family-based interventions for reducing sedentary time in youth: a systematic review of randomized...

Obesity Prevention

Family-based interventions for reducing sedentarytime in youth: a systematic review of randomizedcontrolled trials

S. Marsh1, L. S. Foley1, D. C. Wilks2 and R. Maddison1

1National Institute for Health Innovation,

University of Auckland, Auckland, New

Zealand; 2Sports Centre of the University of

Passau, Passau, Germany

Received 3 June 2013; revised 22 July 2013;

accepted 15 August 2013

Address for correspondence: Ms Samantha

Marsh, National Institute for Health Innovation,

University of Auckland, Private Bag 92019,

Auckland Mail Centre, Auckland 1142, New

Zealand.

E-mail: [email protected]

SummaryFamily involvement in interventions to reduce sedentary time may help fosterappropriate long-term screen-based habits in children. This review systematicallysynthesized evidence from randomized controlled trials of interventions witha family component that targeted reduction of sedentary time, including TVviewing, video games and computer use, in children.

MEDLINE, PubMed, PsycInfo, CINAHL and Embase were searched frominception through March 2012. Seventeen articles were considered eligible andincluded in the review.

Studies were judged to be at low-to-moderate risk of bias. Despite inconsistentstudy results, level of parental involvement, rather than the setting itself, appearedan important determinant of intervention success. Studies including a parentalcomponent of medium-to-high intensity were consistently associated with statis-tically significant changes in sedentary behaviours. Participant age was also iden-tified as a determinant of intervention outcomes; all three studies conducted inpre-school children demonstrated significant decreases in sedentary time. Finally,TV exposure appeared to be related to changes in energy intake rather thanphysical activity.

Future studies should assess the effects of greater parental involvement andchild age on success of sedentary behaviour interventions. More research isrequired to better understand the relationship between screen time and healthbehaviours, particularly energy intake.

Keywords: Adolescents, children, screen time, sedentary behaviour.

obesity reviews (2014) 15, 117–133

Introduction

Screen-based technologies play a significant role in chi-ldren’s lives. They are a highly engaging source of enter-tainment and have become a tool for forming andmaintaining social connections (1). In recent decades, chi-ldren’s accessibility to screen-based activities, includingtelevision (TV), video games and computers/Internet, hasincreased at an unprecedented rate, resulting in greater

amounts of daily time spent being sedentary (2,3). Seden-tary screen time, which refers to a subset of sedentaryactivities, now accounts for a substantial proportion oftotal daily sedentary time in children (4). This issue ofsedentariness, or more specifically screen time, is emergingas an important public health concern.

Time spent engaged in sedentary activities has beenassociated with a number of adverse health and socialoutcomes, including overweight and obesity (5–8). This is

obesity reviews doi: 10.1111/obr.12105

117© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity 15, 117–133, February 2014

particularly concerning given that young children andadolescents have been reported to engage in sedentarybehaviours for between 6–9 (9,10) and 5–8 h d–1 (11,12),respectively. As such, decreasing sedentary time is nowadvocated in tandem with traditional recommendations toincrease physical activity in children.

The effectiveness of interventions aimed at decreasingeither total sedentary time or screen-based sedentary timein children has been assessed in a number of systematicreviews (13–20). According to Steeves et al., the most effec-tive strategies for decreasing screen time in children involveusing tools other than just behaviour modification tech-niques, such as a TV allowance device, and focusing exclu-sively on screen-based behaviours rather than diluting themessage with other health-related behaviours (20). Alter-natively, a review that focused on schools and the generalpopulation reported no differences in the effectiveness ofsingle and multiple health behaviour interventions (18);however, interventions that targeted both the child andthe family were highlighted as being particularly effective.Similarly, in a review that focused on reducing screen timein young children (17), tools used in the home environ-ment, including electronic TV monitors and contingentfeedback systems, and high level of parental involvement,were identified as successful strategies for reducing screentime. Yet, despite the somewhat positive findings fromthese systematic reviews, a recent meta-analysis failed todemonstrate any evidence for the effectiveness of sedentarybehaviour interventions in children, with respect to eitherbody mass index (BMI) or screen time (19). Therefore,despite a seemingly large number of reviews and meta-analyses already conducted in this relatively new field, find-ings are conflicting and the distillation of factors associatedwith successful interventions remains elusive.

It has been proposed that in order to effectively decreasesedentary behaviours, particularly screen time, variablesthat influence these behaviours first need to be identifiedand then suitably targeted (21). According to a systematicreview designed to identify correlates of specific energybalance-related behaviours, factors in the home environ-ment, including parental rules and number of TVs in thehousehold, were found to be significantly correlated withscreen time (22). TV viewing habits of the family (23) andconcurrent consumption of meals while watching TV (24)have also been identified as important factors influencingchildren’s screen time. According to a qualitative studydesigned to explore how the home environment influenceschildren’s electronic-based sedentary behaviours, a numberof factors were identified, including sibling and parentmodelling and reinforcement, personal cognitions, thephysical environment, and rules and restrictions (21). Yet,perhaps the most important finding was that parents wereunconcerned about their children’s excessive exposure toelectronic media, which the authors proposed as a major

barrier to modifying screen time in children. It was there-fore proposed that to effectively target sedentary behav-iours in intervention studies, efforts should be directedtowards influencing modifiable factors of the home envi-ronment (21).

Indeed, family-based behavioural interventions havebeen cited as among the most successful for addressingchildhood obesity (25,26). The family plays a highly influ-ential role in establishment of childhood obesity (26),and parents are integral in the development of theirchild’s eating and physical activity behaviours (27–29).The family system may therefore be a major factor influ-encing engagement in health-promoting activities. Byinvolving the family, changes may be promoted in both thechild and the other family members, which may help createa more supportive social milieu for the child (25). Target-ing family involvement may also make sense at a practicallevel, particularly in younger children where it is often thecaregiver and not the child who makes decisions related tohealthy lifestyle choices (30). Disregard for the importanceof family involvement may undermine the ability of inter-ventions to produce meaningful behavioural change inchildren (31).

With respect to sedentary behaviour interventions, it hasbeen proposed that involvement of parents may be moreimportant than the intervention setting itself (13). Screen-based sedentary activities are highly engaging and reward-ing behaviours, and as such, it may not be suitable orsensible to place the burden of reducing these activitieswholly on the child. Given that the majority of screen-based media is consumed at home, and that several inter-personal and physical environment factors within thehome have been associated with screen time among youth(23,32), there is reason to believe that interventions thatinclude parents/caregivers as agents of change may bemore effective than interventions that ignore their role andfocus solely on the child (26). As such, interventions thatfoster appropriate screen time and sedentary behaviourhabits in the long term may require some level of familyinvolvement.

Although a number of systematic reviews have looked atthe effectiveness of sedentary behaviour interventions atdecreasing sedentary time and/or BMI (13–20), or the effec-tiveness of family/home-based interventions at addressingpaediatric overweight (26,30), no review has specificallyinvestigated the effectiveness of family-based interventionsat decreasing sedentary time. Given the importance ofthe family system in health-promoting activities and thatfactors in the home environment are important correlatesof children’s sedentary time, it is important to evaluate theeffectiveness of family-based interventions in decreasingsedentary behaviours. This work was undertaken to sys-tematically review and synthesize family-based interven-tions with a sedentary behaviour component designed to

118 Family-based sedentary time interventions S. Marsh et al. obesity reviews

© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity15, 117–133, February 2014

decrease children’s sedentary time. The primary aim wasto examine the effectiveness of these interventions withrespect to decreasing sedentary time, and the secondary aimwas to investigate whether level of family involvement/engagement affects this outcome.

Methods

Eligibility criteria

Eligible studies included randomized controlled trials(RCTs) of family-based interventions in children aged 2–18years reporting change in sedentary time as an outcome.Family-based interventions were defined as those involvingat least one parent/caregiver and at least one child. Activeinvolvement of a parent was required. Active involvementrequired contact between the intervention team and theparent/caregiver via telephone, counselling or group ses-sions, or use of a TV-monitoring device at home, whichrequired parental monitoring and therefore participation.Sending newsletters and/or toolkits at home was consideredpassive and therefore did not meet the eligibility criteria ofthe review. Trials that included a voluntary family compo-nent, whereby the parent/caregiver could choose whetheror not to participate, were also excluded from the review.There were no restrictions on body-weight status, interven-tion setting, publication date (up to March 2012) or pub-lication status. Every study reporting sedentary time as anoutcome was considered for the analysis.

Restrictions were placed on the comparison groups ofincluded trials. The following control groups were permit-ted: no intervention, wait-list control and treatment-as-usual control, which involved standard advice about dietand exercise. Studies were excluded if the authors felt thecomparison group was actually an intervention, e.g. if astudy compared the effects of increasing physical activityvs. decreasing sedentary activity, or if one arm focused onthe child while the other focused on a parent.

The primary outcome measure of interest was the changefrom baseline in sedentary time. We permitted any descrip-tion of sedentary time, including total sedentary time, tar-geted and non-targeted (e.g. reading and listening to music)sedentary time, sedentary screen time and video and TVuse. Secondary outcome measures included (i) physicalactivity level; (ii) body composition, including BMI, waistcircumference, body fat and body weight; and (iii) energy/food intake, including vegetable and fruit intake, snackintake and calories consumed.

Search strategy

MEDLINE, PubMed, PsycInfo, CINAHL and Embasewere searched from inception through 13 March 2012.Reference lists of selected studies and reviews were

searched for additional trials, and authors were contactedfor any additional unpublished information. The searcheswere limited to human studies and English languagearticles. Full details of the MEDLINE search strategy areshown in Table 1.

Study selection

For all retrieved studies, the citations and abstracts weredownloaded to EndNote X5 and all duplicates wereremoved. The search results were then screened in anunblinded manner by three authors [SM, LF, DW], withtitles and abstracts divided equally into three batches.Uncertainty of inclusion was resolved by consensus withthe other authors. Full-text articles were retrieved if theinformation provided in the title, abstract and descriptors/MeSH headings appeared to meet the inclusion criteria ofthe review or if there was any uncertainty about eligibility.The retrieved full-text articles were then scanned by twoindependent authors in an unblinded manner. Differencesbetween reviewers were resolved by discussion and a con-sensus was reached. Data were then extracted using a dataextraction sheet.

Data collection process

For each included trial, two authors [SM, LF] extracted thefollowing data using a standardized extraction form thatwas informed by PRISMA (Transparent Reporting ofSystematic Reviews and Meta-analyses) (33) and theCochrane Handbook for Systematic Reviews of Interven-tions (34): (i) characteristics of trial participants (numberof participants, age range, mean age, body-weight statusand disease status); (ii) type of intervention (including spe-cific details of the intervention, setting, level of familyinvolvement and study duration); (iii) type of comparisongroup; (iv) type of outcome measures (including a time-bound measure of sedentary time [primary outcome], andbody composition, physical activity levels and dietaryintake [secondary outcomes]) and (v) details of the study(date of publication, study acronym, unit of randomi-zation). During data extraction, the reviewers also assessedwhether the study authors reported the following: anadequate randomization process, allocation concealment,whether outcomes were assessor blinded, attrition rate andwhether an intention-to-treat analysis was conducted. Dis-agreements were resolved by discussion.

Data items

Sedentary time could be reported as total sedentary time,targeted and non-targeted sedentary time, sedentary screentime or video/TV use; however, it was required to be atime-bound outcome that could be converted to minutes

obesity reviews Family-based sedentary time interventions S. Marsh et al. 119

© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity 15, 117–133, February 2014

per day. As sedentary time was the outcome of interest,studies reporting response rates, e.g. proportion of subjectswho watched less than 2 h per week of TV, were excluded.Where there was ambiguity regarding actual age range,studies were included if the mean age of participants waswithin the pre-specified age range of 2–18 years. Level ofparental involvement was assessed subjectively by theauthors, and all studies were assigned a rating of low,medium or high. Studies that involved parents/caregiversin a purely administrative role, e.g. monitoring of deviceimplementation, were considered to have low parentalinvolvement. Studies that required parents to be involved inmore than just an administrative capacity, e.g. attendanceof meetings/education sessions, were considered to havemedium parental involvement. For a study to be assigned aparental involvement rating of high, parents were requiredto be central/key to the intervention and involved in allaspects of the intervention process.

Risk of bias assessment

To determine the validity of included trials, study qualitywas assessed according to how the studies had minimized

risk of bias and error in their methods (Table 2). TheCochrane Handbook (34) was used to assess risk of biasfor the following domains: selection bias, performance/detection bias, attrition bias and reporting bias. A judge-ment of high risk, low risk, or unclear risk could be given,with unclear risk assigned when there was lack of informa-tion or uncertainty over the potential for bias.

Results

Study selection

A total of 2,086 studies were identified from the databasesearch and other sources, of which 840 were duplicates,leaving 1,246 articles that were screened for eligibility. Atotal of 1,157 articles were deemed not relevant based ona review of information provided in the title, abstract anddescriptors/MeSH headings. Eighty-nine full-text articleswere assessed for eligibility, and after exclusion of 72 thatdid not meet the review inclusion criteria, 17 studies wereconsidered eligible and included in the review. Figure 1illustrates the different steps of the data collectionprocess.

Table 1 Search strategy: MEDLINE (OVID)Search Search term Combination

1 Television/or video games/or computers/or Internet/or cellular phone/or sedentary lifestyle/or Internet/

2 Television.tw.3 Video gam*.tw.4 Computer gam*.tw.5 Active video gam*.tw.6 Active gam*.tw.7 Exergam*.tw.8 Exertainment.tw9 Screen-time.tw.

10 (Screen based OR Screen-based).tw.11 Sedentary behavio*.tw.12 Sedentar*.tw.13 Sitting.tw.14 Low energy expenditure.tw.15 ([Chair or sitting or screen or computer] adj time).tw.16 ([Television adj watch*] or TV watch*).tw.17 Or/1–1618 Intervention studies/19 Intervention.tw.20 18 or 1921 Family/ or family health/22 Family.tw.23 Parent.tw.24 ([Home adj5 based] or home-based).tw.25 ([Family adj5 based] or family-based).tw.26 ([Family adj5 cent*] or family-cent*).tw.27 Or/21–2628 20 and 2729 17 and 2830 Limit 29 to ‘all child (0 to 18 years)’



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yses

used

and

only

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mily

lost

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-up

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pea

rsth

atal

lex

pec

ted

outc

omes

wer

ere

por

ted

Rob

inso

net

al.

2010

(51)

Low

Ran

dom

ized

by

com

put

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the

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ITT,

inte

ntio

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at.



Validity assessment

Overall, the studies included in the review were judged tobe at low to moderate risk of bias (Table 2). Of the 17studies included in the review, change in sedentary behav-iour was the primary endpoint in only 4 (35–38), and it istherefore unknown which of the remaining 13 studies wereadequately powered to detect differences in sedentary time.The definition of sedentary time also varied widely betweenstudies, with a number of studies only considering TVviewing, while others included all screen media (TV, com-puter, video games, etc.).

Study characteristics

Seventeen trials met the inclusion criteria and wereincluded in the review. The trials were divided into fivecategories according to the study setting: home (eightstudies), community (three), school (two), primary care(two) and mixed (two). The characteristics of the includedstudies are presented in Table 3. A total of 3,433 partici-pants were included in the trials, with sample sizes for

individual trials ranging from 10 to 819. Table 4 presentssedentary time outcomes for the included trials. As studypopulations, interventions, study focus and measured out-comes varied widely between the studies, statistical synthe-sis was not appropriate. The below discussion providesa narrative summary of the included studies accordingto setting (home, community, school, primary care andmixed).

Home-based studies

Eight home-based studies were identified (35–37,39–43).The Take Action study (40) was the only interventionjudged to have a high level of parental involvement andincluded face-to-face group sessions and home-based activ-ities, in addition to placement of a TV locking device. Fiveof the home-based studies were judged to have low parentalinvolvement, with the parents’ role being purely adminis-tration and involving either monitoring of a TV electronictime monitor (39), an active video game (41,42) or eithera closed- (35) or open-loop feedback system (43). Inthe closed-loop system, TV was contingent on pedalling a

Records iden fied through database searching (2,071)

Records iden fied through other sources (15)

Records a er duplicates removed (1,246)

Records screened (1,246)

Full-text ar cles assessed for eligibility

(89)

Studies included in qualita ve synthesis

(17)

Records not relevant to review (1,157)

Excluded (72):Not RCTs (16)No me-bound measure of SB (31)No ac ve parent component (10)Protocols/no results (6)Outcomes not reported for child (1)Outcomes not reported for both interven on and control groups (1)Wrong age group (1)No true control group (6)

Iden

tifi

cati

onSc

reen

ing

Elig

ibili

tyIn

clud

ed

Figure 1 PRISMA flow diagram of literaturesearch.



Tab

le3

Cha

ract

eris

tics

ofin

clud

edst

udie

s

Stu

dy

Stu

dy

des

ign

Par

ticip

ants

Inte

rven

tion

Con

trol

Dur

atio

n/Fo

llow

-up

Leve

lof

par

enta

lin

volv

emen

t

Out

com

em

easu

rem

ents

ofin

tere

st

Sed

enta

rytim

e(d

efini

tion)

Sec

ond

ary

outc

omes

Hom

e-b

ased

inte

rven

tions

Ep

stei

net

al.

2008

(39)

RC

TP

aral

lel

2ar

ms

US

A

n=

70M

=37

F=

33A

ge:

4–7

(mea

n6)

year

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verw

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bes

e

TVtim

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evic

ed

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ned

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TVan

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use

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50%

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TV+

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alle

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arm

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ese

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gen

ton

ped

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aren

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vem

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itorin

gof

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Fren

chet

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2011

(40)

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US

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TVlo

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gd

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hom

ein

terv

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nac

tiviti

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aren

tali

nvol

vem

ent:

Mon

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gof

TVtim

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t,12

hom

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ities

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TVD

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2006

(36)

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was

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onPA

Par

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syst

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rese

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TVw

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SS

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htm

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Mad

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2011

(41)

RC

TP

aral

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NZ

n=

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easu

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2009

(37)

RC

TP

aral

lel

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NZ

n=

29M

=18

F=

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9–12

(mea

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TVan

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PAan

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s

Com

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inte

rven

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Esc

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etal

.20

10(4

5)

RC

TP

aral

lel

2ar

ms

US

A

n=

202

M=

104

F=

98A

ge:

6–9

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tions

Fun

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inte

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hw

orks

hop

+b

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thly

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ters

Par

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linv

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men

t:W

orks

hop

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time

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trol

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2008

(46)

RC

TP

aral

lel

2ar

ms

Isra

el

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mTV

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Tab

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Con

tinue

d

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dy

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dy

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nd

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e:8–

12(m

ean

10)

year

sO

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eig

ht/o

bes

e

Fam

ily-b

ased

inte

rven

tion:

18ed

ucat

iona

land

PAse

ssio

ns+

free

fam

ilysw

imm

ing

pas

sP

aren

tali

nvol

vem

ent:

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hg

roup

educ

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nal

sess

ions

(hel

dtw

ice

wee

kly)

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trol

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enta

ryac

tiviti

es(e

.g.

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uter

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and

bod

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htm

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care

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care

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toin

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Den

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(49)

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TP

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A

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RC

TP

aral

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Sw

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652

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inso

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2003

(52)

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Rob

inso

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al.

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(51)

RC

TP

aral

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US

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M=

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1A

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Hea

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Tab

le4

Sum

mar

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lts:

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ge

from

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sed

enta

ryb

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(min

d−1

)

Stu

dy

SB

outc

ome

mea

sure

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nge

inS

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asth

ep

rimar

yen

dp

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?

SB

was

ap

rimar

yfo

cus

Inte

rven

tion

gro

up(9

5%C

I)C

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lgro

up(9

5%C

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etw

een-

gro

upd

iffer

ence

(95%

CI)

Hom

e-b

ased

inte

rven

tions

Ep

stei

net

al.

2008

(39)

TV+

com

put

er✗

✓−1

50(−

268,

−32)

[6m

onth

s]−4

5(−

231,

+142

)[2

4m

onth

s]Fa

ithet

al.

2001

(35)

TV✓

✓−1

86(−

210,

−162

)−1

5(−

27,

−3)

−171

(−19

8,−1

44)

Fren

chet

al.

2011

(40)

TV(a

dol

esce

nts)

✗✗

−49

(−10

8,+1

0)−4

7(−

92,

−2)

−2(−

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stationary cycle ergometer, while the open-loop systemsrequired an individual to increase their level of physicalactivity in order to receive reinforcement (screen time).Only two studies used objective measures of sedentary time(35,39), with sedentary time being the primary endpoint inonly three studies (35–37). Sample sizes ranged from 10(35) to 322 participants (41) and study durations from 6weeks (37) to 2 years (39).

A TV locking device was used in four studies(37,39,40,43), of which TV viewing decreased from base-line to a statistically greater extent in the interventiongroup vs. controls in only one (39,44). In the 2-year U.S.study conducted by Epstein et al. (39), 70 children aged4–7 years were randomized to an intervention to decreaseTV viewing and computer use by 50% or a monitor-ing control group. TV viewing and computer game usedecreased from baseline to a greater extent in the interven-tion vs. control group at both 6 and 24 months (bothP < 0.001 for group X months interaction). Althoughchanges in physical activity did not differ between groups,the intervention was associated with greater improvementsin energy intake (P < 0.05) and zBMI (P = 0.01) comparedwith controls, with a positive relationship found betweenchanges in TV viewing and energy intake (P < 0.001), butnot physical activity (39). Alternatively, a 6-week NewZealand study conducted by Ni Mhurchu et al. (37), whichrandomized 29 children aged 9–12 years to either a TVmonitoring device plus verbal advice to restrict TV or acontrol group (verbal advice to restrict TV), and a 6-weekU.S. study conducted by Roemmich et al. (43), whichrandomized 18 children aged 8–12 years to either an open-loop feedback system + reinforcement or control (TV notcontingent), failed to demonstrate significant differencesbetween the two study groups with respect to changes frombaseline in TV viewing; however, numerically greaterdecreases in TV viewing were demonstrated in both studies(−36 and −33 min d−1). Finally, the multi-component,household-focused Take Action study conducted by Frenchet al. (40), which randomized 90 households in the UnitedStates to either the intervention (discussed previously) orcontrol, also failed to demonstrate a significant between-group difference in the change from baseline in TV viewingin adolescents. However, TV viewing for the householddecreased to a greater extent in the intervention groupcompared with controls (P < 0.05).

The use of open-loop feedback systems were also foundto have varying effects on sedentary outcomes. A 2-monthCanadian study (36), which randomized 30 children aged8–12 years to either an open-loop feedback system orcontrol group (where TV watching was not contingenton physical activity), demonstrated a significant between-group difference in the decrease from baseline in the tar-geted sedentary behaviour (primary endpoint) favouringthe intervention group (−102 min d−1). However, the study

conducted by Roemmich et al. (43) (described previously)was unable to demonstrate a significant difference betweenthe two groups. Although the interventions were similar indesign, the first study was conducted in overweight/obesesubjects, while the second study enrolled children who hada BMI less than the 90th percentile. Importantly, during thefinal 2 weeks of the Canadian study (36), there was evi-dence of a decrease from baseline in physical activity in theintervention group, which was possibly due to a decrease inthe reinforcing efficacy of TV as a reward. Finally, the studyalso showed a significant decrease from baseline in snackintake while watching TV in the intervention groupcompared with controls (907.2–273 kJ d−1 vs. 735–831.6kJ d−1, respectively; P < 0.05).

A small (n = 10), 3-month, randomized U.S. study wasdesigned to assess the effectiveness of a closed-loop systemin children aged 8–12 years, whereby TV was contingenton pedalling a stationary cycle ergometer in the interven-tion group. Children in the control group were able towatch TV and use the bike at their own discretion (35).After 10 weeks, TV viewing (primary endpoint) decreasedfrom baseline to a greater extent in the interventiongroup compared with controls (between-group difference−171 min d−1; 95% CI −198, −144).

Finally, active video games have had varying effects onsedentary time. A U.S. study (42), which enrolled 60 girlswith a mean age of 7.5 years, aimed to assess the feasibilityof an active dance video game on physical activity andsedentary screen time outcomes compared with a wait-list control group. Sedentary screen time significantlydecreased from baseline in the intervention group com-pared with controls (−36 min d−1; 95% CI −67, −5); how-ever, changes from baseline in vigorous physical activityand light physical activity did not differ significantlybetween groups. Alternatively, a large New Zealand studyconducted in 322 children aged 10–14 years (41) wasunable to demonstrate a statistically significant between-group difference in sedentary video game play betweenchildren randomized to an active video game upgradepackage and controls over 6 months (−9 min d−1; 95% CI−19, +36); however, zBMI, body weight, waist circumfer-ence, percentage body fat, fat mass and active video gameplay significantly improved from baseline in the interven-tion group vs. controls. Overall, home-based interventionstended to be effective with respect to sedentary time;however, parental involvement was often of a supervisorynature, and despite their successfulness, sample sizes wereoften small and follow-up too short to comment on thesustainability of these interventions in the long term.

Community-based studies

Three studies investigated the effectiveness of community-based interventions to decrease sedentary behaviours in



children and adolescents (45–47). In general, parental/caregiver participation was judged to be more active forinterventions that included a community component com-pared with the purely home-based ones. The two studiesthat enrolled overweight/obese participants (46,47) signifi-cantly decreased sedentary time compared with controls.Sedentary time, which was subjectively measured in allthree studies, was not the primary endpoint in any of thecommunity-based interventions. Study durations rangedfrom 3 (46) to 6 months (45,47) and enrolled between 22(46) and 202 participants (45).

The 6-month Fun Families pilot study (45), which ran-domly assigned 202 children aged 6–9 years to either theintervention or control group, aimed to evaluate a theory-based, parent-focused intervention to decrease TV andother media use in children. Media use decreased frombaseline to a greater extent in controls vs. the interventiongroup (−88.2 min d−1 vs. −57.0 min d−1); however, the dif-ference between groups did not reach statistical signifi-cance. Despite this, the authors reported positive changes inthe intervention group for proxy measures of media use,including not having a TV in the child’s bedroom, noteating snacks in front of the TV and turning off the TVwhen nobody was watching it (45).

In contrast to the Fun Families pilot, the studies thatsignificantly decreased sedentary behaviours (46,47)included additional diet and physical activity components,were judged to be more intensive and specifically focusedon overweight/obese children. The 3-month study con-ducted in Israel by Nemet et al. (46) randomized 22 obesechildren aged 8–11 years to either a control group or anintensive dietary, behavioural and exercise programme.Parents of children in the intervention group were alsorequired to meet biweekly with a dietitian. A significantlygreater decrease from baseline in TV and computer use wasobserved in the intervention vs. control group (between-group difference −120 min d−1). An interesting findingreported by Nemet et al. (46) was that although studyadherence was satisfactory in the children, parental com-pliance was lower (77% vs. 52%). This was further high-lighted by the finding that although children’s weightimproved during the study, there was no significant changein parental BMI. The parents reported that the interventionwas too time-consuming and demanding, and that theirfocus was on the participation of their child.

The second study to show a significant decrease in seden-tary time (47) was conducted in England over 6 monthsand randomly assigned 116 overweight/obese children aged8–12 years to either a control group or an intensive family-based intervention, which included 18 2-h educational andphysical activity sessions plus a free family swimming pass.Sedentary activities were shown to be reduced to a greaterextent in children in the intervention group compared withcontrols (between-group difference −43.7 min d−1; 95% CI

−77.1, −9.4). After 12 months of follow-up, the statisticallysignificant decrease in sedentary time demonstrated at 6months was not maintained in the intervention group. Thiswas the first randomized controlled trial of a complexfamily-based intervention that was run in the community. Insummary, aspects of the community-based interventionsassociated with positive improvements in sedentary timeincluded more intensive interventions that focused on multi-ple health behaviours rather than just TV and media use.

Primary care-based studies

Two studies assessed the effectiveness of primary care-basedinterventions in adolescents (38) and pre-school children(48). Both interventions were judged to be intensive, with amedium level of parental/caregiver involvement, includingmotivational interviewing by clinicians (48) and healthcareprovider counselling for the parents (38). Both studies reliedon subjective measures of sedentary time, had long studydurations (1 year) and enrolled a large number of partici-pants. In the study conducted by Patrick et al. (38), 819adolescents aged 11–15 years in the United States wererandomized to either a control group or an intervention,which consisted of primary care-based computer-assisteddiet and physical activity assessment and stage-based goalsetting, followed by brief counselling then 1 year of monthlymail and telephone counselling. Parents were also targetedas agents of change and were educated to encourage behav-iour change attempts through active support, positive role-modelling and praise. Sedentary time (primary endpoint)decreased from baseline to a greater extent in participants inthe intervention vs. control group (−77.7 min d−1; 95% CI−105.8, −49.5); however, BMI did not differ significantlybetween the groups (38). In the study conducted in pre-school children aged 2–6 years (n = 475) (48), the inter-vention, which consisted of primary care restructuring,provision of motivational interviewing by clinicians toparents and educational modules targeting TV and fast foodand sugar-sweetened beverage consumption, was associatedwith greater decreases from baseline in TV and video usecompared with control participants (−27.6 min d−1; 95% CI−42.6, −12.0). In brief, the primary care-based studies wereboth intensive, required a medium level of parental involve-ment, had large sample sizes and long study durations.Importantly, both interventions were associated with sig-nificant improvements from baseline in sedentary/screentime compared with controls.

School-based studies

Both school-based interventions were conducted in pre-school children and reported significant improvements insedentary time (49,50). Intervention intensity was high forboth studies and level of parental/caregiver involvement



ranged from medium (50) to high (49), with parents eitherattending seven targeted sessions aimed at reducing mediaconsumption (49) or three interactive information and dis-cussion evenings about the importance of physical activity,health food, limitation of TV use and good sleep behav-iours (50). While the study conducted by Dennision et al.(49) was designed to decrease TV viewing, Puder et al. (50)aimed to improve aerobic fitness and adiposity by makingchanges to the built environment in and around the class-room. The interventions utilized multidimensional lifestylebehaviours, including physical activity, nutrition, mediause and sleep, and targeted the child, pre-school provider/teacher and a parent; however, despite active parentalinvolvement, both studies were primarily child-focused.The 10-month U.S. study conducted by Dennison et al. (49)enrolled 77 children aged 2.5–5.5 years, while the 1-yearSwiss study (50) enrolled 652 children aged 4–6 years. Bothstudies were able to demonstrate significant improvementsfrom baseline in screen-based media use compared withthe comparison groups; however, neither was able to showsignificant between-group difference in the change frombaseline in BMI. Furthermore, despite Dennison et al.(49) reporting a significant decrease in TV/video viewing,changes from baseline in computer and video game play onweekdays and the weekend did not differ between the twogroups. In summary, the two studies conducted in theschool setting enrolled pre-school children, targeted multi-ple health behaviours, had medium to high parentalinvolvement and were associated with significant improve-ments in screen-based media use.

Mixed setting studies

The 2-year Stanford GEMS study (n = 261) (51) and the12-week pilot of the Stanford GEMS study (n = 60) (52)utilized a mixed community- and family-based interventionto target sedentary behaviours in African–American girlsaged 8–10 years. The culturally tailored intervention con-sisted of two components: the community-based GEMSJewels dance classes and the home-based START (SistersTaking Action to Reduce Television) lessons. Both studieswere assigned a parental involvement rating of medium.While neither study found a significant between-group dif-ference in the change from baseline in screen-based seden-tary behaviours, the intervention was associated with anumber of important changes in other outcomes. The Stan-ford GEMS pilot study (52) found a significant decrease inthe number of dinners eaten while watching TV and trendstowards decreases in BMI, exposure to TV, videos andvideo games, and increased after-school physical activity.The pilot study was however only powered to test feasibil-ity and not changes in these other outcomes.

In the 2-year Stanford GEMS study (51), the interventionwas associated with significant improvements in fasting

total cholesterol levels, low-density lipoprotein (LDL) cho-lesterol levels and depressive symptoms. Although changesin BMI did not differ significantly between groups overall(primary endpoint), the intervention was found to signifi-cantly improve BMI in those girls with single/unmarriedparents and those who had higher levels of exposure to TVat baseline. A major limitation of the 2-year study was thelevel of dance class attendance (11.6%), which was lowerthan the projected intervention dose. Overall, the mixed-setting intervention was not associated with significantbetween-group changes in sedentary behaviours, althoughneither study was powered to detect this. Despite neitherstudy demonstrating significant improvements from base-line in screen-based sedentary behaviours, the culturallytailored intervention was associated with importantimprovements in clinical findings in a high-risk populationof girls.

Discussion

Despite the specific focus on family-based RCTs targetinglifestyle interventions in children and adolescents, this sys-tematic review revealed inconsistent evidence with respectto improvements in sedentary time. Differences in the studypopulation, level of family involvement, setting, study aimand intervention type warrant further consideration ofspecific study characteristics that may have contributed todifferences.

Sedentary behaviour

Sedentary behaviour was the primary endpoint in only fourstudies, and of these, three (35,36,38) reported significantreductions in sedentary time; however, small sample sizeand lack of power may have accounted for the lack ofstatistical significance in the fourth (37). Of the four studiesthat specifically targeted sedentary behaviour reduction asa primary endpoint, three of them were set primarily athome (35–37), while the fourth was primary care based(38). The three home-based studies, although generallyeffective at reducing screen time, relied on a TV lockingdevice (37), or either an open- (36) or closed-loop feedbacksystem (35). While relatively effective, there may be accept-ability issues and diminishing returns with such devices inthe long term. Furthermore, these studies utilized smallsample sizes and short-term follow-up, and as such, thelong-term sustainability of such interventions is purelyspeculative at this stage. TV locking devices were also citedas a source of arguments within the family (37). Further-more, while the closed-loop system, which made TV con-tingent on pedalling a stationary cycle ergometer, wasassociated with the greatest between-group difference inthe decrease from baseline in sedentary time (35), theimplementation of such an intervention at a population



level, and for a sustained amount of time, may be imprac-tical and economically unviable.

Participant characteristics

There was some evidence to suggest that certain character-istics of the child and parent may have influenced out-comes. According to a moderator analysis conducted in theStanford GEMS study (51), unmarried parents and greaterbaseline levels of TV exposure predicted greater decreasesin BMI. Furthermore, while there was inconsistent evidencefor an effect of baseline body weight on intervention effec-tiveness, participant age may be a better determinant ofsedentary time outcomes. While interventions in older chil-dren produced conflicting results, more consistent findingswere observed in studies that focused primarily on pre-school children (48–50). All three studies conducted inpre-school children showed significant decreases in seden-tary time. This finding is in agreement with a previousanalysis (19). Targeting younger children has three uniqueadvantages. Firstly, this age corresponds to the time of theadiposity rebound, a critical period in children aged 5–7years associated with the second rise in the BMI curve (53).It has been suggested that childhood obesity preventioninterventions may benefit from targeting such criticalperiods in children’s development (53). Secondly, theseearly years correspond to a time where lifestyle behavioursare still being established (50), and thirdly, younger chil-dren tend to have less volition than older children. Despitethese preliminary findings, the sustainability of interven-tions that target pre-school children still needs to be evalu-ated before recommendations can be made. Ultimately, itmay be useful to identify characteristics of high-risk chil-dren and parents who are more receptive to behaviourchange interventions aimed at decreasing sedentary behav-iours and body weight.

Intervention characteristics

While this review focused on family-based interventions,no limitations were placed on the intervention setting.As previously suggested (13), we found that the level ofparental involvement appeared more important than thesetting itself. Studies that included a parental component ofmedium-to-high intensity were consistently associated withsignificant changes in sedentary behaviours, whether theywere home (40), community (47), school (49) or primarycare based (38), which is consistent with previous research.It has been shown that interventions targeting the parentvs. the child (54) or the parent vs. both the parent and thechild (55) are more effective at targeting the child’s bodyweight, with outcomes maintained up to 7 years after ter-mination of the intervention (54). In such interventions, theparent may be encouraged to act as both a source of

authority and as a role model for their child (56). Thechild’s personal responsibility for changing their ownbehaviours is therefore reduced by creation of a familyenvironment that promotes healthy behaviour choices.However, parental motivation needs to be taken into con-sideration. Nemet et al. (46) found that intervention com-pliance was much lower in obese parents than in theirchildren. Future research should therefore consider theimportance of a parental component and furthermore iden-tify and tailor interventions to better address the needs ofparents considered to be at risk for low compliance.

Secondary outcomes

The interventions included in this review were effective inimproving a number of important secondary outcomes.The Stanford GEMS intervention (51) was associated withimprovements in fasting total cholesterol levels, LDL cho-lesterol levels and depressive symptoms; these changes haverarely been demonstrated in population-based interven-tions aimed at children. Depression has been linked withincreased body weight, and depression and obesity interactreciprocally (57); therefore, changes in depressive symp-toms may be a key indicator of future outcomes. Theimportance of such secondary outcomes as proxy measuresfor future changes in sedentary behaviour and body-weightstatus may require further exploration.

Finally, an important finding was that changes in TVexposure appeared to be related to changes in energy intakerather than changes in physical activity (39). This findingraises an important issue: how are screen-based behaviourslinked with body weight? The proposed mechanismsinclude displacement of physical activity (58,59) andincreased energy intake, via either the effects of food adver-tising and/or overconsumption of energy-dense foods whileengaged in screen-based activities (59–61). Evidence for theeffects on energy intake appears most compelling. Resultsfrom a longitudinal study found that, while screen timewas associated with multiple unfavourable changes in diet,there was a non-substantive inverse association betweenchange in screen time and leisure-time physical activity(62). Similarly, a systematic review of studies that investi-gated the relationship between sedentary behaviour anddietary intake found clear evidence for an associationbetween sedentary time and elements of an unhealthy diet(63). These findings could have important implicationsfor future interventions. If the relationship between screentime and body weight is mediated by energy intake, thenperhaps greater focus needs to be placed on the behaviourssurrounding screen time, such as eating, rather than justtotal amount of time spent engaged in screen-based activ-ities. Given that screen time is highly rewarding and there-fore is difficult to decrease, focusing on associated dietarybehaviours may prove to be a more easily modifiable



behaviour. Parents may find it less difficult to control expo-sure to snack foods during screen time rather than attempt-ing to manage actual screen time itself.

Limitations of this review

This review is limited by the quality of the included studies.Because of the heterogeneity of the included studies, theanticipated quantitative synthesis of sedentary behaviouroutcomes was not feasible. The majority of studies were ofmoderate-to-high quality, although inadequate reportingby authors meant that the risk of bias for a number ofdomains (allocation concealment and random sequencegeneration) was often unable to be established. Other limi-tations included reliance on studies with small sample sizes(35,37,43,46) and short follow-up (36,37,42,43). Further-more, although we reported on performance/detection bias,this measure of bias was not assigned much weight as allthe included studies reported sedentary screen time as anoutcome measure and currently there is no agreed uponmethod for objectively measuring screen time. Anotherlimitation of the review was the inclusion of studies that didnot have change in sedentary time as a primary endpoint.However, given that all interventions involved a sedentarybehaviour component, and reported change in sedentarytime as an outcome, we believe that sedentary behaviourwas at least a secondary focus of all the included studiesand therefore justifies their inclusion in this review.

Implications for future research

This systematic review highlights the need for greaterfamily involvement in interventions aimed at reducingscreen time in children. A number of participant character-istics were identified as factors contributing to either thesuccess or failure of interventions, including age of childrenand motivation of the parent. Future research needs toassess whether interventions that target pre-school childrenare sustained over time, and whether targeting of parentsconsidered to be at high risk for low intervention compli-ance may help improve outcomes. More studies are alsorequired that either primarily target the parent, or utilize amore intensive parent component. Finally, future researchis required to better assess the mechanism(s) underlyingthe relationship between screen time and body weight inchildren. A better understanding of this relationship mayenable development of more targeted and, it is hoped,successful interventions aimed at decreasing sedentarybehaviours in children.

We find ourselves at a crossroads with respect to child-hood obesity prevention and treatment. Screen-basedtechnologies continue to evolve, becoming ever morevaried, accessible and rewarding; however, long-termresults from sedentary behaviour interventions continue to

underwhelm. In response to this issue, there has been a trendtowards the use of electronic locking devices and closed-/open-loop systems in interventions. While such technologi-cal interventions may prove successful in the short term, aswell as having intuitive appeal, fighting technology withtechnology as it were, at a population level, their implemen-tation and long-term effectiveness may be limited. A moredifficult (though, as this review suggests, potentially morefruitful) approach is to involve the parent and family unit asa whole in efforts to reduce children’s screen time. It seemsunreasonable to expect children to restrict their level ofexposure to a media saturated environment, while simulta-neously dismissing the interest of parents in the health andwell-being of their children by neglecting to address the rolethey play in creating a healthy family environment. Thisreview has highlighted the importance of involving parentsmore strongly and directly in future sedentary behaviourinterventions and also the need for further research toinvestigate the link between screen time and other healthbehaviours, particularly energy intake.

Conclusion

This review supports the need for interventions that focuson the family and, more specifically, interventions thatinvolve a parent at more than just a supervisory or admin-istrative level. There is also a need to consider childcharacteristics and the motivation of the parent, withinterventions tailored accordingly. Finally, more research isrequired to address how food-related behaviours moderatethe relationship between screen time and overweight inyouth and how such an understanding may be incorpo-rated into future interventions.

Conflict of interest statement

No conflict of interest was declared.

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