{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,30]],"date-time":"2026-10-30T00:18:22Z","timestamp":1793319502731,"version":"4.5.0"},"reference-count":61,"publisher":"Public Library of Science (PLoS)","issue":"6","license":[{"start":{"date-parts":[[2024,6,14]],"date-time":"2024-06-14T00:00:00Z","timestamp":1718323200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100004825","name":"Nordea-fonden","doi-asserted-by":"publisher","award":["02-2013-2014"],"award-info":[{"award-number":["02-2013-2014"]}],"id":[{"id":"10.13039\/501100004825","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100012774","name":"Innovationsfonden","doi-asserted-by":"publisher","award":["09-067124"],"award-info":[{"award-number":["09-067124"]}],"id":[{"id":"10.13039\/100012774","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosmedicine.org"],"crossmark-restriction":false},"short-container-title":["PLoS Med"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Few cost-effective strategies to shift dietary habits of populations in a healthier direction have been identified. We examined if participating in a chatbot health education program transmitted by Short Messages Service (\u201cSMS-program\u201d) could improve adolescent dietary behaviors and body weight trajectories. We also explored possible added effects of maternal or peer involvement.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods and findings<\/jats:title>\n<jats:p>We conducted a randomized controlled trial (RCT) among adolescents from the Danish National Birth Cohort (DNBC). Eligible were adolescents who during 2015 to 2016 at age 14 years had completed a questionnaire assessing height, weight, and dietary habits. Two thirds were offered participation in an SMS-program, whereas 1\/3 (\u201cnon-SMS group\u201d) received no offer. The SMS program aimed to improve 3 key dietary intake behaviors: sugar-sweetened beverages (SSBs), fruit and vegetables (FV), and fish. The offered programs had 3 factorially randomized schemes; the aims of these were to test effect of asking the mother or a friend to also participate in the health promotion program, and to test the effect of a 4-week individually tailored SMS program against the full 12-week SMS program targeting all 3 dietary factors.<\/jats:p>\n<jats:p>Height and weight and intakes of SSB, FV, and fish were assessed twice by a smartphone-based abbreviated dietary questionnaire completed at 6 months (m) and 18 m follow-up. Main outcome measures were (1) body mass index (BMI) z-score; and (2) an abbreviated Healthy Eating Index (mini-HEI, 1 m window, as mean of z-scores for SSB, FV, and fish).<\/jats:p>\n<jats:p>Among the 7,890 randomized adolescents, 5,260 were assigned to any SMS program; 63% (3,338) joined the offered program. Among the 7,890 randomized, 74% (5,853) and 68% (5,370) responded to follow-ups at 6 m and 18 m, respectively. Effects were estimated by intention-to-treat (ITT) analyses and inverse probability weighted per-protocol (IPW-PP) analyses excluding adolescents who did not join the program.<\/jats:p>\n<jats:p>Mean (standard deviation (SD)) mini-HEI at baseline, 6 m and 18 m was \u22120.01 (0.64), 0.01 (0.59), and \u22120.01 (0.59), respectively. In ITT-analyses, no effects were observed, at any time point, in those who had received any SMS program compared to the non-SMS group, on BMI z-score (6 m: \u22120.010 [95% confidence interval (CI) \u22120.035, 0.015]; <jats:italic>p<\/jats:italic> = 0.442, 18 m: 0.002 [95% CI \u22120.029, 0.033]; <jats:italic>p<\/jats:italic> = 0.901) or mini-HEI (6 m: 0.016 [95% CI \u22120.011, 0.043]; <jats:italic>p<\/jats:italic> = 0.253, 18m: \u22120.016 [95% CI \u22120.045, 0.013]; <jats:italic>p<\/jats:italic> = 0.286).<\/jats:p>\n<jats:p>In IPW-PP analyses, at 6 m, a small decrease in BMI z-score (\u22120.030 [95% CI \u22120.057, \u22120.003]; <jats:italic>p<\/jats:italic> = 0.032) was observed, whereas no significant effect was observed in mini-HEI (0.027 [95% CI \u22120.002, 0.056]; <jats:italic>p<\/jats:italic> = 0.072), among those who had received any SMS program compared to the non-SMS group. At 18 m, no associations were observed (BMI z-score: \u22120.006 [95% CI \u22120.039, 0.027]; <jats:italic>p<\/jats:italic> = 0.724, and mini-HEI: \u22120.005 [95% CI \u22120.036, 0.026]; <jats:italic>p<\/jats:italic> = 0.755).<\/jats:p>\n<jats:p>The main limitations of the study were that DNBC participants, though derived from the general population, tend to have higher socioeconomic status than average, and that outcome measures were self-reported.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>In this study, a chatbot health education program delivered through an SMS program had no effect on dietary habits or weight trajectories in ITT analyses. However, IPW-PP-analyses, based on those 63% who had joined the offered SMS program, suggested modest improvements in weight development at 6 m, which had faded at 18 m. Future research should focus on developing gender-specific messaging programs including \u201cbooster\u201d messages to obtain sustained engagement.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Clinical Trial Registration<\/jats:title>\n<jats:p><jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"http:\/\/clinicaltrials.gov\/\" xlink:type=\"simple\">ClinicalTrials.gov<\/jats:ext-link> Identifier: <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT02809196\" xlink:type=\"simple\">NCT02809196<\/jats:ext-link> <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/clinicaltrials.gov\/study\/NCT02809196\" xlink:type=\"simple\">https:\/\/clinicaltrials.gov\/study\/NCT02809196<\/jats:ext-link>.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pmed.1004383","type":"journal-article","created":{"date-parts":[[2024,6,14]],"date-time":"2024-06-14T17:36:18Z","timestamp":1718386578000},"page":"e1004383","update-policy":"https:\/\/doi.org\/10.1371\/journal.pmed.corrections_policy","source":"Crossref","is-referenced-by-count":13,"title":["An SMS chatbot digital educational program to increase healthy eating behaviors in adolescence: A multifactorial randomized controlled trial among 7,890 participants in the Danish National Birth Cohort"],"prefix":"10.1371","volume":"21","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0628-5292","authenticated-orcid":true,"given":"Anne Ahrendt","family":"Bjerregaard","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2178-7773","authenticated-orcid":true,"given":"Daniel E.","family":"Zoughbie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"J\u00f8rgen Vinsl\u00f8v","family":"Hansen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Charlotta","family":"Granstr\u00f6m","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1926-6610","authenticated-orcid":true,"given":"Marin","family":"Str\u00f8m","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"\u00de\u00f3rhallur Ingi","family":"Halld\u00f3rsson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0743-419X","authenticated-orcid":true,"given":"Inger Kristine","family":"Meder","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1458-7597","authenticated-orcid":true,"given":"Walter Churchill","family":"Willett","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eric L.","family":"Ding","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3017-7096","authenticated-orcid":true,"given":"Sj\u00far\u00f0ur Fr\u00f3\u00f0i","family":"Olsen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2024,6,14]]},"reference":[{"key":"pmed.1004383.ref001","unstructured":"World Health Organization (WHO). 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