Use of Information and Communication Technologies among Adults in Weight Control: Systematic Review and Meta-Analysis

Information and communication technologies are part of our day-to-day life in the execution of all activities, including health care. However, it is not known how much the use of technologies can contribute to the adoption of healthy lifestyle habits. Thus, the objective of this study was to analyze whether the use of information and communication technologies contributes to weight control among adults when compared to the traditional approach method. The search was performed in November 2021 in eight electronic databases in addition to gray literature bases. The quality of the studies was assessed using the Cochrane risk of bias tool. The standardized mean difference was used for the meta-analytic measurement using the random effects model using the Dersimonian–Laid method in the Stata statistical package version 17. The body mass index of the intervention group decreased by an average of 0.56 (95% CI: −0.83; −0.30) when compared to the control group. When comparing the before and after groups, the intervention group also had a greater reduction in BMI (summarized mean: −0.83; 95% CI: −1.40; −0.26). Information and communication technologies contribute to the reduction of the body mass index in the adult population when compared to the traditional model of monitoring. Prospero registration: number 42020186340.


Introduction
Information and communication technologies have provided new lifestyles, consumption, teaching, learning, relationships with professionals and health services [1,2]. Interventions to solve health problems, especially those caused by inadequate habits such as hygiene, food and physical activity, are possible themes as the focus of promotion actions based on interventions mediated by technologies [3,4].
A relevant subject to be discussed and worked on nowadays is food education. The constant increase in the consumption of ultra-processed foods with little nutritional value and to which people have easy access, is a cause for concern; the increase in the consumption of ultra-processed foods by the population can cause future health problems due to the low nutritional value of these foods [5,6].
A healthy diet among adults helps to protect against malnutrition, favors food security, and acts against chronic non-communicable diseases, including diabetes, cardiovascular diseases, stroke, and cancer [7,8].
An integrative literature review, conducted in 2019, included eight studies on the use of digital technologies to promote healthy eating habits among adolescents. The technologies studied were games, websites and programs, and among the changes found with their use, there was a greater consumption of fruits and vegetables and greater practice of physical activity; the study concluded that the use of technologies promoted changes in the lifestyle and healthy eating habits, and that the technology must adapt to social and economic factors in its implementation and use [9].
A systematic review of 88 studies verified the effectiveness of interactive social media interventions among adults and the changes in health behaviors. For changes in body weight, four studies were included that found a decrease in body mass index [10]. However, in these studies, the use of information and communication technologies were not evaluated as part of a weight loss treatment.
Considering that information and communication technologies have been increasingly used in educational processes, including health areas, it is important to investigate the capacity of these resources in generating lifestyle changes. No systematic review was found that evaluated the impact of information and communication technologies on changing eating habits, with the final outcome being changes in body weight among adults. Thus, the objective of this study was to analyze whether the use of information and communication technologies contributes to weight control among adults when compared to the traditional approach method-face-to-face (presential) and without the use of information and communication technologies.

Method
The systematic review study was registered in the Prospective International Registry of Systematic Reviews (PROSPERO) under the Center for Reviews and Dissemination (CRD) number 42020186340. The protocol design was performed according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analyses [11] (Supplementary Material S1).

Eligibility Criteria
Studies of randomized clinical trials that compared the use of information and communication technologies in the development of healthy eating habits and conventional treatment in weight control among adults from 18 to 65 years were considered eligible. Any type of technology that used cell phones, smartphones, computers and software was considered as information and communication technologies. As a traditional approach, the service was exclusively face-to-face and without the use of information and communication technologies.
The BMI, also called the Quételet index, was used as a measure for assessing weight control. This measure is calculated by dividing body mass in kilograms by the square of height in meters, it is an indicator of the nutritional status of adults. BMI is classified as: (a) less than 18.5: underweight; (b) 18.5 and 24.9: normal weight; (c) 25 and 29.9: overweight; (d) equal to or above 30: obesity [12].
Body weight was chosen as the outcome because the assessment of the population's body composition is the most-used method in the population's nutritional diagnosis, as it is cheap, non-invasive, universally applicable and well accepted by the population [13,14].
Studies with pregnant or postpartum women, participants with terminal illnesses such as cancer, pilot studies, and studies in which technological resources were used in both groups were excluded.

Information Search, Query Strategy and Selected Studies
The search was performed in November 2021 in the following databases: Medline, Embase, Central, LILACS, SciELO, Web of Science, Scopus and PsychInfo using the search strategy considering the controlled vocabularies Medical Subject Headings (MeSH) and Emtree, free terms related to the topic, as well as their synonyms, keywords and using Boolean operators to combine the descriptors (Supplementary Material S2). The Peer Review of Electronic Search Strategies (PRESS) tool was used to qualify the search strategy by an independent reviewer. There was no restriction for language or publication date. A search for references in the selected articles was also carried out, in the gray literature in the bases, including: OpenGrey, ProQuest, National Technical Information Service (NTIS), MedRxiv, BiorXiv, and WHO Library Database. The following clinical trial registry databases were consulted: clinicaltrials.gov, International Clinical Trials Registry Platform, The European Union Clinical Trials Register, Brazilian Registry of Clinical Trials (ReBEC).
For the study selection process, the Rayyan platform was used. Initially, a calibration of the selection was carried out with the reviewers to confirm their understanding of the eligibility criteria. After excluding duplicate studies, two reviewers assessed the title and abstract for full reading-Oliveira, T.W.; Oliveira, L.M.L.; Andrade, L.A. Disagreements were resolved by consensus or by consulting another reviewer-Pereira, P.S.P.

Data Extraction
Data was extracted by Oliveira, T.W.; Pereira, P.P.S.; Pereira, D.S. in a standardized spreadsheet, including the following data: title, first author and year, parents, sample size, mean age, sex, marital status, education, race, focus of intervention, intervention time, BMI in the control group and in the intervention group before and after the actions. For studies with information with standard deviation values, the authors were contacted requesting this information.

Methodological Quality
The quality of the studies was assessed using the Cochrane risk of bias tool. This tool is composed of two parts, which contain seven domains, namely: random sequence generation, allocation concealment, blinding of participants and professionals, blinding of outcome assessors, incomplete outcomes, selective outcome reporting and other sources of bias. For each of these domains, the risk of bias is assessed, being classified as high, uncertain (nuclear) or low risk of bias [15].

Data Analysis
The data analysis process was performed using the program STATA ® version 17 (StataCorp LLC, College Station, TX, USA), serial number: 301706385466. The degree of statistical heterogeneity of the studies was evaluated using the I-Square (I2), applying the following cut-off points: 0 to 40% not very important; 30 to 60% moderate; 50 to 90% substantial; and 75 to 100% considerable [15]. The standardized mean difference was used for the meta-analytic measurement of the evaluated results. To estimate statistical significance, 95% confidence intervals were calculated. The random effects model was used through the Dersimonian-Laid method. The random effects model was chosen to adopt a more conservative approach, since statistical heterogeneity was considered high for one of the meta-analyses. Furthermore, high methodological heterogeneity was perceived between the studies. It was not possible to measure publication bias as fewer than 10 studies were included in the meta-analyses [15].
The focus of information and communication technology interventions were: weight loss, diet, eating behavior change, physical activity, recipes, personalized dietary advice, goals, personalized feedback, eating disorders, body satisfaction, healthy lifestyle, diabetes prevention and its implications, reducing blood glucose, understanding which foods are rich in fat, sugar and salt, reducing fat intake, and increasing consumption of fruits and vegetables. Regarding gender, only one study had a sample composed of a majority of men [22], and one study had only women [31] and another study had only men [29]. The mean age of the study ranged between 24 and 58 years. The intervention time had a minimum of three months [17,20,24,25,27,28,30] and a maximum of 21 months [18]. Of the 16 studies included, only five provided information on schooling, one mentioned the highest level of education being high school [26], in another study the intervention group was mostly at the levels of high school and higher education in the control group [21,26], in the other studies the most frequent level was higher education [16,22,24]. One of the studies was carried out among university students [20].
The focus of information and communication technology interventions were: weight loss, diet, eating behavior change, physical activity, recipes, personalized dietary advice, goals, personalized feedback, eating disorders, body satisfaction, healthy lifestyle, diabetes prevention and its implications, reducing blood glucose, understanding which foods are rich in fat, sugar and salt, reducing fat intake, and increasing consumption of fruits and vegetables.
Among the technologies that were used in the intervention, they are divided into: weekly sending of texts, images and video by Short Message Service (SMS), e-mail or social network applications (for example, WhatsApp); games; websites with educational programs; web conferences; or virtual reality. In the control group, the strategies used were: standard care, performed in an office or hospital, by doctors and other professionals. Only one study indicated that follow-up was carried out specifically by a nutritionist [18]; another study mentions that it provided orientation based on the guidelines and that patients received attention in primary care. One study mentions that medical care was provided with nutritional guidelines [27]; another study [16] mentions that informative pamphlets were used in the guidelines.  Seven studies presented information that made it possible to carry out the metaanalysis. It was possible to verify that the BMI of the group that received the interventions decreased by an average of 0.56 (95% CI: −0.83; −0.30) and presented low heterogeneity between studies (Figure 2). When comparing the groups before and after the interventions, the group that participated in the actions through information and communication technologies also had a greater reduction in BMI (mean: −0.83; 95% CI: −1.40; −0.26) with moderate heterogeneity (I:64.95%) (Figure 3). phlets were used in the guidelines.
Seven studies presented information that made it possible to carry out the meta-analysis. It was possible to verify that the BMI of the group that received the interventions decreased by an average of 0.56 (95% CI: −0.83; −0.30) and presented low heterogeneity between studies (Figure 2). When comparing the groups before and after the interventions, the group that participated in the actions through information and communication technologies also had a greater reduction in BMI (mean: −0.83; 95% CI: −1.40; −0.26) with moderate heterogeneity (I:64.95%) (Figure 3).
Regarding the evaluation of the methodological quality of the studies, the risk of blinding bias of the participants and evaluators was classified as low, as it was considered that in no intervention it was possible to have blinding (Figure 4). Biases introduced due to incomplete outcome and selective reporting were assessed as high in 20% of studies. In general, the studies were evaluated as having good methodological quality (most items had a higher frequency for low and uncertain risk of bias).    Regarding the evaluation of the methodological quality of the studies, the risk of blinding bias of the participants and evaluators was classified as low, as it was considered that in no intervention it was possible to have blinding (Figure 4). Biases introduced due to incomplete outcome and selective reporting were assessed as high in 20% of studies. In general, the studies were evaluated as having good methodological quality (most items had a higher frequency for low and uncertain risk of bias).

Discussion
Information and communication technologies contributed to greater weight loss when compared to conventional interventions-face-to-face only. The most performed actions were courses divided into online modules, sending SMS, and food control through a calorie-counting application. The focus of interventions was weight loss, increased healthy eating, individualized dietary advice, prevention of eating disorders, improved body image, diabetes and its implications, lowering blood glucose, and participation in physical activity.
Most studies were conducted in groups with an average age of over 40 years, which shows that the use of information and communication technologies can be a good option for health education, health self-management and monitoring by health professionals in older adults. old. Only five studies presented the level of education and most had high school or higher education. A higher level of education was related to a higher level of food quality. Low schooling was related to worse quality of life, higher prevalence of noncommunicable chronic diseases, mental disorders and depression. A study conducted in

Discussion
Information and communication technologies contributed to greater weight loss when compared to conventional interventions-face-to-face only. The most performed actions were courses divided into online modules, sending SMS, and food control through a calorie-counting application. The focus of interventions was weight loss, increased healthy eating, individualized dietary advice, prevention of eating disorders, improved body image, diabetes and its implications, lowering blood glucose, and participation in physical activity.
Most studies were conducted in groups with an average age of over 40 years, which shows that the use of information and communication technologies can be a good option for health education, health self-management and monitoring by health professionals in older adults. old. Only five studies presented the level of education and most had high school or higher education. A higher level of education was related to a higher level of food quality. Low schooling was related to worse quality of life, higher prevalence of non-communicable chronic diseases, mental disorders and depression. A study conducted in one in Brazil, in 2018, found that people with twelve or more years of schooling had a prevalence of fruit and vegetable consumption of 38% against 23% of individuals with up to eight years of schooling [32].
Weight losses or dietary changes are always greater after the intervention and tend to decrease after that period. In a meta-analysis of four studies with behavioral interventions, including with 301 participants who followed the interventions for six months, showed a favorable effect on lowering BMI in children younger than 12 years of age who received parent-focused interventions compared to usual practices. However, at 12 months of followup, the meta-analysis of three studies, including 264 participants, did not show a significant reduction in BMI, but there were significant changes in the dietary pattern [33].
In our meta-analysis, we found some studies indicating that there was weight loss in the first six months and after that period, this weight remained stable [23]. Two other studies reported that there was weight loss in the first six months and it was not maintained at 12 months, but there were significant improvements in food quality [26,27].
Among the studies that reported that they had the help of feedback, either by SMS or calls, six studies in this review reported that they used these tools to increase adherence to the technology used [16,17,[21][22][23]28]. The experience of constantly receiving feedback reinforces that adherence to the use of technology increases self-assessment and monitoring of diet and physical activity [17].
In this review, six studies were found that claimed to use a psychological approach in the intervention [19,20,23,24,26,31]. It is known that eating behavior is related to the psychological aspects of food intake and how the behavior impacts on consumption, so it is preferable that the approach goes beyond nutritional behavior [34].
Virtual environments help in the development and training of technological skills, bringing many benefits to those who use them, but in addition to autonomy, it also increases the responsibility for their own performance [35]. In this review, a study developed a webbased application that aimed to monitor diet and physical activity while instructing and encouraging healthy diet and physical activity [17].
An effective intervention requires greater efficiency of mobile technology, social support and human interaction, in addition to an adaptive approach, that is, according to the profile of the user [36]. The studies presented show the importance of combining the use of technologies for a more efficient and effective health care.
One of the limitations identified was related to the lack of detail on the type of care that the control group received in some of the studies. Importantly, the results of interventions to reduce BMI may vary with age, due to differences in metabolism and nutritional needs. However, in general, it was found through meta-analysis that information and communication technologies can be a good tool in self-management of weight control through health education and used as support for face-to-face care for health professionals. Another limitation of this study is that among the studies included in the meta-analysis, it was not possible to measure publication bias, as fewer than 10 studies were included.
As a strength of this study, the rigor in its conduct can be cited: search of sensitive literature, no publication language or date restrictions, inclusion of a search of gray literature and selection of studies, data extraction and methodological evaluation carried out independently by at least two authors. The present systematic review followed PRISMA.

Conclusions
This study found that information and communication technologies can contribute to the reduction of BMI in the adult population when compared to the traditional follow-up model. The use of technologies has been the agenda of health policies, with the aim of reducing the rates of diseases that depend on eating behaviors and that can be modified throughout life, and that in addition to weight loss, there is a change in eating behavior.
Therefore, the results of this review provide answers to the questions of this research and seek to promote the development of research in the area of public health with the production of educational technologies and evaluation of their impact with the adult public, contributing to policies of nutrition and adequate and healthy food.
The use of technologies as an adjunct to conventional care should still be investigated. Given the current moment that the world is going through, the pandemic caused by the new coronavirus, it is important to replicate this research after this period to verify the impact of information and communication technologies on changing lifestyle habits.