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TRANSCRIPT
Review
Nutrition Education and Dietary Behavior Change Games:A Scoping Review
Tom Baranowski, PhD,1 Courtney Ryan, MS, RD,1 Andres Hoyos-Cespedes,2
and Amy Shirong Lu, PhD3,4
Abstract
Games provide an attractive venue for engaging participants and increasing nutrition-related knowledgeand dietary behavior change, but no review has appeared devoted to this literature. A scoping reviewof nutrition education and dietary behavior change videogames or interactive games was conducted. Asystematic search was made of PubMed, Agricola, and Google Scholar. Information was abstracted from 22publications. To be included, the publication had to include a videogame or interactive experience involvinggames (a videogame alone, minigames inserted into a larger multimedia experience, or game as part of ahuman-delivered intervention); game’s design objective was to influence dietary behavior, a psychosocialdeterminant of a dietary behavior, or nutrition knowledge (hereinafter referred to as diet-related); must havebeen reported in English and must have appeared in a professional publication, including some reportof outcomes or results (thereby passing some peer review). This review was restricted to the diet-relatedinformation in the selected games. Diversity in targeted dietary knowledge and intake behaviors, targetedpopulations/audiences, game mechanics, behavioral theories, research designs, and findings was revealed.The diversity and quality of the research in general was poor, precluding a meta-analysis or systematicreview. All but one of the studies reported some positive outcome from playing the game(s). One reportedthat a web-based education program resulted in more change than the game-based intervention. Studies ofgames may have been missed; a number of dietary/nutrition games are known for which no evaluation is known;and the data presented on the games and research were limited and inconsistent. Conclusions and Implications: Afirmer research base is needed to establish the efficacy and effectiveness of nutrition education and dietarybehavior change games.
Keywords: Games, Nutrition education, Dietary behavior change, Scoping
Introduction
D ietary intake has been related to heart disease, dia-betes, several cancers, stroke, and perhaps adiposity.1
Dietary behavior change programs have been shown tochange diet, but the mediating variables are not clear.2,3
Nutrition knowledge change programs (usually called nu-trition education) by themselves have been shown to beinadequate to change behavior,4 but some knowledge is alikely precondition of effective behavior change.5 Dietary
behavior change programs are needed that appeal to largenumbers and diverse types of people who could benefit fromthe educational/behavior change procedures. Innovativeapproaches to dietary change are needed to engage partic-ipants in enjoyable experiences to reach the largest numberof participants.
Electronic media are an increasingly popular channelfor health promotion, meeting the needs and interests ofmodern populations.6–8 At least six types of electronicmedia for health promotion have been identified: web-based
1Department of Pediatrics, USDA/ARS Children’s Nutrition Research Center, Baylor College of Medicine, Houston, Texas.2Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts.3Health Technology Lab, Department of Communication Studies, College of Arts, Media & Design, Bouve College of Health Sciences,
Northeastern University, Boston, Massachusetts.4Department of Health Sciences, Bouve College of Health Sciences, Northeastern University, Boston, Massachusetts.
GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical ApplicationsVolume 8, Number 3, 2018ª Mary Ann Liebert, Inc.DOI: 10.1089/g4h.2018.0070
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educational/therapeutic programs; tailored motivational mes-saging systems; data collection and feedback systems; activevideogames (also called exergames); diverse interactive mul-timedia; and diverse games.7 This review concerns games orinteractive media incorporating games. A recent review ofschool nutrition education resources identified 14 of 32curricula as incorporating games of one type or another toenhance learning, but provided no identification or analysisof the games.9 This suggests that games are increasinglyrecognized as an important learning tool, but the role andeffectiveness of the games need to be analyzed. There hasbeen recent interest in the use of ‘‘gamification,’’ which in-corporates aspects of games into the design of media inter-ventions.10 Gamification most often has employed rewards,10
thereby not including some of the most interesting aspects ofgames, for example, repeated losing under the rules of thegame to learn a new principle without real-world conse-quences, and are most appropriately reviewed when con-sidering those behavior change procedures,11,12 not whenreviewing the effects of games.
No consistent, commonly accepted concept exists for whatconstitutes a game. Games generally have rules that governactions within the game with the possibility of winning and,importantly, losing based on the rules; feedback on playwithin the game (often points assigned); and a story or nar-rative (or an associated back story), among many otherpossible game elements.13 Games can provide attractivelearning and behavior change media since they can be de-signed to provide fun, enjoyment, or engagement (therebyproviding intrinsic motivation to play)14; a multisensoryexperience to facilitate different learning styles15; safe op-portunities for drill and practice with feedback; training forhigher-order skills, such as critical thinking, problem solv-ing, team work, strategic thinking, and planning16; roleplaying for constructivist learning17; experimentation withnew identities; development of social skills18; modeling ofbehaviors19; training in self-regulation19; and/or immersionof players in a storyline into which behavior change proce-dures can be built.20
While several systematic reviews and/or meta-analyseshave appeared on games for health,6,21–24 and even in-cluded a few nutrition education games as a subcomponent,no review has appeared devoted to the consideration ofgames for nutrition education or dietary behavior changealone. Some reviews have indicated that research on fewnutrition games have appeared25; one found only fourgames26; a review of digital interventions included only onenutrition education game,27 and another included onlysix.28 This scoping review of the diet-related video or in-teractive games literature attempts to describe the currentstate of the art in a substantial number of studies involvingnutrition education games and identify limitations in theresearch, which need to be remedied to advance this im-portant intervention medium.
Methods
A protocol for this analysis was not preregistered due tothe long idea-incubation period and a lack of clarity aboutwhat we might find in our literature search. The structure andsequence of this review follows the PRISMA guidelines, aspossible.29
Eligibility criteria
To be included in this review, the publication had to in-clude a videogame or interactive experience involving games(i.e., the intervention was a videogame alone, minigameswere inserted into a larger multimedia experience, or a gamewas part of a human-delivered intervention); the game’s de-sign objective was to influence dietary behavior, a psycho-social variable believed to be a determinant of a dietarybehavior, or some aspect of nutrition knowledge (hereinafterreferred to as diet-related); must have been reported in En-glish and must have appeared in a professional publication,including some report of outcomes or results (thereby pass-ing some peer review). No additional exclusionary criteriawere employed. This review was restricted to the diet-relatedinformation in the selected games.
Information sources
Following the guidelines for a scoping review,30 this re-view included two search cycles. Both searches of the lit-erature were conducted using PubMed, Agricola (theagricultural database, since the U.S. Department of Agri-culture appeared to fund much of the early work on nutritiongames), and Google Scholar, using the search terms (Nutri-tion AND Games) and (Diet AND Games).
Search
One author conducted the initial systematic search of thedatabases through December 31, 2016, while the first authorculled the articles for whether a game was involved in theidentified articles. A second cycle was performed duringSeptember 2017, including only the articles produced fromJanuary 1, 2017 to September 30, 2017.
Study selection
Since the method of game delivery varied by time, therewas an initial interest in the historical development of gamesfor nutrition education. An intensive effort was made toidentify any article that concerned a game involving nutritionor diet. This preliminary, broad, exploratory search revealedarticles on a substantial variety of games involving nutritioneducation, including card, board, video, and other deliverychannels. One hundred eighty-five abstracts of articles wereanalyzed; duplicates were removed. Since many of thesearticles were not research-based (i.e., no evaluation of ef-fects), the investigators narrowed the focus to include articlesmeeting the eligibility criteria uncovered through the initialad hoc search. Two coders reviewed the abstracts of thesearticles; duplicate entries were removed; and selected articleswere retrieved and abstracted. In the search process, anumber of intervention articles were identified that used oneor more multimedia formats, but did not include games,31–39
and thereby were not included in this review.
Data collection process
To ensure inter-rater reliability and to authenticate data ex-traction and interpretation quality, two independent reviewerssystematically analyzed the abstracts. Final selection was basedon a 92% agreement between reviewers. Data abstraction wasstarted after both reviewers received coding training and
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performed a coding of 10% of the articles as a pilot for testingreliability. Differences were resolved by multiple, internal, in-depth discussions. Following training, each coder reviewed andextracted data from the 22 articles separately. The first authorprovided the final determination for all variables.
Data items
Each row in Tables 1–3 concerns a different study. Thestudies were summarized in regard to first author, year,country, game name, the key goals and hypotheses, whethera story/narrative was included, game elements or mechanics,behavior change procedures and theories employed, setting,target group, method of delivery, research design, samplesize, outcome measures (specifically subjectively reportedand objective measures), and diet-related outcomes. Story,often considered a key game element,6 was coded as presentwhen there were characters other than the player, a logicallysequenced set of events (storyline or arc), with the storyending and the outcome depending on game play. Gameelements or mechanisms were abstracted as possible from thereports provided.
Risk of bias in individual studies
Quality of study or research bias items from the CochraneCollaboration Risk of Bias Tool (CCRBT) and the EffectivePublic Health Practice Project Quality Assessment Tool(EPHPP)40 were applied to all studies. Table 3 reports on therisk of bias/quality of research characteristics of each study,including whether the method of randomization was reported;randomization was concealed at baseline; prior power calcu-lations were conducted; assessors were blinded; completenessof follow-up reported; selection bias reported; validity orreliability of the measures reported; possible confoundingvariables were accounted for in the analyses; and the trialprotocol was preregistered.
Synthesis of results
Many of the included studies were pilot, feasibility orproof-of-concept studies with small samples, weak designs,and inconsistent and inadequate assessment, thereby pre-cluding a meta-analysis or systematic review. Thus, themajor value of this scoping review is to report the breadth oftarget groups, objectives and game mechanics, and identifyspecific research enhancements necessary to document thevalue of the gaming approach to diet-related change.
Results
Study selection
One hundred eighty-five articles were identified in thepreliminary search: 61 from Agricola and 124 from PubMed.An additional 50 articles were identified in the second cycle.Twenty-two articles were identified on nutrition education ordietary change video or interactive games, hereinafter re-ferred to as game.
Study characteristics
The first game article identified was published in 2001,with the number per year steadily increasing to eight in2015–2017.
Risk of bias within studies
The quality or research bias of individual trials was poor,and is summarized in Table 3. Eleven of the 22 articles (50%)were randomized clinical trials (RCTs), and 3 (14%) weregroup cluster RCTs. Four (18%) were single-group pre-postdesigns; two (9%) were not randomized control designs, onewas a cross-over trial, and one was an A-B–A-B reversal de-sign. The method of randomization, concealment of randomi-zation at baseline, and trial preregistration was reported by noneof these trials (Table 3). Five (23%) reported statistical powercalculations before the conduct of the trial. While blinding ofparticipants is not possible in behavior change trials, blinding ofassessors is possible and was reported in only one trial.
Completeness of follow-up (withdrawals, dropouts) wasreported in 12 trials (55%). Selection bias (sample repre-sentativeness and participation rates) were reported by fivetrials (23%). Validity and/or reliability of the measures wasreported by 14 trials (64%). Accounting for possible con-founders of outcomes was reported by nine trials (41%).Whether the investigators reported analyses of all the pre-specified outcomes could not be assessed since none of theresearch protocols were preregistered.
Results of studies
Only one of the games reported no changes from playingthe game on behavior or its determinants,41 but only 27.6%of the students in that study played the game. All the otherstudies reported some positive outcomes from game play, butfew studies identified a primary outcome, and none identifiedwhat percentages of all possible or expected outcomes thegames impacted. Another study revealed that a web-basededucation program was more effective than the game-basededucation.42 Most changes were relatively small, but feweffect sizes were reported.
Synthesis of results
Thirteen of these games (59%) targeted children at school,three (14%) targeted children at home, three (14%) in alaboratory, one any place, and only two (5%) targeted adults.The sample sizes varied from 1876 to 20. There were 14(64%) individual or group randomized clinical trials. Thegames were developed and tested largely in the United States(n = 13; 59%), Europe (n = 8; 36%), or Asia (n = 1).
A story (or narrative) was specifically included in 15games (68%). The other game elements or game mechanicsvaried enormously. A number of well-known popular exist-ing game formats/mechanics should have been well knownto the target audience (thereby minimizing the need to learnnew game rules), for example, the concentration memorygame, and adapted these game elements to achieve educationpurposes or influence behavior.
Five of these games (23%) could be categorized more asprimarily targeting some aspect of nutrition knowledge,while nine other games (41%) could be categorized more astargeting dietary behavior change, and eight (36%) as pri-marily targeting some combination of dietary psychosocialvariables and behavior. A diverse variety of educational and/or behavioral change theories with attendant diversity in thecorresponding knowledge or behavior change procedureswere identified as providing the conceptual foundation and
NUTRITION EDUCATION AND DIETARY BEHAVIOR CHANGE GAMES 3
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Ta
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who
pla
yed
the
nonhea
lthy
ver
sion
wil
lli
ke
nonhea
lthy
food
more
than
the
oth
ergro
up;
H3:
Chil
dre
nw
ho
pla
yed
the
hea
lthy
ver
sion
wil
lex
hib
itgre
ater
nutr
itio
nal
know
ledge,
com
par
edw
ith
chil
dre
nw
ho
pla
yed
ale
sshea
lthy
ver
sion
of
the
sam
egam
e
�S
tory
:Y
es�
Chil
dch
arac
ter
gra
bs
asn
ack—
ifhea
lthy,
gai
ns
5poin
ts�
Bom
ban
dbull
ets
nee
dto
evad
e�
2le
vel
s:ch
arac
ter
can
fly
Nutr
itio
nknow
ledge
chan
ge
Food
exposu
reth
eory
(Bir
ch)
7B
aran
ow
ski6
6
2011,
US
A,
Esc
ape
from
Dia
b,
and
Nanosw
arm
:In
vasi
on
from
Inner
Space
Eval
uat
eth
eef
fect
of
pla
yin
gtw
ose
rious
vid
eogam
eson
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dre
n’s
die
t,physi
cal
acti
vit
y,
scre
enm
edia
use
,an
dad
iposi
tyH
1:
Chil
dre
nw
ho
pla
yth
etw
ose
rious
gam
esw
ill
incr
ease
thei
rfr
uit
and
veg
etab
lean
dw
ater
inta
ke,
and
physi
cal
acti
vit
y,
and
dec
reas
eth
eir
scre
enti
me
and
BM
I
�S
tory
:Y
es�
Act
ion-a
dven
ture
story
/nar
rati
ve
�G
ames
not
spec
ified
�M
aste
ryle
arnin
gof
ener
gy
bal
ance
for
know
ledge
chan
ge
�M
odel
ing
of
beh
avio
rsan
dco
pin
gac
tion
and
copin
gim
ple
men
tati
on
inte
nti
ons
�B
ehav
iora
lin
ocu
lati
on
�T
ailo
red
val
ue-
bas
edm
essa
gin
g
Soci
alco
gnit
ive
and
self
-det
erm
inat
ion
theo
ries
and
elab
ora
tion
likel
ihood
model
(conti
nued
)
6
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
1.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eK
eygoals
and
hyp
oth
eses
Sto
ry/n
arr
ati
ve/g
am
em
echanic
sB
ehavi
or
change
pro
cedure
sT
heo
ries
nam
ed
8B
anos8
9
2013,
Spai
n,
ET
IOB
EM
ate
s
Eval
uat
eth
eef
fica
cyan
dac
cepta
bil
ity
of
ET
IOB
EM
ate
son
chil
dre
n’s
nutr
itio
nal
know
ledge
com
par
edto
atr
adit
ional
pap
er–pen
cil
mode
of
info
rmat
ion
del
iver
yH
1:
Chil
dre
npla
yin
gE
TIO
BE
Mate
sw
ill
impro
ve
thei
rnutr
itio
nal
know
ledge;
and
ET
IOB
EM
ate
sw
ill
be
acce
pta
ble
and
pla
yab
le(m
ediu
mto
hig
hsc
ore
s)
�S
tory
:Y
es�
The
Hea
lthy
Pla
te:
Cat
egori
zefo
ods
info
od
pyra
mid
cate
gori
es�
The
Mem
ory
Gam
e:C
once
ntr
atio
nty
pe
gam
eto
find
pai
r-w
ise
mat
ches
of
foods
and
then
answ
erques
tions
about
food—
easy
,m
ediu
m,
and
dif
ficu
ltle
vel
s�
Super
ET
IOB
E:
Pla
yer
hel
ps
det
ecti
ve
solv
eca
ses
of
chil
dre
nhav
ing
imbal
ance
ddie
tan
dP
A
Ener
gy
bal
ance
know
ledge
enhan
cem
ent
None
spec
ified
9S
chnei
der
90
2012,
US
A,
Fit
ter
Cri
tter
s
Tes
tth
eac
cepta
bil
ity
of
anonli
ne
vid
eogam
efo
rim
pro
vin
ghea
lthy
die
tan
dac
tivit
yin
elem
enta
rysc
hool
studen
tsH
1:
Chil
dre
nw
ho
pla
yth
egam
ew
ill
find
ithig
hly
acce
pta
ble
and
incr
ease
thei
rnutr
itio
nan
dac
tivit
yknow
ledge,
atti
tudes
,an
dse
lf-
effi
cacy
�S
tory
:N
o�
Pla
yer
sre
sponsi
ble
for
the
hea
lth
of
aC
ritt
er�
17
ques
ts�
Met
ers
for
Cri
tter
’shea
lth
and
die
t�
Food
tofe
edC
ritt
er:
Should
not
exce
edfa
t,su
gar
,ca
lori
esal
lotm
ents
�C
ookin
g:
To
feed
Cri
tter
�W
ork
:C
ritt
erca
nea
rnm
oney
atw
ork
;hea
lthie
rC
ritt
erea
rns
more
money
�S
ick
day
s:W
hen
Cri
tter
issi
ck,
cannot
earn
money
�D
ecora
tions:
Cri
tter
’sea
rnin
gs
use
dto
dec
ora
tehouse
None
stat
edN
one
stat
ed
(conti
nued
)
7
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
1.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eK
eygoals
and
hyp
oth
eses
Sto
ry/n
arr
ati
ve/g
am
em
echanic
sB
ehavi
or
change
pro
cedure
sT
heo
ries
nam
ed
10
Folk
vord
44
2013,
Net
her
lands,
Adve
rgam
es
Exam
ine
the
effe
ctof
adver
gam
esth
atpro
mote
ener
gy-d
ense
snac
ks
or
fruit
on
chil
dre
n’s
adli
bit
um
snac
kan
dfr
uit
consu
mpti
on
and
exam
ine
whet
her
this
consu
mpti
on
dif
fere
dac
cord
ing
tobra
nd
and
pro
duct
type
(ener
gy-d
ense
snac
ks
and
fruit
)H
1:
Pla
yin
gad
ver
gam
esth
atpro
mote
food
incr
ease
sgen
eral
calo
ric
inta
ke;
H2:
Pla
yin
gan
adver
gam
eth
atpro
mote
sfo
od
incr
ease
spro
duct
type–
rela
ted
food
inta
ke;
H3:
Incr
ease
dfo
od
inta
ke
afte
rpla
yin
gan
adver
gam
eis
not
spec
ific
toa
cert
ain
bra
nd
but
wil
lal
soen
han
ceth
ein
take
of
abra
nd
pro
moti
ng
pro
duct
sin
the
sam
epro
duct
cate
gory
�S
tory
:N
o�
Conce
ntr
atio
nty
pe
mem
ory
gam
eat
tem
pti
ng
tom
atch
pai
r-w
ise
imag
esof
foods
�T
he
hea
lthy
or
unhea
lthy
bra
nds
appea
red
on
the
bac
ksi
des
of
the
card
sto
be
turn
edover
�D
igit
alti
mer
and
tim
ebar
tosu
pply
urg
ency
�P
leas
ant
sound
when
chil
dm
ade
am
atch
edpai
r;unple
asan
tso
und
for
nonm
atch
ing
pai
rs
Exposu
reto
bra
nd
nam
esC
ue
reac
tivit
yth
eory
(conce
ntr
atio
nty
pe
mem
ory
gam
e)
11
Maj
um
dar
91
2013,
US
A,
Cre
atu
re101
Eval
uat
eth
eef
fica
cyof
pla
yin
gC
reatu
re-1
01
atpro
moti
ng
ener
gy
bal
ance
-rel
ated
beh
avio
rs(E
BR
Bs)
H1:
Adole
scen
tsw
ho
pla
yed
Cre
atu
re-1
01
would
signifi
cantl
yin
crea
seth
eir
FV
and
wat
erin
take
and
PA
;an
ddec
reas
ein
take
of
pro
cess
edsn
acks
(e.g
.,ch
ips,
candy),
SB
,an
dre
crea
tional
scre
enti
me
�S
tory
:Y
es�
Pla
yer
scr
eate
dow
nav
atar
san
dw
orl
ds
�B
etw
een-p
layer
com
munic
atio
nof
goal
san
dac
com
pli
shm
ents
�S
tory
/nar
rati
ve:
Murp
hy
inT
wee
n,
char
acte
rsin
Tw
een
bec
ame
addic
ted
tofo
ods
and
acti
vit
ies
bro
ught
from
Ear
th�
Pla
yer
lear
ned
hea
lthfu
lnes
sof
beh
avio
rsw
hen
hel
pin
gcr
eatu
res
chan
ge
�A
uto
nom
ysu
pport
ive
envir
onm
ent
�L
earn
edco
mpet
ence
�D
iet-
rela
ted
know
ledge
chan
ge
�G
oal
sett
ing
for
per
sonal
beh
avio
rch
ange
Soci
alco
gnit
ive
and
self
-det
erm
inat
ion
theo
ries
(conti
nued
)
8
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
1.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eK
eygoals
and
hyp
oth
eses
Sto
ry/n
arr
ati
ve/g
am
em
echanic
sB
ehavi
or
change
pro
cedure
sT
heo
ries
nam
ed
12
Folk
vord
92
2014,
Net
her
lands,
var
ious
adver
gam
es
Exam
ine
the
moder
atin
gro
leof
impuls
ivit
yon
the
effe
ctof
adver
gam
esth
atpro
mote
ener
gy-d
ense
snac
ks
on
chil
dre
n’s
snac
kin
take
H1:
Pla
yin
gad
ver
gam
espro
moti
ng
ener
gy-d
ense
snac
ks
incr
ease
sca
lori
cin
take;
H2a:
Sti
mula
ting
resp
onse
inhib
itio
nby
rew
ardin
gre
frai
nin
gfr
om
eati
ng
dec
reas
esca
lori
cin
take;
H2b:
Chil
dre
nre
war
ded
for
refr
ainin
gfr
om
eati
ng
hav
ea
low
erca
lori
cin
take
when
they
pla
ya
nonfo
od
adver
gam
eth
anw
hen
they
pla
ya
food
adver
gam
e;H
3:
Impuls
ive
chil
dre
nea
tm
ore
;H
4:
Rew
ardin
gre
frai
nin
gw
ill
hav
ele
ssin
fluen
ceon
hig
him
puls
ive
chil
dre
n,
espec
iall
yw
hen
pla
yin
ga
food
adver
gam
e
�S
tory
:N
o�
Conce
ntr
atio
nty
pe
mem
ory
gam
eat
tem
pti
ng
tom
atch
pai
r-w
ise
imag
esof
foods
�T
he
hea
lthy
or
unhea
lthy
bra
nds
appea
red
on
the
bac
ksi
des
of
the
card
sto
be
turn
edover
�D
igit
alti
mer
and
tim
ebar
tosu
pply
urg
ency
�P
leas
ant
sound
when
chil
dm
ade
am
atch
edpai
r;unple
asan
tso
und
for
nonm
atch
ing
pai
rs
Exposu
reto
bra
nd
nam
esC
ue
reac
tivit
yth
eory
13
Johnso
n-G
lenber
g93
2014,
US
A,
Ali
enH
ealt
h
Ass
ess
the
feas
ibil
ity
and
effi
cacy
of
gam
eon
nutr
itio
nknow
ledge
among
anold
ergro
up
of
chil
dre
nH
1:
Pla
yin
gA
lien
Hea
lth
wil
lbe
feas
ible
and
resu
ltin
incr
ease
dnutr
itio
nknow
ledge
�S
tory
:Y
es�
Sto
ry:
Fin
dal
ien
under
your
bed
�L
evel
1:
Stu
den
tpai
rsnee
dto
dis
cuss
and
choose
bet
wee
nhea
lthy
and
unhea
lthy
foods
wit
hin
10
seco
nds
�K
inec
tse
nse
dch
ild
sele
ctio
nan
dch
anged
tonex
tch
oic
e�
Chil
dre
nen
gag
edin
PA
bet
wee
nch
oic
es�
Lev
el2:
Focu
sed
atte
nti
on
on
nutr
ient
info
rmat
ional
bar
sto
mak
efo
od
sele
ctio
n�
Lev
el3:
Dra
gfo
ods
onto
MyP
late
icon
tom
ake
abal
ance
dlu
nch
for
the
Ali
en
Hea
lthy
die
tknow
ledge
chan
ge
Em
bodim
ent
theo
ry
(conti
nued
)
9
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
1.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eK
eygoals
and
hyp
oth
eses
Sto
ry/n
arr
ati
ve/g
am
em
echanic
sB
ehavi
or
change
pro
cedure
sT
heo
ries
nam
ed
14
Jones
94
2014,
US
A,
The
FIT
Gam
e
Dev
elop
anin
terv
enti
on
des
igned
toin
crea
seF
Vco
nsu
mpti
on
whil
em
inim
izin
gm
ater
ial
and
labor
cost
sto
the
school
H1:
Chil
dre
nw
ho
pla
yed
the
gam
ew
ould
incr
ease
thei
rco
nsu
mpti
on
or
targ
eted
FV
�S
tory
:Y
es�
Sto
ry:
Hel
pF
ITs
captu
reth
evil
lain
ous
VA
Ts
�N
ewsc
ript
each
day
read
by
teac
her
�D
aily
goal
toea
t60%
or
hig
her
of
yes
terd
ay’s
school
fruit
or
veg
etab
lein
take
�C
om
pet
itio
nfo
rbes
tsc
hool
in3
elim
inat
ion
rounds
�W
on
gam
ecu
rren
cyfo
rev
eryday
school
exce
eded
goal
�S
tuden
tsse
lect
edsc
hool
equip
men
tto
purc
has
ew
ith
gam
ecu
rren
cy
Rew
ard
of
goal
atta
inm
ent
(set
by
teac
her
s)S
oci
alan
doper
ant
lear
nin
gth
eori
es
15
Rosi
95
2015,
Ital
y,
Men
uC
om
pose
r,an
dJu
mp
Mania
Eval
uat
ean
IT-b
ased
inte
rven
tion
on
chil
dre
n’s
fruit
and
veg
etab
lein
take
H1:
Chil
dre
nw
ho
pla
yed
thes
egam
esas
par
tof
ala
rger
educa
tional
pro
gra
mw
ould
eat
more
fruit
and
veg
etab
les
�S
tory
:N
o�
Men
uC
om
pose
r:C
hoose
fruit
and
veg
etab
les
bas
edon
corr
esponden
ceto
5ru
les
of
ahea
lthy
die
tan
ddra
gto
adis
hw
ith
colo
red
spac
es�
Chil
dre
nw
ith
hig
her
Men
usc
ore
sre
ceiv
edm
ore
tim
eon
Jum
pM
ania
gam
efo
rw
hic
hch
ildre
nw
ere
expec
ted
tom
atch
sequen
cepat
tern
sw
ith
feet
�H
ealt
hy
die
tknow
ledge
chan
ge
�R
ewar
dw
ith
PA
None
spec
ified
16
Shar
ma9
6
2015,
US
A,
Ques
tto
Lava
Mounta
in
Eval
uat
eth
efe
asib
ilit
y,
acce
pta
bil
ity,
and
effe
cts
of
the
Ques
tto
Lava
Mounta
inco
mpute
rgam
eon
die
tary
beh
avio
rs,
physi
cal
acti
vit
ybeh
avio
rs,
and
psy
choso
cial
fact
ors
among
ethnic
ally
div
erse
chil
dre
nH
1:
Chil
dre
nw
ho
pla
yQ
ues
tto
Lava
Mounta
inw
ill
exper
ience
bet
ter
die
tary
and
physi
cal
acti
vit
ybeh
avio
rs
�S
tory
:Y
es�
Act
ion
adven
ture
story
/nar
rati
ve:
Not
�M
ake
hea
lthy
food
choic
esto
pro
gre
ssth
rough
gam
ean
dw
in�
Maz
es,
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ract
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IVE
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TY
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OO
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l use
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urn
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nny
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ith,
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nt
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lthy
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enti
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=1876
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.,a
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aran
ow
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A,
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/n
=1578
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sure
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uit
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usi
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mpti
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erra
no
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A,
Super
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pre
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:post
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/n=
115
Mea
sure
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itio
nknow
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ls,
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-effi
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on
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ese
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ls,
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self
-effi
cacy
,at
titu
de
or
inte
nti
on
4S
ilk
42
2008,
US
A,
The
Fanta
stic
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enge
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C)
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post
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n=
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sure
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itio
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tera
cy,
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atte
nti
on
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egam
e,under
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din
gth
em
essa
ge,
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nti
on
touse
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the
futu
re
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site
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tici
pan
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tly
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hes
tknow
ledge/
lite
racy
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tenti
on,
ease
of
under
stan
din
g,
and
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nti
on
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inth
efu
ture
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eng
88
2009,
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A,
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htW
ay
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oung
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ame
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ups,
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,post
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post
2/n
=40
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sure
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dto
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ng
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lthy
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t:se
lf-e
ffica
cy,
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ceiv
edben
efits
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rier
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tenti
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NE
Pknow
ledge
ques
tionnai
rean
dgam
eli
kea
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ity
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fect
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ay
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uded
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ease
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itio
nknow
ledge,
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-effi
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ceiv
edben
efits
of
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lthy
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ng;
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ow
-up
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ctonly
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ded
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OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
2.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eSet
ting/t
arg
etgro
up;
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ign/s
am
ple
size
Mea
sure
s
Res
ult
sand
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usi
ons
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ctiv
e(s
elf-
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ed)
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ctiv
e
6D
ias4
3
2011,
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ugal
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ealt
hy
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rgam
e,L
ess
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lthy
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rgam
e
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ool/
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ncr
ete
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atio
nal
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e,7–8
yea
rsold
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eal
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T,
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ups,
post
only
/n
=231
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sure
d:
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lthy
ver
sus
not
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sele
ctio
nta
sk,
likin
gof
each
food
pre
sente
d,
know
ledge
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lthy
foods
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dre
nw
ho
pla
yed
the
Hea
lthy
Adve
rgam
ech
ose
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lthy
snac
ks
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edia
tely
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rgam
epla
yw
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eth
ose
pla
yin
gth
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ess
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lthy
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rgam
ech
ose
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lthy
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ks;
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hy
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rgam
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lthy
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ks
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e,but
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lthie
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acks
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aran
ow
ski6
6
2011,
US
A,
Esc
ape
from
Dia
b,
and
Nanosw
arm
:In
vasi
on
from
Inner
Space
Hom
e/10–12
yea
rsold
Gam
esw
ithin
ast
ory
-dri
ven
mult
imed
iapro
duct
ion
RC
T,
2gro
ups,
pre
,m
id,
post
1,
post
2/n
=153
Mea
sure
dth
ree
24-h
our
die
tary
reca
lls
atea
chas
sess
men
tpoin
tfo
rfr
uit
,veg
etab
les,
wat
er,
and
tota
len
ergy;
Soci
alD
esir
abil
ity
of
Res
ponse
scal
e
BM
I,w
aist
circ
um
fere
nce
,tr
icep
ssk
info
ldP
layin
gD
iab
and
Nano
incr
ease
dfr
uit
and
veg
etab
leco
nsu
mpti
on
by
about
0.6
7se
rvin
gs
per
day
,but
not
wat
erin
take
nor
body
com
posi
tion
8B
anos8
9
2012,
Spai
n,
ET
IOB
EM
ate
s
Hom
e/3rd
–6th
gra
des
,7–11
yea
rsold
Gam
eas
par
tof
ala
rger
clin
ical
inte
rven
tion
RC
T,
2gro
ups,
pre
,post
/n
=228
Nutr
itio
nal
Know
ledge
Ques
tionnai
re,
Gam
eA
ccep
tabil
ity–P
layab
ilit
yQ
ues
tionnai
re,
Gam
eP
layin
gH
abit
sQ
ues
tionnai
re
Cal
ibra
ted
elec
tronic
stad
iom
eter
(hei
ght
and
wei
ght
for
BM
I)
Pla
yin
gE
TIO
BE
Mate
ssi
gnifi
cantl
yin
crea
sed
nutr
itio
nknow
ledge;
*50%
of
par
tici
pan
tsli
ked
the
gam
e
9S
chnei
der
90
2012,
US
A,
Fit
ter
Cri
tter
s
Sch
ool/
5th
gra
de,
8–12
yea
rsold
Gam
eal
one
1gro
up,
pre
,post
/n=
97
Nutr
itio
nan
dphysi
cal
acti
vit
yknow
ledge,
hea
lthy
eati
ng
atti
tude,
die
tse
lf-e
ffica
cy,
and
vid
eogam
eac
cepta
bil
ity
None
Pla
yin
gF
itte
rC
ritt
ers
signifi
cantl
yin
crea
sed
die
tse
lf-e
ffica
cyan
dposi
tive
atti
tudes
tow
ard
hea
lthy
foods;
but
no
chan
ge
indie
tknow
ledge
10
Folk
vord
44
2013,
Net
her
lands,
Adve
rgam
es
Lab
/3rd
–4th
gra
des
,x
=8.9
yea
rsG
ame
alone
RC
T,
4gro
ups,
post
only
/n
=270
Hunger
bef
ore
and
aten
d;
reco
gnit
ion
of
bra
nd
and
pro
duct
ingam
e
Wei
ghed
food
inta
ke
atsn
ack
over
5m
inute
s,B
MI
Pla
yin
gan
adver
gam
eco
nta
inin
gfo
od
cues
incr
ease
dgen
eral
ener
gy
inta
ke,
regar
dle
ssof
the
adver
tise
dbra
nd
or
pro
duct
type
(ener
gy-d
ense
snac
ks
or
fruit
);th
isac
tivit
ypar
ticu
larl
yin
crea
sed
the
inta
ke
of
ener
gy-d
ense
snac
kfo
ods;
pla
yin
gth
efr
uit
ver
sion
of
the
adver
gam
edid
not
signifi
cantl
yin
crea
sefr
uit
inta
ke
11
Maj
um
dar
91
2013,
US
A,
Cre
atu
re101
Sch
ool/
6th
–7th
gra
des
,11–13
yea
rsold
Gam
eal
one
GR
T,
2gro
ups,
pre
,post
/n
=341
Mea
sure
of
freq
uen
cyan
dam
ount
of
bev
erag
ean
dsn
ack
item
sN
one
Stu
den
tsw
ho
pla
yed
Cre
atu
re101
report
edsi
gnifi
cant
dec
reas
esin
freq
uen
cyan
dam
ount
of
swee
tbev
erag
esan
dfr
equen
cyan
dam
ount
of
pro
cess
edsn
ack
inta
ke
(conti
nued
)
14
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
2.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eSet
ting/t
arg
etgro
up;
des
ign/s
am
ple
size
Mea
sure
s
Res
ult
sand
concl
usi
ons
Subje
ctiv
e(s
elf-
report
ed)
Obje
ctiv
e
12
Folk
vord
92
2014,
Net
her
lands,
var
ious
adver
gam
es
Lab
/3rd
–4th
gra
des
Gam
eal
one
RC
T,
4gro
ups,
post
only
/n
=261
Pre
-exper
imen
tal
hunger
and
full
nes
s;at
titu
de
tow
ard
bra
nds
and
foods
show
nin
gam
e;an
dim
puls
ivit
y:
door
open
ing
task
Wei
ghed
snac
kca
lori
ein
take,
BM
IP
layin
gan
adver
gam
ew
ith
food
cues
incr
ease
dca
lori
cin
take;
rew
ardin
gch
ildre
nto
refr
ain
from
eati
ng
calo
ries
work
ed;
rew
ardin
gch
ildre
nto
refr
ain
from
eati
ng
work
edm
ore
among
low
impuls
ive
chil
dre
n,
and
those
who
pla
yed
the
nonfo
od
cue
gam
e
13
Johnso
n-G
lenber
g93
2014,
US
A,
Ali
enH
ealt
h
Res
earc
hla
b/6
th–7th
gra
des
Gam
eal
one,
but
pla
yed
inpai
rsin
front
of
clas
sroom
2gro
ups,
pre
,post
1,
post
2/
n=
20
Nutr
itio
nknow
ledge
and
food
choic
ete
stN
one
Know
ledge
incr
ease
dm
ore
inth
eco
ntr
ol
gro
up
atim
med
iate
post
,but
rever
sed
atpost
2to
favor
the
exper
imen
tal
gro
up
14
Jones
94
2014,
US
A,
The
FIT
Gam
e
Sch
ool/
1st
–5th
gra
des
Gam
ein
conte
xt
of
school
lunch
room
and
com
pet
itio
nw
ith
anoth
ersc
hool
1gro
up,
targ
eted
ver
sus
nonta
rget
edF
V/n
=180
None
Mea
sure
food
wei
ghts
consu
med
atsc
hool
usi
ng
wei
ght
scal
es
Pla
yin
gT
he
FIT
Gam
esi
gnifi
cantl
yin
crea
sed
fruit
and
veg
etab
leco
nsu
mpti
on
foll
ow
ing
bas
elin
e;w
ith
no
signifi
cant
incr
ease
innonta
rget
edfr
uit
or
veg
etab
leco
nsu
mpti
on
15
Rosi
95
2015,
Ital
y,
Men
uC
om
pose
r,an
dJu
mp
Mania
Sch
ool/
3rd
–5th
gra
des
,8–11
yea
rsold
Gam
eas
par
tof
curr
iculu
mdel
iver
edby
teac
her
s1
gro
up,
pre
,post
/n=
76
5-a
-day
food
dia
ryto
mea
sure
fruit
and
veg
etab
lein
take
None
Pla
yin
gth
ese
gam
esin
crea
sed
veg
etab
lein
take
by
27.8
%,
but
not
fruit
or
juic
es
16
Shar
ma9
6
2015,
US
A,
Ques
tto
Lava
Mounta
in
Sch
ool/
4th
–5th
gra
des
Gam
eal
one
RC
T,
2gro
ups,
pre
,post
/n
=94
Tw
ora
ndom
24-h
our
die
tary
reca
lls
for
kca
l,m
acro
nutr
ients
,fr
uit
,veg
etab
les,
fiber
,su
gar
s,to
tal
fat
and
calc
ium
;an
dnum
ber
of
day
sbre
akfa
st
Hei
ght
and
wei
ght
for
BM
IP
layin
gQ
ues
tto
Lava
Mounta
insi
gnifi
cantl
ydec
reas
edsu
gar
inta
ke
pre
-to
post
-inte
rven
tion,
and
signifi
cantl
yim
pro
ved
Nutr
itio
nA
ttit
ude
Sca
le17
Thom
pso
n45
2015,
US
A,
Squir
e’s
Ques
t!II
Hom
e/4th
–5th
gra
des
,9–11
yea
rsold
Gam
esin
tegra
ted
into
story
-dri
ven
mult
imed
iaex
per
ience
RC
T,
4gro
ups,
pre
,post
1,
post
2/n
=400
Thre
eunan
nounce
d24-h
our
die
tary
reca
lls
atea
chdat
aco
llec
tion
per
iod
usi
ng
the
Nutr
ient
Dat
aS
yst
emfo
rR
esea
rch
(ND
SR
-2009)
conduct
eddir
ectl
yw
ith
the
chil
d;
two
wee
kday
and
one
wee
ken
dday
reca
lls;
fruit
and
veg
etab
lepre
fere
nce
ques
tionnai
re
None
Pla
yin
gSquir
e’s
Ques
t!II
signifi
cantl
yin
crea
sed
fruit
and
veg
etab
lein
take
only
inth
eA
ctio
nIm
ple
men
tati
on
Inte
nti
ons
gro
up
atboth
post
1an
dpost
2
(conti
nued
)
15
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
2.
(Co
ntin
ued
)
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
eSet
ting/t
arg
etgro
up;
des
ign/s
am
ple
size
Mea
sure
s
Res
ult
sand
concl
usi
ons
Subje
ctiv
e(s
elf-
report
ed)
Obje
ctiv
e
18
Spook
41
2016,
Net
her
lands,
Bala
nce
It
Any
pla
ce/s
econdar
y,
voca
tional
studen
ts,
16–21
yea
rsold
Gam
eal
one
pla
yed
indiv
idual
lyor
com
pet
itiv
ely
RC
T,
2gro
ups,
pre
,post
1,
post
2/n
=231
Food
freq
uen
cyques
tionnai
refo
rfr
uit
,veg
etab
le,
snac
k,
and
soft
dri
nk
inta
kes
;an
dat
titu
de,
self
-ef
fica
cyan
din
tenti
on
toea
thea
lthy
foods
None
Only
27.6
%of
studen
tsuse
dB
ala
nce
It;
no
signifi
cant
bet
wee
n-g
roup
dif
fere
nce
sw
ere
det
ecte
dfo
rbeh
avio
ror
det
erm
inan
ts
19
Shiy
ko
97
2016,
US
A,
SpaP
lay
Hom
e/w
om
endie
tary
chan
ge
conte
mpla
tors
Gam
eal
one
1gro
up,
pre
,post
1,
post
2,
post
3/n
=47
Sel
f-re
port
edhei
ght
and
wei
ght
for
BM
I;G
ener
alN
utr
itio
nK
now
ledge
ques
tionnai
refo
rad
ult
s;R
eadin
ess
toC
han
ge
Ques
tionnai
refo
rnutr
itio
nan
dsw
eete
ned
bev
erag
es
Tel
emet
ryti
me-
stam
ped
gam
epla
yac
tions
Par
tici
pat
ion
var
ied
subst
anti
ally
;se
lf-r
eport
edB
MI
was
low
eran
dnutr
itio
nknow
ledge
was
hig
her
among
those
who
spen
tm
ore
tim
epla
yin
gSpaP
lay
20
Fra
tice
lli9
8
2016,
Ital
y,
Gust
avo
inG
nam
’sP
lanet
Sch
ool/
17–21
yea
rsold
Gam
eal
one
Cro
ss-o
ver
,pre
,post
1,
post
2/
n=
65
Hea
lthy
food
know
ledge
ques
tionnai
rean
dgam
ele
vel
of
fun
None
Mea
ndie
tknow
ledge
incr
ease
dsi
gnifi
cantl
yaf
ter
pla
yin
gG
ust
avo
inG
nam
’sP
lanet
,w
ith
no
dif
fere
nce
inth
e‘‘
fun’’
of
pla
yin
gG
ust
avo
ver
sus
aco
mm
erci
algam
e
21
Joyner
99
2017,
US
A,
FIT
Gam
e3
Sch
ool/
K–5th
gra
des
Gam
ein
conte
xt
of
asc
hool
clas
sroom
and
com
pet
ing
wit
han
oth
ersc
hool
A-B
–A
-Bre
ver
sal/
n=
572
None
Pla
tew
aste
met
hod
usi
ng
wei
ght
scal
esm
easu
red:
veg
etab
les
serv
ed,
was
te,
and
unse
rved
,le
avin
gin
take
Duri
ng
phas
eB
1,
veg
etab
leco
nsu
mpti
on
incr
ease
dby
anav
erag
eof
15.1
gper
chil
dper
day
(69%
);duri
ng
phas
eB
2,
veg
etab
lein
take
incr
ease
dby
37
gper
chil
dper
day
(18%
);fr
uit
consu
mpti
on,
not
targ
eted
for
impro
vem
ent,
did
not
signifi
cantl
yin
crea
se;
mai
nte
nan
ceof
effe
ctbey
ond
the
gam
eis
pro
ble
mat
ic
22
Wan
g100
2017,
Hong
Kong,
Esc
ape
from
Dia
b
Sch
ool/
8–12
yea
rsold
Gam
eal
one
2gro
ups,
pre
,post
1,
post
2/
n=
179
Gam
eim
mer
sion;
inre
gar
dto
fruit
,veg
etab
lean
dw
ater
inta
ke:
intr
insi
cm
oti
vat
ion,se
lf-e
ffica
cy,
and
pre
fere
nce
s;an
dso
cial
des
irab
ilit
yof
resp
onse
None
At
post
1,
pla
yin
gE
scape
from
Dia
bsi
gnifi
cantl
yin
crea
sed
intr
insi
cm
oti
vat
ion
for
fruit
and
for
wat
er;
chan
ge
inim
mer
sion
was
not
signifi
cantl
yre
late
dto
chan
ges
of
oth
erdie
tm
easu
res;
agam
edes
igned
for
chil
dre
nin
wes
tern
audie
nce
sca
nbe
use
dw
ith
Engli
sh-s
pea
kin
gst
uden
ts
GR
T,
gen
eral
random
ized
tria
l;R
CT
,ra
ndom
ized
clin
ical
tria
l.
16
Dow
nloa
ded
by N
OR
TH
EA
STE
RN
UN
IVE
RSI
TY
LA
W S
CH
OO
L f
rom
ww
w.li
eber
tpub
.com
at 1
2/07
/18.
For
per
sona
l use
onl
y.
Ta
ble
3.
Risk
of
Bia
s,
Qu
ality
of
Resea
rch
In
dica
to
rs
fo
rE
ach
Stu
dy
IDR
efer
ence
;ye
ar,
countr
y,nam
eof
gam
e
Met
hod
of
random
izin
gre
port
ed(Y
/N)
Random
izati
on
at
base
line
(Y/N
)
Pri
or
pow
erca
lcula
tions
(Y/N
)
Bli
ndin
gof
ass
esso
rs(Y
/N)
Com
ple
tenes
sof
foll
ow
-up
(Y/N
)
Sel
ecti
on
bia
sre
port
ed(Y
/N)
Vali
dit
y/re
liabil
ity
of
mea
sure
report
ed(Y
/N)
Acc
ounti
ng
for
poss
ible
confo
under
sre
port
ed(Y
/N)
Pre
regis
tere
dtr
ial
(Y/N
)
1T
urn
in86
2001,
Fra
nce
,A
lim
enta
ryM
yD
ear
Joe
(4):
Sto
re,
Gues
sW
ho,
Gra
nny
Sm
ith,
The
Res
taura
nt
NN
NN
YN
NN
N
2B
aran
ow
ski6
7
2003,
US
A,
Squir
e’s
Ques
t!
NN
YN
YN
YY
N
3S
erra
no
87
2004,
US
A,
Super
Sort
erM
ore
or
Les
s
NN
NN
YN
YN
N
4S
ilk
42
2008,
US
A,
The
Fanta
stic
Food
Chall
enge
(FF
C)
NN
NN
YN
YY
N
5P
eng
88
2009,
US
A,
Rig
htW
ay
Cafe
NN
NN
YN
YN
N
6D
ias4
3
2011,
Port
ugal
,H
ealt
hy
Adve
rgam
e,L
ess
Hea
lthy
Adve
rgam
e
NN
NN
YN
NN
N
7B
aran
ow
ski6
6
2011,
US
A,
Esc
ape
from
Dia
b,
and
Nanosw
arm
:In
vasi
on
from
Inner
Space
NN
YN
NN
YY
N
8B
anos8
9
2013,
Spai
n,
ET
IOB
EM
ate
s
NN
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operationalization of the theory constructs for the game. So-cial cognitive theory appears to have been the most commonlystated theory, and nutrition knowledge change was the mostcommonly mentioned behavior change procedure.
The measures used to assess outcomes were perhaps evenmore diverse wherein different measures were often em-ployed to assess the same knowledge or behavior constructacross studies. Five studies (23%) reported more objectivemethods of dietary intake assessment (e.g., weighed platewaste): three of these as part of laboratory-based tests of theeffects of diet-related advergames, and two as part of a test ofgame play in a school lunchroom/cafeteria.
Three articles studied the effects of food advergames43,44
and showed that exposure to only 5 minutes of game playinfluenced the child’s dietary intake immediately followingthe game. This suggests the possible strong (at least short-term) behavioral impacts of dietary game play.
One game systematically varied two forms of a behaviorchange procedure, action and coping implementation inten-tions, and tested impact on fruit and vegetable intake within afour-group RCT.45 Since the programming keeps all otheraspects of game play comparable, this is an ideal method forconducting tests of behavior change procedures for use invideogames, and perhaps outside of games.
Discussion
Summary of the evidence
While all but one of the articles reported some positiveoutcomes from playing the game(s), the quality of much (butnot all) of the research reported left much to be desired,making it difficult to determine the extent to which gameshad the intended, and reported, effects. The research on diet-related change games diverged in regard to target popula-tions, dietary behavior targets (e.g., fruit, vegetables, generalnutrition information, Mediterranean diet), theories (social-cognitive, persuasion, health belief model, attachment, socio-constructivist, or even none), game elements/mechanics,behavior change procedures, research designs, and measures.As a result, a meaningful meta-analysis or systematic reviewwas not possible across all these studies at this time.
Comparisons to other reviews
A recent review of advergames alone indicated a smalleffect increasing unhealthy food intake.46 While that was notthe primary focus of the current review, it does indicate thatgames can influence dietary intake to some extent undersome circumstances. The review, including six games forhealth, noted the generally positive effects on nutritionknowledge, but the diversity in delivery, poor measurementof process variables and engagement, and thereby the in-ability to draw conclusions about effects.28 We noted similarpatterns, but in a larger number of nutrition education gamestudies, and provided a more detailed assessment of thelimitations in the research methods.
Future directions/needed research
Conceptual frameworks exist to guide the development ofsophisticated G4H (Games for Health).47 Research fromthree large behavior change trials (not using games) usedmediating variable analyses to validate a multi-theoretical
model to specify the conceptual framework for the design ofhealth behavior change interventions that are likely to beeffective.48 Several conceptual models have been advancedto account for how games may influence diet-related out-comes.49–51 Some of these models interrelate game elementsand behavior change principles,50,51 while others emphasizethe relevance of food cues and individual predisposing fac-tors (e.g., impulsivity).49 Little research, however, has testedaspects of these models with games. Much of the effort indiet-related games has been to design, develop, and test agame or interactive experience including game(s) to influ-ence outcomes, rather than test principles of game mechanicsor behavior-mediating variables within games. Research isurgently needed that systematically varies aspects of gamemechanics or behavior change procedures within games tooptimize their effects on game engagement,52 maintenanceof interest, psychosocial mediators of change, and behaviorchange (shorter or longer terms). Thompson et al. system-atically varied four types of goal setting/implementationintentions within Squire’s Quest! and demonstrated that ac-tion implementation intention was the only procedure tomaintain changes 3 months after the end of the game.45 Thisresearch provides an important model for making futurecontributions to an understanding of how game mechanicscan influence change in behavior.
No commonly accepted compendium or taxonomy of el-ements in games exists. The ‘‘game lenses’’ identified bySchell13; the ‘‘playful experience cards’’ of Bjork and Ho-lopainen53; and/or Lucero et al.’s playful experiences list54
preliminarily enumerate items for consideration. Without acommonly accepted compendium, consistencies in gamemechanics across games may have been missed since dif-ferent words may have been used to specify an essentiallycommon underlying mechanic or set of mechanics. Devel-oping and obtaining consensus for such a taxonomic com-pendium should be a high priority to permit the identificationand comparison of game elements in future systematic re-views and meta-analyses and also to identify mechanics thatare most engaging. Such taxonomic compendia would alsofacilitate the conduct of process evaluations,55 which relateparticipation in game elements to outcomes.
A compendium of behavior change procedures has beenproposed,56 although challenges have been reported inclassifying procedures into the proposed categories.57 Such acommon taxonomy should also be used in games research toclearly specify what procedures were employed. Of coursethe same procedure (e.g., goal setting) could be implementedin a variety of ways in the context of a game,58 with eachvariant possibly affecting outcome in a different way, indi-cating specific details of the intervention design need to bepresented in the reported outcome or process evaluations.
Fifteen games (68%) incorporated a story or narrative inone form or another. Given the potential for story immersionto influence attention to change procedures (especially be-havior change messaging),20 developing and incorporatingstories into nutrition education games may be a way to en-hance effectiveness. Alternatively, the incorporation of astory into a game may distract the player from active gameplay, thereby reducing player game enjoyment.59 Severalstories have been tested and demonstrated to change be-havior without a game.36,60 A study that designs and com-pares separate story and game elements with their integration
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would be an important contribution to our knowledge ofnutrition education games (and games in general).
There seems to be an implicit assumption that simplyproviding a diet-related change program in a game formatwill automatically make the activity fun, or engaging, andthereby motivate the player to substantially increase theknowledge or change the behavior at substantial levels. Al-ternatively, one of the studies revealed that a web-basededucation program was more effective that a game-basedprogram.42 Unfortunately, the relative quality of these twoprograms cannot be meaningfully assessed from the pub-lished information, and thus it is not clear if primarily themedium (web-based or game-based) or qualities of the pro-grams influenced this outcome. The modest changes inknowledge and behavior that have been reported in thesestudies suggest the assumption of game dominance is notwell supported. The role of ‘‘fun’’ in games and game playhas not been well specified; the definition and measurementof fun or enjoyment has not been clearly delineated61; storyor narrative may contribute to the fun of games, but this hasnot been clearly assessed.62 If fun in games was better un-derstood, games might be designed to enhance the fun as-pects to, in turn, enhance the dietary change.
Many of these games targeted nutrition knowledge, oftenas the primary or only target. Each set of authors appears tohave created their own measure of nutrition knowledge withunknown psychometric properties. While knowledge foracademic purposes (e.g., types of dietary fats; how sodium,potassium, and magnesium interact to influence blood pres-sure) can be valuable, all these games were targeted in oneway or another to positively impact health, often throughdietary behavior change. The field would benefit from a li-brary of nutrition knowledge items that tapped informationthat were preconditions for behavior change (e.g., how tomake a salad) and could be incorporated into computeradaptive testing63 to provide brief measures of outcomescomparable across studies.
Developing a diet-related intervention that can be expectedto impact body mass index (perhaps the most prevalentnutrition-related health problem) for obesity prevention re-quires that the game impact the necessary relevant knowledgeand psychosocial variable(s) (e.g., knowledge, self-efficacy,intrinsic motivation) to change the targeted behavior(s) (e.g.,diet, physical activity, sedentary behavior, and/or sleep) for along enough time to change body composition.64 There arefew examples of such large games. The time to develop andevaluate them can take years,65,66 and the cost for their de-velopment can be staggering (millions of dollars). It seemsunlikely that this level of funding will become generallyavailable for game development anytime soon. Rather thancreating a single integrated multimedia experience that in-corporates games to address dietary change, it may be ap-propriate to develop a comprehensive intervention structure(including multimedia and face-to-face components) intowhich a series of games could be developed and inserted toachieve those outcomes for which games are most effective,for example, knowledge enhancement, simulation of inter-personal interactions, etc. Alternatively, dietary behaviorchange requires learning some new skills that could be learnedthrough games, for example, food preparation,67 menu plan-ning, effective food parenting practices,68 and even tastetesting. Games attempting to increase these skills or behaviors
could be developed, tested, and incorporated into larger be-havior change programs.
There has been substantial concern about the quality ofresearch, also called risk of bias, in general69–74 and how toincorporate issues of quality into systematic reviews.75,76
The general quality of the evidence in support of games onnutrition knowledge or behavior change outcomes77 was lowand needs further enhancement. This has been pointed outelsewhere.78,79 Only five of these nutrition education gamestudies used objective measures of dietary intake to assessdietary change outcomes. Subjective measures tend to besubject to bias (i.e., low validity or accuracy) and unreli-ability (or imprecision).80 Both active and passive methodsof more objective dietary intake assessment81 are being de-veloped and refined for use in uncontrolled community set-tings and should be considered for future use as measures ofoutcome of games for nutrition education. G4H researchersneed to expend substantially more effort to enhance thequality of this research if for no other reason than self-interest, that is, to increase the likelihood of obtainingfunding for future research.82
Many of the studies identified a substantial number ofbehavioral, psychosocial, and/or anthropometric or physio-logical outcomes, without specifying a primary outcome.This approach to evaluation runs a high risk of type 1 sta-tistical error (i.e., obtaining a statistically significant effectpurely by chance).83,84 Diet-related game research shouldspecify a primary outcome upon which power calculationsare conducted, with prespecified hypotheses or models of theway in which game play is expected to influence the out-come.85 In this way, tests can be made of whether the gameinfluenced the targeted variable(s) as designed. The strongerour knowledge base about how games result in change, themore effective ensuing games can be if designed based onwhat has been learned.
Limitations
One or more game studies may have been missed. Anumber of diet-related games have been available for pur-chase, but about which nothing has been published. (At leastone game developer has been overheard saying ‘‘I have allthe evaluation I want or need. My games sell.’’) A recentsystematic review of G4H identified a total of 1743 gamesproduced between 1983 and 2016, of which 99 (6.4%) wereabout nutrition education and eating disorders.8 The numberof academic publications that evaluated the efficacies ofthose games is far less than the games produced. This reviewwas based on reports of games in publications that tended toprovide minimal details, which could have resulted in mis-characterizing the games or studies. On one hand, we maymiss existing games that were effective but never evaluated.On the other hand, actual play of the games might haveprovided different characterizations and insights, but manyof the games no longer function on modern technology.
Conclusion
To the best of our knowledge, this is the first Englishreview devoted to diet-related video or interactive games.Although a variety of diet-related games have been reported,the research base is inadequate to ascertain whether puttingnutrition education or diet-related behavior change into a
20 BARANOWSKI ET AL.
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game format consistently results in the desired outcomes, orwhat aspects of game elements or behavior change proce-dures appear to be most effective. Future diet-related gameresearch should use randomized controlled designs; commonvalidated outcome measures (preferably more objectivemeasures); behavior change procedures as specified in recenttaxonomic inventories; and be guided by conceptual modelsthat reflect the complexities of game design, user experience,and their interactivity. A taxonomic inventory of game ele-ments needs to be developed to clearly specify game designs,and facilitate game reporting and comparisons of outcomes.Research is needed that systematically varies game elementsbetween different versions of the same game to test whatgame elements produce the most change. Different conceptsof fun in game play need to be comparatively tested. Perhapswe need a leaderboard of game researchers and their num-bers of publications weighted by the quality of their contri-butions to make a game of it.
Acknowledgments
This work is a publication of the U.S. Department of Agri-culture (USDA/ARS) Children’s Nutrition Research Center,Department of Pediatrics, Baylor College of Medicine, Hous-ton, Texas, and had been funded in part with federal funds fromthe USDA/ARS under Cooperative Agreement No. 58-3092-5-001. The authors thank Harley Edge for helping with articleselection and coding process.
Author Disclosure Statement
No competing financial interests exist.
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100. Wang JJ, Baranowski T, Lau PW, et al. Story immersionmay be effective in promoting diet and physical activity inChinese children. J Nutr Educ Behav 2017; 49:321–329 e1.
Address correspondence to:Tom Baranowski, PhD
Department of PediatricsUSDA/ARS Children’s Nutrition Research Center
Baylor College of Medicine1100 Bates Street
Houston, TX 77030
E-mail: [email protected]
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