GAMES FOR HEALTH JOURNAL: Research, Development, and Clinical Applications Volume 8, Number 3, 2018 Review ª Mary Ann Liebert, Inc. DOI: 10.1089/g4h.2018.0070

Nutrition Education and Dietary Behavior Change Games: A Scoping Review

Tom Baranowski, PhD,1 Courtney Ryan, MS, RD,1 Andre´s Hoyos-Cespedes,2 and Amy Shirong Lu, PhD3,4

Abstract

Games provide an attractive venue for engaging participants and increasing nutrition-related knowledge and dietary behavior change, but no review has appeared devoted to this literature. A scoping review of nutrition education and dietary behavior change videogames or interactive games was conducted. A systematic search was made of PubMed, Agricola, and Google Scholar. Information was abstracted from 22 publications. To be included, the publication had to include a videogame or interactive experience involving games (a videogame alone, minigames inserted into a larger multimedia experience, or game as part of a human-delivered intervention); game’s design objective was to influence dietary behavior, a psychosocial determinant of a dietary behavior, or nutrition knowledge (hereinafter referred to as diet-related); must have been reported in English and must have appeared in a professional publication, including some report of outcomes or results (thereby passing some peer review). This review was restricted to the diet-related information in the selected games. Diversity in targeted dietary knowledge and intake behaviors, targeted populations/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 systematic review. All but one of the studies reported some positive outcome from playing the game(s). One reported that a web-based education program resulted in more change than the game-based intervention. Studies of games 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: A firmer research base is needed to establish the efficacy and effectiveness of nutrition education and dietary behavior change games.

Keywords: Games, Nutrition education, Dietary behavior change, Scoping

Introduction behavior change programs are needed that appeal to large numbers and diverse types of people who could benefit from ietary intake has Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only. been related to heart disease, dia- the educational/behavior change procedures. Innovative Dbetes, several cancers, stroke, and perhaps adiposity.1 approaches to dietary change are needed to engage partic- Dietary behavior change programs have been shown to ipants in enjoyable experiences to reach the largest number change diet, but the mediating variables are not clear.2,3 of participants. Nutrition knowledge change programs (usually called nu- Electronic media are an increasingly popular channel trition education) by themselves have been shown to be for health promotion, meeting the needs and interests of inadequate to change behavior,4 but some knowledge is a modern populations.6–8 At least six types of electronic likely precondition of effective behavior change.5 Dietary media 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.

1 2 BARANOWSKI ET AL.

educational/therapeutic programs; tailored motivational mes- Eligibility criteria saging systems; data collection and feedback systems; active To be included in this review, the publication had to in- videogames (also called exergames); diverse interactive mul- 7 clude a videogame or interactive experience involving games timedia; and diverse games. This review concerns games or (i.e., the intervention was a videogame alone, minigames interactive media incorporating games. A recent review of were inserted into a larger multimedia experience, or a game school nutrition education resources identified 14 of 32 was part of a human-delivered intervention); the game’s de- curricula as incorporating games of one type or another to sign objective was to influence dietary behavior, a psycho- enhance learning, but provided no identification or analysis 9 social variable believed to be a determinant of a dietary of the games. This suggests that games are increasingly behavior, or some aspect of nutrition knowledge (hereinafter recognized as an important learning tool, but the role and referred to as diet-related); must have been reported in En- effectiveness of the games need to be analyzed. There has glish and must have appeared in a professional publication, been recent interest in the use of ‘‘gamification,’’ which in- including some report of outcomes or results (thereby pass- corporates aspects of games into the design of media inter- 10 10 ing some peer review). No additional exclusionary criteria ventions. Gamification most often has employed rewards, were employed. This review was restricted to the diet-related thereby not including some of the most interesting aspects of information in the selected games. games, for example, repeated losing under the rules of the game to learn a new principle without real-world conse- quences, and are most appropriately reviewed when con- Information sources sidering those behavior change procedures,11,12 not when Following the guidelines for a scoping review,30 this re- reviewing the effects of games. view included two search cycles. Both searches of the lit- No consistent, commonly accepted concept exists for what erature were conducted using PubMed, Agricola (the constitutes a game. Games generally have rules that govern agricultural database, since the U.S. Department of Agri- actions within the game with the possibility of winning and, culture appeared to fund much of the early work on nutrition importantly, losing based on the rules; feedback on play games), and Google Scholar, using the search terms (Nutri- within the game (often points assigned); and a story or nar- tion AND Games) and (Diet AND Games). rative (or an associated back story), among many other 13 possible game elements. Games can provide attractive Search learning and behavior change media since they can be de- signed to provide fun, enjoyment, or engagement (thereby One author conducted the initial systematic search of the providing intrinsic motivation to play)14; a multisensory databases through December 31, 2016, while the first author experience to facilitate different learning styles15; safe op- culled the articles for whether a game was involved in the portunities for drill and practice with feedback; training for identified articles. A second cycle was performed during higher-order skills, such as critical thinking, problem solv- September 2017, including only the articles produced from ing, team work, strategic thinking, and planning16; role January 1, 2017 to September 30, 2017. playing for constructivist learning17; experimentation with new identities; development of social skills18; modeling of Study selection 19 19 behaviors ; training in self-regulation ; and/or immersion Since the method of game delivery varied by time, there of players in a storyline into which behavior change proce- 20 was an initial interest in the historical development of games dures can be built. for nutrition education. An intensive effort was made to While several systematic reviews and/or meta-analyses 6,21–24 identify any article that concerned a game involving nutrition have appeared on games for health, andevenin- or diet. This preliminary, broad, exploratory search revealed cluded a few nutrition education games as a subcomponent, articles on a substantial variety of games involving nutrition no review has appeared devoted to the consideration of education, including card, board, video, and other delivery games for nutrition education or dietary behavior change channels. One hundred eighty-five abstracts of articles were alone. Some reviews have indicated that research on few 25 analyzed; duplicates were removed. Since many of these nutrition games have appeared ; one found only four articles were not research-based (i.e., no evaluation of ef- games26; a review of digital interventions included only one 27 fects), the investigators narrowed the focus to include articles Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only. nutrition education game, and another included only 28 meeting the eligibility criteria uncovered through the initial six. This scoping review of the diet-related video or in- ad hoc search. Two coders reviewed the abstracts of these teractive games literature attempts to describe the current articles; duplicate entries were removed; and selected articles state of the art in a substantial number of studies involving were retrieved and abstracted. In the search process, a nutrition education games and identify limitations in the number of intervention articles were identified that used one research, which need to be remedied to advance this im- or more multimedia formats, but did not include games,31–39 portant intervention medium. and thereby were not included in this review.

Methods Data collection process A protocol for this analysis was not preregistered due to To ensure inter-rater reliability and to authenticate data ex- the long idea-incubation period and a lack of clarity about traction and interpretation quality, two independent reviewers what we might find in our literature search. The structure and systematically analyzed the abstracts. Final selection was based sequence of this review follows the PRISMA guidelines, as on a 92% agreement between reviewers. Data abstraction was possible.29 started after both reviewers received coding training and NUTRITION EDUCATION AND DIETARY BEHAVIOR CHANGE GAMES 3

performed a coding of 10% of the articles as a pilot for testing Risk of bias within studies reliability. Differences were resolved by multiple, internal, in- The quality or research bias of individual trials was poor, depth discussions. Following training, each coder reviewed and and is summarized in Table 3. Eleven of the 22 articles (50%) extracted data from the 22 articles separately. The first author were randomized clinical trials (RCTs), and 3 (14%) were provided the final determination for all variables. group cluster RCTs. Four (18%) were single-group pre-post designs; two (9%) were not randomized control designs, one Data items was a cross-over trial, and one was an A-B–A-B reversal de- Each row in Tables 1–3 concerns a different study. The sign. The method of randomization, concealment of randomi- studies were summarized in regard to first author, year, zation at baseline, and trial preregistration was reported by none country, game name, the key goals and hypotheses, whether of these trials (Table 3). Five (23%) reported statistical power a story/narrative was included, game elements or mechanics, calculations before the conduct of the trial. While blinding of behavior change procedures and theories employed, setting, participants is not possible in behavior change trials, blinding of target group, method of delivery, research design, sample assessors is possible and was reported in only one trial. size, outcome measures (specifically subjectively reported Completeness of follow-up (withdrawals, dropouts) was and objective measures), and diet-related outcomes. Story, reported in 12 trials (55%). Selection bias (sample repre- often considered a key game element,6 was coded as present sentativeness and participation rates) were reported by five when there were characters other than the player, a logically trials (23%). Validity and/or reliability of the measures was sequenced set of events (storyline or arc), with the story reported by 14 trials (64%). Accounting for possible con- ending and the outcome depending on game play. Game founders of outcomes was reported by nine trials (41%). elements or mechanisms were abstracted as possible from the Whether the investigators reported analyses of all the pre- reports provided. specified outcomes could not be assessed since none of the research protocols were preregistered. Risk of bias in individual studies Quality of study or research bias items from the Cochrane Results of studies Collaboration Risk of Bias Tool (CCRBT) and the Effective Only one of the games reported no changes from playing Public Health Practice Project Quality Assessment Tool the game on behavior or its determinants,41 but only 27.6% 40 (EPHPP) were applied to all studies. Table 3 reports on the of the students in that study played the game. All the other risk of bias/quality of research characteristics of each study, studies reported some positive outcomes from game play, but including whether the method of randomization was reported; few studies identified a primary outcome, and none identified randomization was concealed at baseline; prior power calcu- what percentages of all possible or expected outcomes the lations were conducted; assessors were blinded; completeness games impacted. Another study revealed that a web-based of follow-up reported; selection bias reported; validity or education program was more effective than the game-based reliability of the measures reported; possible confounding education.42 Most changes were relatively small, but few variables were accounted for in the analyses; and the trial effect sizes were reported. protocol was preregistered. Synthesis of results Synthesis of results Thirteen of these games (59%) targeted children at school, Many of the included studies were pilot, feasibility or three (14%) targeted children at home, three (14%) in a proof-of-concept studies with small samples, weak designs, laboratory, one any place, and only two (5%) targeted adults. and inconsistent and inadequate assessment, thereby pre- The sample sizes varied from 1876 to 20. There were 14 cluding a meta-analysis or systematic review. Thus, the (64%) individual or group randomized clinical trials. The major value of this scoping review is to report the breadth of games were developed and tested largely in the United States target groups, objectives and game mechanics, and identify (n = 13; 59%), Europe (n = 8; 36%), or Asia (n = 1). specific research enhancements necessary to document the A story (or narrative) was specifically included in 15 value of the gaming approach to diet-related change. games (68%). The other game elements or game mechanics

Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only. varied enormously. A number of well-known popular exist- Results ing game formats/mechanics should have been well known Study selection to the target audience (thereby minimizing the need to learn new game rules), for example, the concentration memory One hundred eighty-five articles were identified in the game, and adapted these game elements to achieve education preliminary search: 61 from Agricola and 124 from PubMed. purposes or influence behavior. An additional 50 articles were identified in the second cycle. Five of these games (23%) could be categorized more as Twenty-two articles were identified on nutrition education or primarily targeting some aspect of nutrition knowledge, dietary change video or interactive games, hereinafter re- while nine other games (41%) could be categorized more as ferred to as game. targeting dietary behavior change, and eight (36%) as pri- marily targeting some combination of dietary psychosocial Study characteristics variables and behavior. A diverse variety of educational and/ The first game article identified was published in 2001, or behavioral change theories with attendant diversity in the with the number per year steadily increasing to eight in corresponding knowledge or behavior change procedures 2015–2017. were identified as providing the conceptual foundation and Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only.

Table 1. Author, Year, Country, Game Name, Study Goals, Hypotheses, Story/Narrative, Game Mechanics, Behavior Change Procedures, Theories

Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 1 Turnin86 Evaluate primary school  Story: Yes Nutrition knowledge None mentioned 2001, France, children’s acquisition of  Store: Classify foods into change Alimentary My Dear Joe nutritional knowledge and categories (4): Store, Guess Who, improvement of eating habits  Guess Who: Children guess Granny Smith, The from playing four serious name of food after it being Restaurant games described H1: Children who play the  Granny Smith: Children select four games would increase breakfast and snack food items their nutritional knowledge by correcting Granny’s errors and eat healthier  The Restaurant: Catch foods jumping out of fridge and place them to ‘‘balance’’ a meal 2 Baranowski67 Test the impact of a nutrition  Story: Player enters training to  FV knowledge change Social cognitive theory 2003, USA, Squire’s education multimedia program be Squire and help King fight  Establish meal FV

4 Quest! with games on servings of off Slimes and Mogs schemas fruit, 100% juice, and  Not specified  Progressively more vegetables among fourth- challenging goal setting grade students H1: Children who play Squire’s Quest! will increase their intake of fruit, 100% juice, and vegetables 3 Serrano87 Test a multimedia package  Story: Yes Food Good Pyramid, Theory of intrinsically 2004, USA, Super including two games on  Super Sorter: Categorize knowledge change motivating instruction Sorter More or Less fourth/fifth-grade students’ foods that appear into food diet-related knowledge, skills, pyramid categories; self-efficacy, attitude and progressively faster with each intention round H1: Children who play the  More or Less: Evaluate meals games as a part of the Food and menus to include foods Pyramid Games package will from all five groups increase their nutrition related knowledge and psychosocial variables

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 4 Silk42 Examine the effectiveness of  Story: No Nutrition knowledge Media uses and 2008, USA, The three modalities for delivery  Fantastic Food Challenge (4 change gratification and flow Fantastic Food of nutrition education: game, games): theories Challenge (FFC) web, or pamphlet, on nutrition (1) Categorize falling foods knowledge and likeability (2) Estimate ‘‘cost H1: Participants will report effectiveness’’ based on size, greater liking of the numbers of servings, and cost interactive game; H2: Participants will have higher nutrition literacy scores with information media (pamphlet, website) than from game; H3: Participants receiving

5 information media (pamphlet, website) will retain more nutrition knowledge than from videogame 5 Peng88 Teach about nutrition and weight  Story: Yes  Tailored healthy eating Health belief model, 2009, USA, RightWay management knowledge and  Role playing similar to The information (kcal, wt, theory of reasoned Cafe´ increase people’s self-efficacy Sims personal food pyramid) action, and social and perceived benefits of  Game player is star in a TV  Positive feedback and cognitive theory healthy eating, as well as their show ‘‘Star of Healthy rewarding points for intention to be on a healthy Lifestyle’’ choosing healthy food diet  Player who manages daily diet  Dialogues set H1: Participants who played to reach optimal weight wins descriptive norms RightWay Cafe´ would increase  Create personal avatar  Information on their healthy nutrition,  Weekly simulated weight immediate benefits from knowledge, self-efficacy, change in avatar based on food a healthy diet perceived benefits, and selections  Game presented change intentions goals

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 6 Dias43 Test impact of healthy and  Story: Yes Nutrition knowledge Food exposure theory 2011, Portugal, Healthy nonhealthy advergames on  Child character grabs a change (Birch) Advergame Less children’s immediate food snack—if healthy, gains 5 Healthy Advergame choices, liking, and nutritional points knowledge  Bomb and bullets need to H1: Children’s spontaneous evade snack selection will reflect the  2 levels: character can fly food content of the advergame they play; H2: Children’s food liking will reflect the food content of the advergame they play: (a) The group who played the healthy version will like healthy food more than the other group; (b) the group who played the nonhealthy version will like nonhealthy 6 food more than the other group; H3: Children who played the healthy version will exhibit greater nutritional knowledge, compared with children who played a less healthy version of the same game 7 Baranowski66 Evaluate the effect of playing  Story: Yes  Mastery learning of Social cognitive and self- 2011, USA, Escape two serious videogames on  Action-adventure story/ energy balance for determination theories from Diab, and children’s diet, physical narrative knowledge change and elaboration Nanoswarm: Invasion activity, screen media use, and  Games not specified  Modeling of behaviors likelihood model from Inner Space adiposity and coping H1: Children who play the two action and coping serious games will increase implementation their fruit and vegetable and intentions water intake, and physical  Behavioral inoculation activity, and decrease their  Tailored value-based screen time and BMI messaging

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 8 Ban˜os89 Evaluate the efficacy and  Story: Yes Energy balance knowledge None specified 2013, Spain, ETIOBE acceptability of ETIOBE  The Healthy Plate: Categorize enhancement Mates Mates on children’s nutritional foods in food pyramid knowledge compared to a categories traditional paper–pencil mode  The Memory Game: of information delivery Concentration type game to H1: Children playing ETIOBE find pair-wise matches of Mates will improve their foods and then answer nutritional knowledge; and questions about food—easy, ETIOBE Mates will be medium, and difficult levels acceptable and playable  Super ETIOBE: Player helps (medium to high scores) detective solve cases of children having imbalanced diet and PA 7 9 Schneider90 Test the acceptability of an  Story: No None stated None stated 2012, USA, Fitter online videogame for  Players responsible for the Critters improving healthy diet and health of a Critter activity in elementary school  17 quests students  Meters for Critter’s health and H1: Children who play the diet game will find it highly  Food to feed Critter: Should acceptable and increase their not exceed fat, sugar, calories nutrition and activity allotments knowledge, attitudes, and self-  Cooking: To feed Critter efficacy  Work: Critter can earn money at work; healthier Critter earns more money  Sick days: When Critter is sick, cannot earn money  Decorations: Critter’s earnings used to decorate house

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 10 Folkvord44 Examine the effect of  Story: No Exposure to brand names Cue reactivity theory 2013, Netherlands, advergames that promote  Concentration type memory (concentration type Advergames energy-dense snacks or fruit game attempting to match memory game) on children’s ad libitum snack pair-wise images of foods and fruit consumption and  The healthy or unhealthy examine whether this brands appeared on the consumption differed backsides of the cards to be according to brand and turned over product type (energy-dense  Digital timer and time bar to snacks and fruit) supply urgency H1: Playing advergames that  Pleasant sound when child promote food increases made a matched pair; general caloric intake; H2: unpleasant sound for Playing an advergame that nonmatching pairs promotes food increases product type–related food

8 intake; H3: Increased food intake after playing an advergame is not specific to a certain brand but will also enhance the intake of a brand promoting products in the same product category 11 Majumdar91 Evaluate the efficacy of playing  Story: Yes  Autonomy supportive Social cognitive and self- 2013, USA, Creature Creature-101 at promoting  Players created own avatars environment determination theories 101 energy balance-related and worlds  Learned competence behaviors (EBRBs)  Between-player  Diet-related knowledge H1: Adolescents who played communication of goals and change Creature-101 would accomplishments  Goal setting for personal significantly increase their FV  Story/narrative: Murphy in behavior change and water intake and PA; and Tween, characters in Tween decrease intake of processed became addicted to foods and snacks (e.g., chips, candy), activities brought from Earth SB, and recreational screen  Player learned healthfulness of time behaviors when helping creatures change

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 12 Folkvord92 Examine the moderating role of  Story: No Exposure to brand names Cue reactivity theory 2014, Netherlands, impulsivity on the effect of  Concentration type memory various advergames advergames that promote game attempting to match energy-dense snacks on pair-wise images of foods children’s snack intake  The healthy or unhealthy H1: Playing advergames brands appeared on the promoting energy-dense backsides of the cards to be snacks increases caloric turned over intake; H2a: Stimulating  Digital timer and time bar to response inhibition by supply urgency rewarding refraining from  Pleasant sound when child eating decreases caloric made a matched pair; intake; H2b: Children unpleasant sound for rewarded for refraining from nonmatching pairs eating have a lower caloric intake when they play a nonfood advergame than when they play a food advergame; H3: Impulsive children eat

9 more; H4: Rewarding refraining will have less influence on high impulsive children, especially when playing a food advergame 13 Johnson-Glenberg93 Assess the feasibility and  Story: Yes Healthy diet knowledge Embodiment theory 2014, USA, Alien efficacy of game on nutrition  Story: Find alien under your change Health knowledge among an older bed group of children  Level 1: Student pairs need to H1: Playing Alien Health will discuss and choose between be feasible and result in healthy and unhealthy foods increased nutrition knowledge within 10 seconds  Kinect sensed child selection and changed to next choice  Children engaged in PA between choices  Level 2: Focused attention on nutrient informational bars to make food selection  Level 3: Drag foods onto MyPlate icon to make a balanced lunch for the Alien

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 14 Jones94 Develop an intervention  Story: Yes Reward of goal attainment Social and operant 2014, USA, The FIT designed to increase FV  Story: Help FITs capture the (set by teachers) learning theories Game consumption while villainous VATs minimizing material and labor  New script each day read by costs to the school teacher H1: Children who played the  Daily goal to eat 60% or game would increase their higher of yesterday’s school consumption or targeted FV fruit or vegetable intake  Competition for best school in 3 elimination rounds  Won game currency for everyday school exceeded goal  Students selected school equipment to purchase with game currency 15 Rosi95 Evaluate an IT-based  Story: No  Healthy diet knowledge None specified 2015, Italy, Menu intervention on children’s fruit  Menu Composer: Choose fruit change 10 Composer, and Jump and vegetable intake and vegetables based on  Reward with PA Mania H1: Children who played correspondence to 5 rules of a these games as part of a larger healthy diet and drag to a dish educational program would with colored spaces eat more fruit and vegetables  Children with higher Menu scores received more time on Jump Mania game for which children were expected to match sequence patterns with feet 16 Sharma96 Evaluate the feasibility,  Story: Yes  Healthy diet knowledge Social cognitive theory 2015, USA, Quest to acceptability, and effects of  Action adventure story/ enhancement and theory of reasoned Lava Mountain the Quest to Lava Mountain narrative: Not  Subjective norms action computer game on dietary  Make healthy food choices to behaviors, physical activity progress through game and behaviors, and psychosocial win factors among ethnically  Mazes, interactive activities, diverse children simulations of nutrition H1: Children who play Quest concepts to Lava Mountain will  Increasing challenges across experience better dietary and levels of game physical activity behaviors

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 17 Thompson45 Test the efficacy of active versus  Story: Yes  FV knowledge change Social cognitive, self- 2015, USA, Squire’s coping implementation  Action adventure story/  Action and/or coping determination, Quest! II intentions on the dietary narrative: King Brocwell and implementation behavioral inoculation, intake of healthy children Queen Nutrition are defending intentions and maintenance H1: One of the forms the Kingdom of Fivealot from  Badges awarded for theories and the (unspecified) of the Mog goal attainment elaboration likelihood implementation intentions will  Player wants to become knight  Create personal schema model result in greater change in to help the King and Queen; for FV at meals intake of fruit and vegetables has to become a Squire  Behavioral inoculation at immediate post and 3-  Squire has to face challenges  FV recipe preparation month post-assessments (eat more FV) to build  Parent engagement strength through newsletter and  FV knowledge games: Diverse website game mechanics (10) 18 Spook41 Evaluate the effects of Balance It  Story: No  Goal setting/action and Intervention mapping, goal 2016, Netherlands, on students’ dietary intake,  Obtain cards by changing diet passive implementation setting, self-monitoring,

11 Balance It PA, and the psychosocial  Use cards to build a tower intentions feedback determinants  Want tallest tower, but need to  Barrier identification H1: Students who played ‘‘balance it’’  Feedback on goal Balance It would have  Competition with other attainment healthier dietary intake and players  Peer support from physical activity player forum 19 Shiyko97 Evaluate game play patterns of  Story: No  Goal setting Self-determination and 2016, USA, SpaPlay SpaPlay and its impact on  Need to develop a spa resort  Self monitoring stages of change BMI and nutritional  Healthy eating earns points to  Social interaction/ theories knowledge among women build spa support H1: Progress in the SpaPlay  Self-created avatar game will lead to increased  Minigames nutrition knowledge and  Quests: Setting and attaining a decreased BMI health behavior goal to attain in coming week  Sparks: Single-time health behavior  Collaborative/cooperative tasks  Chef game: Create healthy dishes

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Table 1. (Continued) Reference; year, country, Behavior change ID name of game Key goals and hypotheses Story/narrative/game mechanics procedures Theories named 20 Fraticelli98 Test the improvement of  Story: Yes  Foal feedback Transtheoretical model of 2016, Italy, Gustavo in knowledge about healthy  Story: Gustavo and his cat  Reward change, social cognitive Gnam’s Planet nutrition and enjoyment in escape to unknown planet,  Punishment theory, self- adolescents cannot return unless live  Shaping determination theory, H1: Playing the web game healthy, player needs to help  Instructions and elaboration Gustavo in Gnam’s Planet in  3 levels likelihood model comparison with a leisure web game will improve knowledge about healthy nutrition and enjoyment in adolescents 21 Joyner99 Test the efficacy of the FIT  Story: Yes Reward of goal attainment Not clearly specified 2017, USA, FIT Game 3 Game to increase vegetable  Story/narrative: Help FITs (set by teachers) intake capture the villainous VATs H1: Presenting the FIT Game  New script each day read by materials in comic book teacher format on the school cafeteria  Daily goal to eat 60% or wall would significantly higher of yesterday’s school 12 increase vegetable fruit or vegetable intake consumption  Competition for best school in 3 elimination rounds  Won game currency for every day school exceeded goal  Students selected school equipment to purchase with game currency 22 Wang100 Evaluate the effect of playing a  Story: Yes  Mastery learning of Social cognitive, self- 2017, Hong Kong, health videogame designed for  Action-adventure story/ energy balance for determination, and Escape from Diab Western children on diet and narrative knowledge change elaboration likelihood PA-related psychosocial  Games not specified  Modeling of behaviors theories variables and behaviors and coping action and among Chinese children coping implementation H1: Playing Escape from Diab intentions will enhance diet and PA  Behavioral inoculation psychosocial variables and  Tailored value-based increased story immersion will messaging result in larger effects

BMI, body mass index; FV, fruit and vegetables; PA, physical activity. Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only.

Table 2. Author, Year, Country, Game Name, Settings, Target Groups, Design, Sample Size, Measures, Results and Conclusions Measures Reference; year, country, Setting/target group; ID name of game design/sample size Subjective (self-reported) Objective Results and conclusions 1 Turnin86 School/healthy 7–12-year-old Diet record at home, with help from None Children in the games group had 2001, France, children the parents, covering 3 significantly higher knowledge Alimentary My Dear Joe Part of teacher presented consecutive days including one and better balanced diet; more (4): Store, Guess Who, intervention weekend (variables: kcal, carbohydrate, less fat, less Granny Smith, The GRT, 2 groups, post only/ macronutrients, saccharose, protein, less saccharose, more Restaurant n = 1876 calcium, fiber); nutrition calcium, and more fiber. The knowledge questionnaire games group had a better snack at (variables: global nutrition 10 a.m., a less copious lunch and knowledge and 8 knowledge less nibbling subscales), eating habits questionnaire (variables: whether meals and snacks were consumed) 2 Baranowski67 School/4th grade, 8–12 years old Measured fruit and veggie intake None Children participating in Squire’s 2003, USA, Squire’s Games inserted in multimedia using Food Intake Recording Quest! increased their FJV Quest! story with behavior change Software System (FIRSSt) consumption by 1.0 serving per

13 procedures day more than the children not GRT, 2 groups, pre, post/ receiving the program n = 1578 3 Serrano87 School/Latino 4th–5th graders, Measured nutrition knowledge, None Children playing these games 2004, USA, Super 10–13 years old skills, self-efficacy, attitude, significantly increased nutrition Sorter More or Less Games part of larger intention knowledge and skills, but not multimedia program self-efficacy, attitude or intention RCT, 2 groups, E: pre, post, C: post only/n = 115 4 Silk42 State extension office, other Measured nutrition literacy, liking None Website participants had 2008, USA, The agencies, home/low-income of, attention to the game, consistently highest knowledge/ Fantastic Food mothers Games alone understanding the message, and literacy, attention, ease of Challenge (FFC) RCT, 3 groups, post1, post2/ intention to use the game in the understanding, and intention to n = 155 future use in the future 5 Peng88 Research lab/young adults Measured in regard to eating a None Short-term effects of RightWay 2009, USA, RightWay Game alone RCT, 2 groups, healthy diet: self-efficacy, Cafe´ included increased nutrition Cafe´ pre, post1, post2/n = 40 perceived benefits and barriers, knowledge, self-efficacy and intention; EFNEP knowledge perceived benefits of healthy questionnaire and game eating; 1-month follow-up likeability showed maintenance of effect only for self-efficacy

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Table 2. (Continued) Measures Reference; year, country, Setting/target group; ID name of game design/sample size Subjective (self-reported) Objective Results and conclusions 6 Dias43 School/Piaget’s concrete Measured: healthy versus not food None Children who played the Healthy 2011, Portugal, Healthy operational stage, 7–8 years selection task, liking of each food Advergame chose more healthy Advergame, Less old Game alone presented, knowledge of healthy snacks immediately after game Healthy Advergame RCT, 2 groups, post only/ foods play while those playing the Less n = 231 Healthy Advergame chose less healthy snacks; children who played the Less Healthy Advergame liked the less healthy snacks more that those playing the Healthy Advergame, but those playing the Healthy Advergame did not like the healthier snacks more 7 Baranowski66 Home/10–12 years old Measured three 24-hour dietary BMI, waist circumference, Playing Diab and Nano increased 2011, USA, Escape Games within a story-driven recalls at each assessment point triceps skinfold fruit and vegetable consumption from Diab, and multimedia production for fruit, vegetables, water, and by about 0.67 servings per day, Nanoswarm: Invasion RCT, 2 groups, pre, mid, total energy; Social Desirability but not water intake nor body from Inner Space post1, post2/n = 153 of Response scale composition 8 Ban˜os89 Home/3rd–6th grades, 7–11 Nutritional Knowledge Calibrated electronic Playing ETIOBE Mates 2012, Spain, ETIOBE years old Game as part of a Questionnaire, Game stadiometer (height and significantly increased nutrition 14 Mates larger clinical intervention Acceptability–Playability weight for BMI) knowledge; *50% of RCT, 2 groups, pre, post/ Questionnaire, Game Playing participants liked the game n = 228 Habits Questionnaire 9 Schneider90 School/5th grade, 8–12 years old Nutrition and physical activity None Playing Fitter Critters significantly 2012, USA, Fitter Game alone knowledge, healthy eating increased diet self-efficacy and Critters 1 group, pre, post/n = 97 attitude, diet self-efficacy, and positive attitudes toward healthy videogame acceptability foods; but no change in diet knowledge 10 Folkvord44 Lab/3rd–4th grades, x = 8.9 years Hunger before and at end; Weighed food intake at Playing an advergame containing 2013, Netherlands, Game alone recognition of brand and product snack over 5 minutes, food cues increased general Advergames RCT, 4 groups, post only/ in game BMI energy intake, regardless of the n = 270 advertised brand or product type (energy-dense snacks or fruit); this activity particularly increased the intake of energy-dense snack foods; playing the fruit version of the advergame did not significantly increase fruit intake 11 Majumdar91 School/6th–7th grades, 11–13 Measure of frequency and amount None Students who played Creature 101 2013, USA, Creature years old of beverage and snack items reported significant decreases in 101 Game alone frequency and amount of sweet GRT, 2 groups, pre, post/ beverages and frequency and n = 341 amount of processed snack intake

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Table 2. (Continued) Measures Reference; year, country, Setting/target group; ID name of game design/sample size Subjective (self-reported) Objective Results and conclusions 12 Folkvord92 Lab/3rd–4th grades Pre-experimental hunger and Weighed snack calorie Playing an advergame with food 2014, Netherlands, Game alone fullness; attitude toward brands intake, BMI cues increased caloric intake; various advergames RCT, 4 groups, post only/ and foods shown in game; and rewarding children to refrain n = 261 impulsivity: door opening task from eating calories worked; rewarding children to refrain from eating worked more among low impulsive children, and those who played the nonfood cue game 13 Johnson-Glenberg93 Research lab/6th–7th grades Nutrition knowledge and food None Knowledge increased more in the 2014, USA, Alien Game alone, but played in choice test control group at immediate post, Health pairs in front of classroom but reversed at post 2 to favor the 2 groups, pre, post1, post2/ experimental group n = 20 14 Jones94 School/1st–5th grades None Measure food weights Playing The FIT Game significantly 2014, USA, The FIT Game in context of school consumed at school increased fruit and vegetable Game lunchroom and competition using weight scales consumption following baseline; with another school with no significant increase in 15 1 group, targeted versus nontargeted fruit or vegetable nontargeted FV/n = 180 consumption 15 Rosi95 School/3rd–5th grades, 8–11 5-a-day food diary to measure fruit None Playing these games increased 2015, Italy, Menu years old and vegetable intake vegetable intake by 27.8%, but Composer, and Jump Game as part of curriculum not fruit or juices Mania delivered by teachers 1 group, pre, post/n = 76 16 Sharma96 School/4th–5th grades Two random 24-hour dietary recalls Height and weight for BMI Playing Quest to Lava Mountain 2015, USA, Quest to Game alone for kcal, macronutrients, fruit, significantly decreased sugar Lava Mountain RCT, 2 groups, pre, post/ vegetables, fiber, sugars, total fat intake pre- to post-intervention, n = 94 and calcium; and number of days and significantly improved breakfast Nutrition Attitude Scale 17 Thompson45 Home/4th–5th grades, 9–11 Three unannounced 24-hour dietary None Playing Squire’s Quest! II 2015, USA, Squire’s years old recalls at each data collection significantly increased fruit and Quest! II Games integrated into story- period using the Nutrient Data vegetable intake only in the driven multimedia experience System for Research (NDSR- Action Implementation Intentions RCT, 4 groups, pre, post1, 2009) conducted directly with the group at both post1 and post2 post2/n = 400 child; two weekday and one weekend day recalls; fruit and vegetable preference questionnaire

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Table 2. (Continued) Measures Reference; year, country, Setting/target group; ID name of game design/sample size Subjective (self-reported) Objective Results and conclusions 18 Spook41 Any place/secondary, vocational Food frequency questionnaire for None Only 27.6% of students used 2016, Netherlands, students, 16–21 years old fruit, vegetable, snack, and soft Balance It; no significant Balance It Game alone played drink intakes; and attitude, self- between-group differences were individually or competitively efficacy and intention to eat detected for behavior or RCT, 2 groups, pre, post1, healthy foods determinants post2/n = 231 19 Shiyko97 Home/women dietary change Self-reported height and weight for Telemetry time-stamped Participation varied substantially; 2016, USA, SpaPlay contemplators Game alone BMI; General Nutrition game play actions self-reported BMI was lower and 1 group, pre, post1, post2, Knowledge questionnaire for nutrition knowledge was higher post3/n = 47 adults; Readiness to Change among those who spent more Questionnaire for nutrition and time playing SpaPlay sweetened beverages 20 Fraticelli98 School/17–21 years old Healthy food knowledge None Mean diet knowledge increased 2016, Italy, Gustavo in Game alone questionnaire and game level of significantly after playing Gnam’s Planet Cross-over, pre, post1, post2/ fun Gustavo in Gnam’s Planet, with n = 65 no difference in the ‘‘fun’’ of

16 playing Gustavo versus a commercial game 21 Joyner99 School/K–5th grades None Plate waste method using During phase B1, vegetable 2017, USA, FIT Game 3 Game in context of a school weight scales measured: consumption increased by an classroom and competing with vegetables served, average of 15.1 g per child per another school waste, and unserved, day (69%); during phase B2, A-B–A-B reversal/n = 572 leaving intake vegetable intake increased by 37 g per child per day (18%); fruit consumption, not targeted for improvement, did not significantly increase; maintenance of effect beyond the game is problematic 22 Wang100 School/8–12 years old Game immersion; in regard to fruit, None At post1, playing Escape from Diab 2017, Hong Kong, Game alone vegetable and water intake: significantly increased intrinsic Escape from Diab 2 groups, pre, post1, post2/ intrinsic motivation, self-efficacy, motivation for fruit and for water; n = 179 and preferences; and social change in immersion was not desirability of response significantly related to changes of other diet measures; a game designed for children in western audiences can be used with English-speaking students

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Table 3. Risk of Bias, Quality of Research Indicators for Each Study Selection Accounting Method Prior power Blinding Completeness bias Validity/reliability for possible Reference; year, of randomizing Randomization calculations of assessors of follow-up reported of measure confounders Preregistered ID country, name of game reported (Y/N) at baseline (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) reported (Y/N) reported (Y/N) trial (Y/N) 1 Turnin86 NNNNYNNNN 2001, France, Alimentary My Dear Joe (4): Store, Guess Who, Granny Smith, The Restaurant 2 Baranowski67 NNYNYNYYN 2003, USA, Squire’s Quest! 3 Serrano87 NNNNYNYNN 2004, USA, Super Sorter More or Less 4 Silk42 NNNNYNYYN 2008, USA, The Fantastic Food Challenge (FFC) 17 5 Peng88 NNNNYNYNN 2009, USA, RightWay Cafe´ 6 Dias43 NNNNYNNNN 2011, Portugal, Healthy Advergame, Less Healthy Advergame 7 Baranowski66 NNYNNNYYN 2011, USA, Escape from Diab, and Nanoswarm: Invasion from Inner Space 8 Ban˜os89 NNNNNYYNN 2013, Spain, ETIOBE Mates 9 Schneider90 NA NA N N N N Y N N 2012, USA, Fitter Critters 10 Folkvord44 NNNNNANYYN 2013, Netherlands, Advergames

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Table 3. (Continued) Selection Accounting Method Prior power Blinding Completeness bias Validity/reliability for possible Reference; year, of randomizing Randomization calculations of assessors of follow-up reported of measure confounders Preregistered ID country, name of game reported (Y/N) at baseline (Y/N) (Y/N) (Y/N) (Y/N) (Y/N) reported (Y/N) reported (Y/N) trial (Y/N) 11 Majumdar91 NNNNNYYYN 2013, USA, Creature 101 12 Folkvord92 NNNNNANYNN 2014, Netherlands, various advergames 13 Johnson-Glenberg93 NA NA N N N N N N N 2014, USA, Alien Health 14 Jones94 NA NA N N NA N N NA N 2014, USA, The FIT Game 15 Rosi95 NA NA N N N N N N N 2015, Italy, Menu Composer, and Jump Mania 18 16 Sharma96 NNNNYYNYN 2015, USA, Quest to Lava Mountain 17 Thompson45 NYYYYNNYN 2015, USA, Squire’s Quest! II 18 Spook41 NNYNYNYNN 2016, Netherlands, Balance It 19 Shiyko97 NA NA N N Y N Y Y N 2016, USA, SpaPlay 20 Fraticelli98 NA NA N N Y N Y N N 2016, Italy, Gustavo in Gnam’s Planet 21 Joyner99 NA NA N N NA Y N NA N 2017, USA, FIT Game 3 22 Wang100 NA NA Y N Y Y Y Y N 2017, Hong Kong, Escape from Diab

N, no, did not meet that indicator; NA, indicator not applicable; Y, yes, met that indicator. NUTRITION EDUCATION AND DIETARY BEHAVIOR CHANGE GAMES 19

operationalization of the theory constructs for the game. So- model to specify the conceptual framework for the design of cial cognitive theory appears to have been the most commonly health behavior change interventions that are likely to be stated theory, and nutrition knowledge change was the most effective.48 Several conceptual models have been advanced commonly mentioned behavior change procedure. to account for how games may influence diet-related out- The measures used to assess outcomes were perhaps even comes.49–51 Some of these models interrelate game elements more diverse wherein different measures were often em- and behavior change principles,50,51 while others emphasize ployed to assess the same knowledge or behavior construct the relevance of food cues and individual predisposing fac- across studies. Five studies (23%) reported more objective tors (e.g., impulsivity).49 Little research, however, has tested methods of dietary intake assessment (e.g., weighed plate aspects of these models with games. Much of the effort in waste): three of these as part of laboratory-based tests of the diet-related games has been to design, develop, and test a effects of diet-related advergames, and two as part of a test of game or interactive experience including game(s) to influ- game play in a school lunchroom/cafeteria. ence outcomes, rather than test principles of game mechanics Three articles studied the effects of food advergames43,44 or behavior-mediating variables within games. Research is and showed that exposure to only 5 minutes of game play urgently needed that systematically varies aspects of game influenced the child’s dietary intake immediately following mechanics or behavior change procedures within games to the game. This suggests the possible strong (at least short- optimize their effects on game engagement,52 maintenance term) behavioral impacts of dietary game play. of interest, psychosocial mediators of change, and behavior One game systematically varied two forms of a behavior change (shorter or longer terms). Thompson et al. system- change procedure, action and coping implementation inten- atically varied four types of goal setting/implementation tions, and tested impact on fruit and vegetable intake within a intentions within Squire’s Quest! and demonstrated that ac- four-group RCT.45 Since the programming keeps all other tion implementation intention was the only procedure to aspects of game play comparable, this is an ideal method for maintain changes 3 months after the end of the game.45 This conducting tests of behavior change procedures for use in research provides an important model for making future videogames, and perhaps outside of games. contributions to an understanding of how game mechanics can influence change in behavior. Discussion No commonly accepted compendium or taxonomy of el- ements in games exists. The ‘‘game lenses’’ identified by Summary of the evidence Schell13; the ‘‘playful experience cards’’ of Bjork and Ho- While all but one of the articles reported some positive lopainen53; and/or Lucero et al.’s playful experiences list54 outcomes from playing the game(s), the quality of much (but preliminarily enumerate items for consideration. Without a not all) of the research reported left much to be desired, commonly accepted compendium, consistencies in game making it difficult to determine the extent to which games mechanics across games may have been missed since dif- had the intended, and reported, effects. The research on diet- ferent words may have been used to specify an essentially related change games diverged in regard to target popula- common underlying mechanic or set of mechanics. Devel- tions, dietary behavior targets (e.g., fruit, vegetables, general oping and obtaining consensus for such a taxonomic com- nutrition information, Mediterranean diet), theories (social- pendium should be a high priority to permit the identification cognitive, persuasion, health belief model, attachment, socio- and comparison of game elements in future systematic re- constructivist, or even none), game elements/mechanics, views and meta-analyses and also to identify mechanics that behavior change procedures, research designs, and measures. are most engaging. Such taxonomic compendia would also As a result, a meaningful meta-analysis or systematic review facilitate the conduct of process evaluations,55 which relate was not possible across all these studies at this time. participation in game elements to outcomes. A compendium of behavior change procedures has been Comparisons to other reviews proposed,56 although challenges have been reported in classifying procedures into the proposed categories.57 Such a A recent review of advergames alone indicated a small common taxonomy should also be used in games research to effect increasing unhealthy food intake.46 While that was not clearly specify what procedures were employed. Of course the primary focus of the current review, it does indicate that the same procedure (e.g., goal setting) could be implemented games can influence dietary intake to some extent under 58 Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only. in a variety of ways in the context of a game, with each some circumstances. The review, including six games for variant possibly affecting outcome in a different way, indi- health, noted the generally positive effects on nutrition cating specific details of the intervention design need to be knowledge, but the diversity in delivery, poor measurement presented in the reported outcome or process evaluations. of process variables and engagement, and thereby the in- Fifteen games (68%) incorporated a story or narrative in ability to draw conclusions about effects.28 We noted similar one form or another. Given the potential for story immersion patterns, but in a larger number of nutrition education game to influence attention to change procedures (especially be- studies, and provided a more detailed assessment of the havior change messaging),20 developing and incorporating limitations in the research methods. stories into nutrition education games may be a way to en- hance effectiveness. Alternatively, the incorporation of a Future directions/needed research story into a game may distract the player from active game Conceptual frameworks exist to guide the development of play, thereby reducing player game enjoyment.59 Several sophisticated G4H (Games for Health).47 Research from stories have been tested and demonstrated to change be- three large behavior change trials (not using games) used havior without a game.36,60 A study that designs and com- mediating variable analyses to validate a multi-theoretical pares separate story and game elements with their integration 20 BARANOWSKI ET AL.

would be an important contribution to our knowledge of could be developed, tested, and incorporated into larger be- nutrition education games (and games in general). havior change programs. There seems to be an implicit assumption that simply There has been substantial concern about the quality of providing a diet-related change program in a game format research, also called risk of bias, in general69–74 and how to will automatically make the activity fun, or engaging, and incorporate issues of quality into systematic reviews.75,76 thereby motivate the player to substantially increase the The general quality of the evidence in support of games on knowledge or change the behavior at substantial levels. Al- nutrition knowledge or behavior change outcomes77 was low ternatively, one of the studies revealed that a web-based and needs further enhancement. This has been pointed out education program was more effective that a game-based elsewhere.78,79 Only five of these nutrition education game program.42 Unfortunately, the relative quality of these two studies used objective measures of dietary intake to assess programs cannot be meaningfully assessed from the pub- dietary change outcomes. Subjective measures tend to be lished information, and thus it is not clear if primarily the subject to bias (i.e., low validity or accuracy) and unreli- medium (web-based or game-based) or qualities of the pro- ability (or imprecision).80 Both active and passive methods grams influenced this outcome. The modest changes in of more objective dietary intake assessment81 are being de- knowledge and behavior that have been reported in these veloped and refined for use in uncontrolled community set- studies suggest the assumption of game dominance is not tings and should be considered for future use as measures of well supported. The role of ‘‘fun’’ in games and game play outcome of games for nutrition education. G4H researchers has not been well specified; the definition and measurement need to expend substantially more effort to enhance the of fun or enjoyment has not been clearly delineated61; story quality of this research if for no other reason than self- or narrative may contribute to the fun of games, but this has interest, that is, to increase the likelihood of obtaining not been clearly assessed.62 If fun in games was better un- funding for future research.82 derstood, games might be designed to enhance the fun as- Many of the studies identified a substantial number of pects to, in turn, enhance the dietary change. behavioral, psychosocial, and/or anthropometric or physio- Many of these games targeted nutrition knowledge, often logical outcomes, without specifying a primary outcome. as the primary or only target. Each set of authors appears to This approach to evaluation runs a high risk of type 1 sta- have created their own measure of nutrition knowledge with tistical error (i.e., obtaining a statistically significant effect unknown psychometric properties. While knowledge for purely by chance).83,84 Diet-related game research should academic purposes (e.g., types of dietary fats; how sodium, specify a primary outcome upon which power calculations potassium, and magnesium interact to influence blood pres- are conducted, with prespecified hypotheses or models of the sure) can be valuable, all these games were targeted in one way in which game play is expected to influence the out- way or another to positively impact health, often through come.85 In this way, tests can be made of whether the game dietary behavior change. The field would benefit from a li- influenced the targeted variable(s) as designed. The stronger brary of nutrition knowledge items that tapped information our knowledge base about how games result in change, the that were preconditions for behavior change (e.g., how to more effective ensuing games can be if designed based on make a salad) and could be incorporated into computer what has been learned. adaptive testing63 to provide brief measures of outcomes comparable across studies. Limitations Developing a diet-related intervention that can be expected One or more game studies may have been missed. A to impact body mass index (perhaps the most prevalent number of diet-related games have been available for pur- nutrition-related health problem) for obesity prevention re- chase, but about which nothing has been published. (At least quires that the game impact the necessary relevant knowledge one game developer has been overheard saying ‘‘I have all and psychosocial variable(s) (e.g., knowledge, self-efficacy, the evaluation I want or need. My games sell.’’) A recent intrinsic motivation) to change the targeted behavior(s) (e.g., systematic review of G4H identified a total of 1743 games diet, physical activity, sedentary behavior, and/or sleep) for a produced between 1983 and 2016, of which 99 (6.4%) were long enough time to change body composition.64 There are about nutrition education and eating disorders.8 The number few examples of such large games. The time to develop and of academic publications that evaluated the efficacies of evaluate them can take years,65,66 and the cost for their de- those games is far less than the games produced. This review Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only. velopment can be staggering (millions of dollars). It seems was based on reports of games in publications that tended to unlikely that this level of funding will become generally provide minimal details, which could have resulted in mis- available for game development anytime soon. Rather than characterizing the games or studies. On one hand, we may creating a single integrated multimedia experience that in- miss existing games that were effective but never evaluated. corporates games to address dietary change, it may be ap- On the other hand, actual play of the games might have propriate to develop a comprehensive intervention structure provided different characterizations and insights, but many (including multimedia and face-to-face components) into of the games no longer function on modern technology. which a series of games could be developed and inserted to achieve those outcomes for which games are most effective, Conclusion for example, knowledge enhancement, simulation of inter- personal interactions, etc. Alternatively, dietary behavior To the best of our knowledge, this is the first English change requires learning some new skills that could be learned review devoted to diet-related video or interactive games. through games, for example, food preparation,67 menu plan- Although a variety of diet-related games have been reported, ning, effective food parenting practices,68 and even taste the research base is inadequate to ascertain whether putting testing. Games attempting to increase these skills or behaviors nutrition education or diet-related behavior change into a NUTRITION EDUCATION AND DIETARY BEHAVIOR CHANGE GAMES 21

game format consistently results in the desired outcomes, or 10. Sardi L, Idri A, Fernandez-Aleman JL. A systematic re- what aspects of game elements or behavior change proce- view of gamification in e-Health. J Biomed Inform 2017; dures appear to be most effective. Future diet-related game 71:31–48. research should use randomized controlled designs; common 11. Corepal R, Tully MA, Kee F, et al. Behavioural incentive validated outcome measures (preferably more objective interventions for health behaviour change in young people measures); behavior change procedures as specified in recent (5–18 years old): A systematic review and meta-analysis. taxonomic inventories; and be guided by conceptual models Prev Med 2018; 110:55–66. that reflect the complexities of game design, user experience, 12. Lewis ZH, Swartz MC, Lyons EJ. What’s the point?: A and their interactivity. A taxonomic inventory of game ele- review of reward systems implemented in gamification ments needs to be developed to clearly specify game designs, interventions. Games Health J 2016; 5:93–99. The Art of Game Design, A Book of Lenses, and facilitate game reporting and comparisons of outcomes. 13. Schell J. 2nd ed. Boca Raton, FL: CRC Press; 2015. Research is needed that systematically varies game elements 14. Mellecker R, Lyons EJ, Baranowski T. Disentangling fun between different versions of the same game to test what and enjoyment in exergames using a expanded design, game elements produce the most change. Different concepts play, experience framework: A narrative review. Games of fun in game play need to be comparatively tested. Perhaps Health J 2013; 2:142–149. we need a leaderboard of game researchers and their num- 15. Castelhano N, Silva F, Rezende M, et al. Ludic content in bers of publications weighted by the quality of their contri- multisensory stimulation environments: An exploratory butions to make a game of it. study about practice in Portugal. Occup Ther Int 2013; 20: 134–143. Acknowledgments 16. Nouchi R, Taki Y, Takeuchi H, et al. Brain training game This work is a publication of the U.S. Department of Agri- boosts executive functions, working memory and proces- sing speed in the young adults: A randomized controlled culture (USDA/ARS) Children’s Nutrition Research Center, trial. PLoS One 2013; 8:e55518. Department of Pediatrics, Baylor College of Medicine, Hous- 17. Levitt C, Adelman DS. Role-playing in nursing theory: ton, Texas, and had been funded in part with federal funds from Engaging online students. J Nurs Educ 2010; 49:229–232. the USDA/ARS under Cooperative Agreement No. 58-3092-5- 18. Granic I, Lobel A, Engels RC. The benefits of playing 001. The authors thank Harley Edge for helping with article video games. Am Psychol 2014; 69:66–78. selection and coding process. 19. Baranowski T, Thompson D, Buday R, et al. Design of video games for children’s diet and physical activity be- Author Disclosure Statement havior change. Int J Comp Sci Sport 2010; 9:3–17. No competing financial interests exist. 20. Lu AS, Baranowski T, Thompson D, et al. Story immer- sion of videogames for youth health promotion: A review of literature. Games Health J 2012; 1:199–204. References 21. DeSmet A, Van Ryckeghem D, Compernolle S, et al. A 1. Boeing H, Bechthold A, Bub A, et al. Critical review: meta-analysis of serious digital games for healthy lifestyle Vegetables and fruit in the prevention of chronic diseases. promotion. Prev Med 2014; 69:95–107. Eur J Nutr 2012; 51:637–663. 22. Guy S, Ratzki-Leewing A, Gwadry-Sridhar F. Moving 2. Teixeira PJ, Carraca EV, Marques MM, et al. Successful beyond the stigma: Systematic review of video games and behavior change in obesity interventions in adults: A their potential to combat obesity. Int J Hypertens 2011; systematic review of self-regulation mediators. BMC Med 2011:179124. 2015; 13:84. 23. Kharrazi H, Lu AS, Gharghabi F, et al. A scoping review 3. Diep CS, Chen TA, Davies VF, et al. Influence of be- of health game research: Past, present, and future. Games havioral theory on fruit and vegetable intervention effec- Health J 2012; 1:153–164. tiveness among children: A meta-analysis. J Nutr Educ 24. Lu AS, Kharrazi H, Gharghabi F, et al. A systematic re- Behav 2014; 46:506–546. view of health videogames on childhood obesity preven- 4. Contento I, Balch GI, Bronner YL, et al. The effectiveness tion and intervention. Games Health J 2013; 2:131–141. of nutrition education and implications for nutrition edu- 25. Khanana K, Law ELC. Designing children’s digital games cation policy, programs, and research: A review of re- on nutrition with playability heuristics. In: CHI’13 Ex-

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98. Fraticelli F, Marchetti D, Polcini F, et al. Technology- Address correspondence to: based intervention for healthy lifestyle promotion in Ital- Tom Baranowski, PhD ian adolescents. Ann Ist Super Sanita 2016; 52:123–127. Department of Pediatrics 99. Joyner D, Wengreen HJ, Aguilar SS, et al. The FIT Game USDA/ARS Children’s Nutrition Research Center III: Reducing the operating expenses of a game-based Baylor College of Medicine approach to increasing healthy eating in elementary 1100 Bates Street schools. Games Health J 2017; 6:111–118. Houston, TX 77030 100. Wang JJ, Baranowski T, Lau PW, et al. Story immersion may be effective in promoting diet and physical activity in Chinese children. J Nutr Educ Behav 2017; 49:321–329 e1. E-mail: [email protected] Downloaded by NORTHEASTERN UNIVERSITY LAW SCHOOL from www.liebertpub.com at 12/07/18. For personal use only.