An Innovative, Multimedia-Based Intervention for Promoting Changes in Lifestyle in Italian Families

1. Introduction

In recent decades, several epidemiological studies have highlighted poor dietary habits and unhealthy lifestyles among children and adolescents [1,2,3,4,5,6,7], alongside a growing number of adults with cardiovascular risk factors and eating disorders (EDs) [8]. Factors such as increasingly hectic lifestyles, leading to meals more frequently eaten away from home, and the rise in consumption of foods rich in saturated fats and simple sugars — typical of fast food — have contributed to the increase in obesity rates. Furthermore, there is increased exposure to video games and sedentary behaviours.

World Health Organization (WHO) has estimated that in Italy 50% of adults (according to the PASSI study [9]) and 30% of children (according to the “OKkio alla Salute” study⁹) are overweight or obese. According to 2023 OKkio alla Salute data, Italy ranks among the European countries with the highest prevalence of weight excess in the school-age population, with 19% of children being overweight, 9.8% obese, and 2.6% severely obese⁹, with well-documented health consequences [10,11].

Despite many educational initiatives and pediatric recommendations, achieving a lasting change in dietary habits remains challenging. In this context, the Mediterranean Diet represents an effective nutritional model for preventing chronic degenerative diseases and improving quality of life [12,13,14]. However, the ZOOM8 study [15] showed that adherence to the Mediterranean Diet among Italian children is one of the lowest in Europe, underscoring the need for more impactful and effective strategies [16].

The present research aims to:

• formulate and test effective interventions and tools to sustainably promote the health of children and families;
• improve family dietary habits, rediscovering the pleasure of preparing and sharing daily meals, starting with breakfast.

The tools we designed and implemented, with the active involvement of more than 100 dietitian-nutritionists, appears to address this need. In facts, we have created a website with sections specifically designed for parents (or other adults in the family), children or teachers; we also build up social media pages (Facebook and Instagram) along with a Facebook page dedicated to teachers only, which includes didactic materials.

These platforms allowed us to provide evidence-based information to more than 91,000 users between 2019 and 2021. Since 2022, those platforms are not being updated, but they are still highly visited: the website alone (www.sanogiustocongusto.it) counts more than 305,000 visitors up to now.

Recent literature suggests that social media, if used appropriately, can be powerful tools for health education [17,18,19]. Our project fostered ongoing dialogue between families and professionals, with encouraging results, particularly for children who engaged with dieticians via social media or by participating to a recipe contest, that is, creating healthy and tasty meals together with one or both parents.

Children’s eating behaviours are strongly influenced by family environment. Parents, teachers, and grandparents play a key role in encouraging checking new foods and acquiring healthy habits. The “BATMAN Project — Children at the Table” [20], launched by Istituto Oncologico Romagnolo in 2016, and the project “Sano, Giusto e con Gusto! (Heatly, Right and Tasty)”, started in 2019, demonstrated that tasting experiences and active participation in meal preparation led to improvements in children’s taste preferences. Using simple recipes and the “kitchen-as-a-fun”, educational moment fosters food awareness and long-term adoption of healthy lifestyles.

The objective of this study is to assess whether the proposed methodology effectively brings changes in eating habits and lifestyles of adults and children/adolescents participating in the study.

It is worth noting that, in general, the quality of information on the web is often variable, and, therefore, it is crucial that the content is delivered by health professionals [21,22,23,24,25,26].

2. Materials and Methods

To test our methodology, we conducted an experimental study involving children, adolescents, and adults who joined the project, with the use of an innovative multimedia approach. Such approach included the creation of an interactive, dedicated website with downloadable educational materials, as well as a cooking contest engaging both adults and children to work together.

2.1. Interventional Experimental Study on a Population Sample

• Problem: Does sample A (adults) adhere to the Mediterranean Diet? / Sample analysis
• Intervention: Use of downloadable interactive and multimedia educational materials. How many participants modified their eating habits?
• Comparison: Among adults stratified by their level of education
• Outcome: Did sample B (children and adolescents), educated by the same adults, achieve changes in eating habits and lifestyle? / Sample analysis

2.2. Sample

• Adults (teachers, parents, educators, grandparents) randomly recruited among registrants in the national project.
• Children and adolescents guided by the adults (teachers and/or parents/grandparents) to improve their eating and lifestyle habits.

2.3. Primary Outcomes

• To assess eating habits in adults; specifically, adherence to the Mediterranean Diet, before and after the intervention
• To assess eating habits in children and adolescents; specifically, adherence to the Mediterranean Diet and time dedicated to physical activity, before and after the intervention
• To assess BMI in all study participants: adults, children, and adolescents, before and after the intervention. BMI has been used also for children according to [27].

2.4. Secondary Outcomes

To assess differences in adherence to the Mediterranean Diet among adult groups with different level of education, before and after the intervention

2.5. Study Phases

The study was divided into three phases:

• The first phase aimed to provide a snapshot of the nutritional status, eating habits, and lifestyle of all participants.
• The second phase delivered the intervention through interactive materials distributed via dedicated social media channels.
• The third phase assessed the results after the intervention.

Data were collected, processed, and interpreted before and after the intervention to detect differences. Data collection employed validated questionnaires, data processing was conducted using Excel spreadsheets, and statistical analysis was performed using SPSS software.

2.6. Recruitment

We recruited new participants to the scientific study through a newsletter invitation. Subsequently, participating adults underwent remote training by watching eight videos presenting the scientific basis of the project, participation procedures, and use of the educational materials. The modules were released on the project’s Facebook page (Sano, Giusto e con Gusto), then shared on each professional’s social channels. The videos remain available in the events section of the website for public access.

The modules were:

• Module 1 — Scientific foundations
• Module 2 — The project: objectives, target, implementation
• Module 3 — Adolescents and food
• Module 4 — Educational pathway
• Module 5 — Food intolerances, cross-cultural plates, and environmental sustainability
• Module 6 — Physical activity
• Module 7 — Cooking together
• Module 8 — How to register for the project and the recipe contest “super-championship”.

2.7. Website Contents (Publicly Accessible Area)

• Healthy, Fair, and Tasty Recipes! (parents could take inspiration from our recipes to create new ones with their children and even participate in the recipe contest with a support from regional dietitian-nutritionists)
• Games and Quizzes! (children and adolescents could download interactive educational games such as crosswords, rebuses, and more)
• Once Upon a Time! Let Me Tell You a Story (a section dedicated to younger children, where two artists specialized in children’s communication narrate pre-approved nutrition-themed fairy tales)
• A section with educational materials for adults (teachers, educators, parents, grandparents) (Figure 1).

2.8. Phase 1—Data Collection

• Assessing adults’ eating habits using the validated PREDIMED questionnaire [28] to determine adherence to the Mediterranean Diet. The questionnaire was modified to include role (teacher, parent, or educator), level of education, age, region, weight, and height. The questionnaire was provided via Google Forms, and the link was emailed to participants, who were preliminarily required to consent to data privacy terms and commitment to complete the study. Duplicates were automatically removed based on email address.
• Assessing children’s and adolescents’ eating habits using the validated KIDMED questionnaire [29,30], also measuring Mediterranean Diet adherence. Additional questions captured weight, height, age, region, amount of physical activity, and indication of which adult guided them. The first question was modified to replace “fruit juices” with freshly squeezed juice or blended fruit, due to their lower sugar content. This questionnaire was proposed via Google Forms, too.

Parents and teachers received both their own and their children’s/adolescents’ questionnaires by email. Children’s questionnaires were identified by an invented nickname plus a number. A consent form and photo/video release were attached to the invitation.

Duration of Phase 1: 2 months — data collection at the start of the school year, followed by analysis and interpretation.

2.9. Phase 2—Intervention

• Support for adults with downloadable multimedia educational materials, created by collaborating dietitian-nutritionists: fact sheets, video clips, healthy and tasty recipes to inspire cooking with children, and other interactive resources available at [www.sanogiustocongusto.it] (http://www.sanogiustocongusto.it). The “Healthy Dish” recipe contest encouraged children to participate actively.
• Support for children and adolescents with downloadable interactive games: crosswords, riddles, etc.
• Support for young children with video fairy tales, dramatized by two Neapolitan theatre artists.
• Support for children and adolescents with physical activity programs: fact sheets and videos created by a motor activity expert using the “Cantaballo” method.

This phase enabled adults to deepen their knowledge and improve their own habits in order to effectively convey healthy messages to their children and adolescents.

Duration of Phase 2: from November to the end of March.

2.10. Phase 3—Evaluation

• Assess changes in adults’ eating habits, particularly adherence to the Mediterranean Diet, using the PREDIMED questionnaire in the same format as Phase 1.
• Assess changes in children’s and adolescents’ eating habits, Mediterranean Diet adherence, and physical activity using the KIDMED questionnaire in the same format as Phase 1.

Children’s questionnaires were again identified by an invented nickname plus a number.

Duration of Phase 3: 2 months — data collection after the educational intervention, followed by analysis and interpretation.

2.11. Study Methods

The core of the study relied on the PREDIMED [28] questionnaire for adults and the KIDMED [29,30] questionnaire for children and adolescents, with added questions as described in the methods section.

2.12. Statistical Analysis

Data were collected in a spreadsheet and analyzed using SPSS statistical software.

2.13. Predimed Score Calculation

The PREDIMED questionnaire (Mediterranean Diet adherence score) is composed of 14 questions designed for adults. A score of +1 is assigned to each answer that expresses adherence to the Mediterranean Diet. The possible score range is from 0 to 14. Three levels of classification are defined:

• ≥10: good adherence to the Mediterranean Diet
• 6–9: medium adherence to the Mediterranean Diet
• 0–5: poor adherence to the Mediterranean Diet

2.14. Kidmed Score Calculation

The KIDMED questionnaire (Mediterranean Diet adherence score) is composed of 16 questions designed for children. A score of +1 is assigned to a “YES” response on those 12 items expressing adherence to the Mediterranean Diet, while a score of −1 is assigned to a “YES” response on those 4 items expressing counter-adherence.

We modified the original questionnaire by including two additional questions: one regarding physical activity (+1 point for the answer “2–3 times per week”), and the other one regarding use of video games and electronic devices for leisure (−1 point for the answer “more than 3 hours per day”).

The possible score range is from 0 to 13 (instead of 12 in the original questionnaire).

The original three-level classification is maintained:

• 8: good adherence to the Mediterranean Diet
• 4–7: medium adherence to the Mediterranean Diet (modifications needed)
• ≤3: poor adherence to the Mediterranean Diet

2.15. Study Duration: One School Year

Rationale for the study duration: some (end-of-cycle) classes (fifth grade of primary school and eighth grade of middle school) will change their teachers at the end of the school year, thus losing their point of reference.

3. Results

3.1. Results on 329 Children Participating in the Study

A total of 329 children participated in the study: 149 boys and 180 girls. Among these, 35.6% were guided by teachers, 26.1% by parents, and 38.3% by both. Regarding BMI calculation, the total sample was divided into two age groups: 6–10 years identified as “Sample A”, and 11–14 years identified as “Sample B”.

3.1.1. Baseline (Time 0)

Sample A (children aged 6–10): 9% (n=23) underweight, 22% (n=58) mildly underweight, 14% (n=36) normal weight, 38% (n=101) overweight, 17% (n=45) obese (Figure 2).

Sample B (children aged 11–14): 7% (n=5) underweight, 29% (n=19) mildly underweight, 8% (n=5) normal weight, 47% (n=31) overweight, 9% (n=6) obese (Figure 3).

Physical activity: In the total sample of 329 children, 55.6% engaged in physical activity 2–3 times per week, while 44.4% engaged less than twice per week.

Regarding screen time, 49.8% spent 2–3 hours daily on TV or video games, 18.8% more than 3 hours daily, and 31.4% none or at most 1 hour daily (Figure 4).

Eating habits: At baseline, the consumption of fruits, vegetables, and fish was low:

only 104 out of 329 children (31.6%) ate vegetables twice daily, 133 out of 329 (40.4%) ate fruits twice daily, and 148 out of 329 (45%) consumed fish at least 2–3 times weekly. However, breakfast habits were good: 79.6% of children ate breakfast regularly (Figure 5).

Adherence to the Mediterranean Diet: At baseline, 46.8% (n=154) had good adherence, 43.5% (n=143) medium adherence, and 9.7% (n=32) poor adherence (Figure 6).

3.1.2. Follow-Up (210 Days)

Sample A (children aged 6–10): 9% (n=23) underweight, 20% (n=54) mildly underweight, 18% (n=47) normal weight, 37% (n=97) overweight, 16% (n=42) obese (Figure 7).

Sample B (children aged 11–14): 11% (n=7) underweight, 29% (n=19) mildly underweight, 19% (n=13) normal weight, 32% (n=21) overweight, 9% (n=6) obese (Figure 8).

Physical activity: After 210 days, 65% of children engaged in physical activity 2–3 times per week, while 35% engaged less (including once a week or never). Regarding screen time, 44.8% spent 2–3 hours daily on TV or video games, 9.2% more than 3 hours daily, and 46% none or at most 1 hour daily (Figure 4).

Eating habits: After 210 days, fruit, vegetable, and fish consumption improved:

191 out of 329 children (58.2%) ate vegetables twice daily, 210 out of 329 (64%) ate fruits twice daily, and 189 out of 329 (58%) consumed fish at least 2–3 times weekly. Breakfast frequency also improved to 86.3% (Figure 5).

Adherence to the Mediterranean Diet: After 210 days, 61.4% (n=202) had good adherence, 36% (n=118) medium adherence, and 2.6% (n=9) poor adherence (Figure 6).

3.2. Results on 122 Adults Participating in the Study

A total of 122 female adults participated.

3.2.1. Baseline (Time 0)

52% (n=64) normal weight, 31% (n=37) overweight, 17% (n=21) obese (Figure 9).

Eating habits: At baseline, fruit, vegetable, and fish consumption was low: 44 out of 122 adults (36%) ate vegetables twice daily, 26 out of 122 (21.3%) ate fruit at least three times daily, 4 out of 122 (3.27%) consumed fish at least three times weekly, and 9 out of 122 (7.37%) consumed legumes three times weekly (Figure 10).

Adherence to the Mediterranean Diet: At baseline, 10.8% (n=13) had good adherence, 72% (n=88) medium adherence, and 17.4% (n=21) poor adherence (Figure 11).

3.2.2. Follow-Up (210 Days)

63% (n=77) normal weight, 30% (n=36) overweight, 7% (n=8) obese (Figure 12).

Eating habits: After 210 days, fruit, vegetable, and fish consumption improved:

65 out of 122 adults (53.2%) ate vegetables twice daily, 38 out of 122 (31.1%) ate fruit at least three times daily, 19 out of 122 (15.5%) consumed fish at least three times weekly, and 21 out of 122 (17.2%) consumed legumes three times weekly (Figure 10).

Adherence to the Mediterranean Diet: After 210 days, 35.4% (n=43) had good adherence, 62.2% (n=76) medium adherence, and 2.4% (n=3) poor adherence (Figure 11).

3.3. Secondary Outcomes

We observed differences in Mediterranean Diet adherence between adult groups with different level of education, before and after the intervention.

Data analysis revealed a significant correlation between body weight status and level of education at both baseline and follow-up. Specifically, normal weight and obesity were associated with a high school diploma (p < 0.0000001), whereas overweight was associated with lower educational attainment (p < 0.0000001) (Figure 13).

4. Discussion

The effectiveness of the method used was assessed by comparing eating habits and lifestyle at baseline and 210 days after the intervention. The impact of the project on both adults and minors confirmed the effectiveness of social media and digital platforms as tools for health promotion and nutrition education when managed by health professionals.

The methodological approach adopted ensured that social media and digital devices were not directly used by minors, but rather proposed and mediated by their primary caregivers—parents, teachers, and educators—who actively guided the educational process. This strategy not only provided greater safety but also strengthened the adult–child relationship through shared activities such as cooking, educational games, recipe preparation, and storytelling. Furthermore, the chosen approach represents a protective strategy against the risks associated with excessive screen use in children, as documented in recent literature [31,32].

After 210 days of our educational intervention, children in Sample A (6–10 years), who were overweight or obese, showed no significant changes, whereas underweight children reached normal weight (+2%). Sample B, consisting of adolescents (11–14 years), who are more attentive to body image, achieved more substantial results. Overweight prevalence dropped from 47% to 32% (a 15% reduction), with 11% reaching normal weight and 4% shifting to underweight.

Additionally, the proportion of children engaging in physical activity 2–3 times per week increased from 55.6% to 65% (+9.4%), with a slight reduction in sedentary behaviour: 44.8% still spent 2–3 hours daily on TV and video games. About 7% more children reported having breakfast regularly.

The proportion of children consuming vegetables twice daily rose from 31.6% to 58.2%, fruit from 40.4% to 64.8%, and fish from 45% to 58%. Good adherence to the Mediterranean Diet was observed in 61.4% of children after the intervention.

Among the 122 adults, after 210 days of our educational intervention, the proportion of overweight individuals showed little change, whereas obesity prevalence decreased from 17% to 7%, with more participants reaching normal weight.

Adults consuming vegetables twice daily increased from 36% to 53.2%, fruit at least three times daily from 21.3% to 31.1%, fish at least three times weekly from 3.27% to 15.5%, and legumes three times weekly from 7.37% to 17.2%. Good adherence to the Mediterranean Diet was observed in 35.4% of adults after the intervention.

In summary, the intervention had a positive impact on eating habits and lifestyle in both children and adults, with significant improvements in adherence to the Mediterranean Diet.

Data analysis revealed a significant correlation between body weight status and educational level of the participating adults, both at baseline and follow-up. Specifically, normal weight and obesity were associated with having a high school diploma (p < 0.0000001), whereas overweight was correlated with lower educational attainment (p < 0.0000001).This study has some limitations. The absence of a control group limits causal interpretation and does not allow exclusion of external influences. Participants were recruited on a voluntary basis, which may have introduced selection bias. In addition, key variables such as weight, height, and dietary habits were self-reported, and the follow-up period was relatively short to assess long-term sustainability of behavioural changes.

5. Conclusions

Several studies have shown that social media represent a powerful tool for health promotion, facilitating the creation of user networks and providing healthcare institutions and professionals with a stable, ongoing communication channel with patients and families.[8,9] These digital platforms, if properly managed, enable not only widespread dissemination of evidence-based information, but also direct, timely, and personalised interaction with the public, enhancing engagement and adherence to prevention programs.

In our study, in addition to social media pages (Facebook, Instagram, and one dedicated to the teachers only), an interactive website was developed, specifically designed to provide educational content, downloadable teaching materials, and self-monitoring tools for both adults (parents, educators, teachers, grandparents) and children/adolescents.

This multichannel approach allowed us an accessible and flexible user engagement, with content tailored to different age groups and educational levels.

Data collected after 210 days from the start of the intervention show positive results on improved eating habits and reduced sedentary behaviours, accompanied by increased time dedicated to physical activity. These behavioural changes were observed across both age subgroups (6–10 years and 11–14 years), with particularly notable effects among those jointly guided by teachers and parents.

The project, which involved the entire family, showed that 96.6% of children and adults achieved good adherence to the Mediterranean Diet and improved their dietary habits.

Regarding body weight changes, modest improvements in BMI values were observed, with an increase in the proportion of normal weight participants and a slight reduction in the percentage of obese children and adults, while the number of overweight children and adults remained nearly unchanged. Therefore, future studies should investigate parents’ perceptions of overweight in their children to better target interventions.

Moreover, although a significant correlation was found between body weight status and level of education, both at baseline and follow-up, it will be useful to assess regional differences (north, center, and south Italy) in future studies.In summary, preliminary findings suggest that an integrated, family-based digital intervention may represent a promising strategy to promote healthier lifestyles and improve adherence to the Mediterranean Diet in children, adolescents, and adults. The involvement of parents, teachers, and health professionals appears to be a key factor in supporting behavioural change. However, the absence of a control group, the use of self-reported data, and the relatively short follow-up period require cautious interpretation of the results. Future controlled studies with longer follow-up are needed to confirm these findings and assess their impact on body weight.