Postintervention adaptations included adding weblinks and participant-selected customizations.

CONCLUSIONS

EMPOWER-SMS COVID-19 was implemented quickly, had a broad reach, and had high engagement and acceptability among socioeconomically diverse participants. The program had high fidelity, low cost, and required minimal staff oversight, which may facilitate future implementation. However, further research is needed to evaluate barriers and enablers to adoption and implementation for health professionals and strategies for long-term maintenance.

Text Messages and Financial Incentives to Increase Physical Activity in Adolescents With Prediabetes and Type 2 Diabetes: Web-Based Group Interviews to Inform Intervention Design

BACKGROUND

Physical activity is a major component of treatment for adolescents with obesity and prediabetes or type 2 diabetes; however, sedentary behavior remains pervasive. An SMS text message-based intervention paired with financial incentives may be an effective way to promote physical activity in this population.

OBJECTIVE

This study aims to obtain end-user feedback on SMS text message content and assess the acceptability of a planned SMS text messaging intervention with financial incentives to motivate youth with prediabetes or type 2 diabetes to increase physical activity.

METHODS

Adolescents with overweight or obesity and prediabetes or type 2 diabetes who attended a large academic pediatric endocrinology clinic were recruited to participate in group interviews (2-4/group) via videoconferencing. Participants were asked to share their thoughts on the use of SMS text messages and financial incentives to remind and motivate them to be more physically active. They rated and provided feedback on specific messages to be used in clinical trials. Participants were also asked about their personal experience with rewards to motivate behavior change and their anticipated reactions to rewards provided for goal attainment (gain-framing) versus those provided and then taken away if a goal was not met (loss-framing). The interviews were conducted by 2 trained interviewers and a note-taker. Content analysis was used to explore themes.

RESULTS

Group interviews were completed with 20 participants (11/20, 55% women; 15/20, 75% with type 2 diabetes; 5/20, 25% with prediabetes) with a mean age of 15 (SD 1; range 12-18) years and a mean BMI of 41 (SD 5) kg/m² (all >95th percentile for age and sex). Most participants were non-Hispanic Black (14/20, 70%) and 10% (2/20) were Hispanics. Participants frequently cited near-continuous smartphone use and agreed that SMS text messages would serve as good reminders to be physically active, but the consensus about the need for short messages was strong. Favorable content included references to what they were likely to be doing when messages were sent (eg, homework or watching television) and messages that were upbeat or informative. Specific physical activity suggestions were rated favorably. Attitudes toward financial incentives varied, with differing opinions about whether loss-framed incentives would be motivating or discouraging. Many participants highlighted the role of intrinsic, rather than extrinsic, motivation in achieving and sustaining behavior change.

CONCLUSIONS

The engagement of adolescents with obesity and diabetes or prediabetes allowed for the refinement of SMS text messages for our planned intervention, with an emphasis on short, upbeat, relatable, and informative messages. Although an SMS text messaging intervention using financial incentives to motivate youth with prediabetes or type 2 diabetes to be more physically active is theoretically acceptable, the impact on actual activity levels in this population requires prospective evaluation in a clinical trial.

Co-Produce, Co-Design, Co-Create, or Co-Construct—Who Does It and How Is It Done in Chronic Disease Prevention? A Scoping Review

Co-production in health literature has increased in recent years. Despite mounting interest, numerous terms are used to describe co-production. There is confusion regarding its use in health promotion and little evidence and guidance for using co-produced chronic disease prevention interventions in the general population. We conducted a scoping review to examine the research literature using co-production to develop and evaluate chronic disease prevention programs. We searched four electronic databases for articles using co-production for health behaviour change in smoking, physical activity, diet, and/or weight management. In 71 articles that reported using co-production, co-design, co-create, co-develop, and co-construct, these terms were used interchangeably to refer to a participatory process involving researchers, stakeholders, and end users of interventions. Overall, studies used co-production as a formative research process, including focus groups and interviews. Co-produced health promotion interventions were generally not well described or robustly evaluated, and the literature did not show whether co-produced interventions achieved better outcomes than those that were not. Uniform agreement on the meanings of these words would avoid confusion about their use, facilitating the development of a co-production framework for health promotion interventions. Doing so would allow practitioners and researchers to develop a shared understanding of the co-production process and how best to evaluate co-produced interventions.

Shifting From Tokenism to Meaningful Adolescent Participation in Research for Obesity Prevention: A Systematic Scoping Review

Background: Traditionally, adolescent participation in research has been tokenistic. Adolescents are rarely afforded the opportunity to influence decision-making in research designed to prevent obesity. Engaging adolescents in meaningful decision-making may enhance research translation. This review aimed to analyze the current modes and nature of adolescent participation in obesity prevention research decision-making. Methods: A systematic scoping review was conducted using Arksey and O'Malley's six-stage framework. Six major databases were searched for peer-reviewed primary research studies with adolescent participation related to obesity, physical activity, and diet. Modes of adolescent participation were categorized based on the Lansdown-UNICEF conceptual framework for measuring outcomes of adolescent participation. The framework outlines three modes of meaningful participation: (i) consultative, which involves taking opinions and needs into consideration; (ii) collaborative, where adolescents are partners in the decision-making process; and (iii) adolescent-led participation where adolescents have the capacity to influence the process and outcomes. The degree of involvement in research cycles was classified based on the National Health and Medical Research Council consumer engagement framework. Five stages of the research cycle were determined: identify, design and develop, conduct, analyze and disseminate. Results: In total, 126 papers describing 71 unique studies were identified. Of these, 69% (49/71) took place in the USA, and 85% (52/61) were conducted in minority or underserved communities, while males were more likely to be under-represented. In 49% (35/71) of studies, participation was consultative and 9% (6/71) of studies involved an adolescent-led approach. Furthermore, 87% (62/71) of studies incorporated adolescent participation in one or more of the research cycle's formative phases, which involve eliciting views, opinions and idea generation. Only 11% of studies engaged adolescents in all five stages of the research cycle where adolescents could have more influence over the research process. Conclusion: Meaningful adolescent participation in the obesity prevention research cycle is limited. Empowering and mobilizing equal partnership with adolescents should be at the forefront of all adolescent-related obesity prevention research.

Codesign of a cardiovascular disease prevention text message bank for older adults

OBJECTIVE

Develop and validate a text message bank to support healthier lifestyle behaviors in older adults at risk for cardiovascular disease utilizing a codesign approach.

METHODS

Initially, the researchers, based on literature, developed a bank of 68 SMS text messages focusing on healthy eating (24 messages), physical activity (24 messages), and motivational feedback (20 messages), based on a scoping review of the literature on promoting behavioral change to engage in healthy lifestyle behaviors. In the next step, a panel of five experts analyzed every subset of SMS text messages. Further validation was conducted by nine older adults (≥ 60 years). The user demographics, telephone literacy, understanding, and appeal for every SMS text message were evaluated using a 31-item questionnaire.

RESULTS

Participants provided an acceptable understanding of the critical concept found in the 49 SMS text message (physical activity M = 1.73 ± 0.18; diet M = 1.73 ± 0.26; motivation M = 1.85 ± 0.25; range 0-2). The average ratings for physical activity (i.e., likability), healthy eating, and motivation were 8.62 ± 0.64, 8.57 ± 0.76, and 8.40 ± 0.83, respectively (range 0-10).

CONCLUSION

Co-designers were able to identify the technological and content requirements for each text message and infographic to enhance understanding and appeal.

PRACTICE IMPLICATIONS

A feasibility study will need to be conducted as a next step to testing the effectiveness of text messages in a mobile-based intervention to promote healthy behaviors in older adults at high CVD risk.

Effectiveness of lifestyle interventions in preventing harmful weight gain among adolescents: A systematic review of systematic reviews

Obesity in adolescence is associated with stigma during school years, early emergence of co-morbidities in adulthood and premature mortality. Adolescence presents a key window of opportunity to intervene for building healthy eating and physical activity routines and prevent weight gain. This review of reviews assesses the evidence on the effectiveness of prevention interventions conducted with adolescents. Nine reviews assessing the effects of lifestyle interventions in adolescents (defined as age 10 to 19 years old) on weight gain were identified from the 10 health databases searched. Only four reviews conducted meta-analyses, of which, three (two exercise-focused) demonstrated positive changes in primary outcomes of body mass index (BMI) and/or BMI z-score (range of decrease in BMI from 0.06 to 0.47 kg/m²⁾ ). Most were conducted in school settings, and all but two reviews were of low quality. Few reviews reported external validity components that would enable clearer directions for policy makers to implement in real-world settings. More than 140 distinct interventions were included in the reviews, but there remains a serious gap in evidence for effective interventions in adolescents.