Video game play, child diet, and physical activity behavior change a randomized clinical trial

How do gamified digital therapeutics work on obesity self-management?

Obesity management can effectively reduce the risks and complications associated with obesity and improve the quality of life of patients. After assessing the advantages and limitations of various obesity management approaches, self-management has been strongly recommended due to the advantages of minimal side effects and lower costs compared to treatment via drugs and surgery. However, successfully implementing lifestyle intervention strategies requires scientific guidance and strong determination. With the development of electronic and information technology, lifestyle intervention has transformed considerably. A new concept, called Gamified Digital Therapeutics (GDTx), represents a gaming format with Digital Therapeutics (DTx). It can effectively enhance patient compliance and accessibility to chronic disease management. Here, we review recent studies on the application of GDTx for the self-management of obesity and discuss three aspects surrounding its completion rates, satisfaction levels, and effectiveness. In contrast to traditional approaches to obesity self-management, implementing GDTx effectively corrects unhealthy dietary and lifestyle habits, markedly enhancing the dissemination of nutritional and exercise-related health knowledge. Of particular significance is the evident improvement in the adherence of obese patients to weight loss programs. Despite numerous studies indicating that GDTx may offer an effective solution for obesity self-management, there are still several limitations in the medicalization of GDTx for self-management of obesity. This review aimed to provide a reference for subsequent studies and promote the widespread application of GDTx in obesity self-management to help reduce the obesity rate and alleviate the burden on obese patients.

Digital Serious Games to Promote Behavior Change in Children With Chronic Diseases: Scoping Review and Development of a Self-Management Learning Framework

BACKGROUND

Digital serious games (SGs) have rapidly become a promising strategy for entertainment-based health education; however, developing SGs for children with chronic diseases remains a challenge.

OBJECTIVE

In this study, we attempted to provide an updated scope of understanding of the development and evaluation of SG educational tools and develop a framework for SG education development to promote self-management activities and behavior change in children with chronic diseases.

METHODS

This study consists of a knowledge base and an analytical base. This study followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines. To build the knowledge base, 5 stages of research were developed, including refining the review question (stage 1), searching for studies (stage 2), selecting relevant studies (stage 3), charting the information (stage 4), and collating the results (stage 5). Eligible studies that developed SG prototypes and evaluated SG education for children with chronic diseases were searched for in PubMed, Embase, Google Scholar, and peer-reviewed journals. In the analytical base, the context-mechanism-output approach and game taxonomy were used to analyze relevant behavioral theories and essential game elements. Game taxonomy included social features, presentation, narrative and identity, rewards and punishment, and manipulation and control. A total of 2 researchers selected the domains for the included behavioral theories and game elements. The intended SG framework was finalized by assembling SG fragments. Those SG fragments were appropriately reintegrated to visualize a new SG framework.

RESULTS

This scoping review summarized data from 16 randomized controlled trials that evaluated SG education for children with chronic diseases and 14 studies on SG frameworks. It showed that self-determination theory was the most commonly used behavioral theory (9/30, 30%). Game elements included feedback, visual and audio designs, characters, narratives, rewards, challenges, competitions, goals, levels, rules, and tasks. In total, 3 phases of a digital SG framework are proposed in this review: requirements (phase 1), design and development (phase 2), and evaluation (phase 3). A total of 6 steps are described: exploring SG requirements (step 1), identifying target users (step 2), designing an SG prototype (step 3), building the SG prototype (step 4), evaluating the SG prototype (step 5), and marketing and monitoring the use of the SG prototype (step 6). Safety recommendations to use digital SG-based education for children in the post-COVID-19 era were also made.

CONCLUSIONS

This review summarizes the fundamental behavioral theories and game elements of the available literature to establish a new theory-driven step-by-step framework. It can support game designers, clinicians, and educators in designing, developing, and evaluating digital, SG-based educational tools to increase self-management activities and promote behavior change in children with chronic diseases.

Oral Health Education for Children: Development of a Serious Game with a User-Centered Design Approach

Background: Children can learn efficiently with well-designed serious games. The use of applications to promote health has proliferated, but there is a lack of scientific studies on educational games in oral health. Materials and Methods: We developed the Brazilian version of a British and Jordanian oral health education game for children from the perspectives of Brazilian specialists and users. This descriptive study, with a qualitative and quantitative approach, comprised three phases: I-Experts' discussion of the appropriateness of the previous version of the game to Brazil; II-Development of the first Brazilian version of the game; and III-Evaluation of the first version with 15 children from 4 to 8 years of age. Results: In Phase I, the specialists agreed with the development of the Brazilian version of the game, with minor adjustments on: advice on eating; advice on oral hygiene habits, users' age group, game characters, and game purpose. Phase II: a version with a few changes in images and recommendations, written and spoken in Brazilian Portuguese. Phase III: The global average of correct answers in the game's tasks was 75.3%, ranging from 50.0% to 100%. Children reported having fun with the game, and most understood the content and its interface; their parents found the information relevant and enjoyed the gameplay with their children. Conclusions: The Oral Health Education Game offered basic information for preventing dental caries to Brazilian children aged 4-8 years old in an interactive and fun way; it could support professionals in improving oral health education.

Interventions to prevent obesity in children aged 5 to 11 years old

BACKGROUND

Prevention of obesity in children is an international public health priority given the prevalence of the condition (and its significant impact on health, development and well-being). Interventions that aim to prevent obesity involve behavioural change strategies that promote healthy eating or 'activity' levels (physical activity, sedentary behaviour and/or sleep) or both, and work by reducing energy intake and/or increasing energy expenditure, respectively. There is uncertainty over which approaches are more effective and numerous new studies have been published over the last five years, since the previous version of this Cochrane review.

OBJECTIVES

To assess the effects of interventions that aim to prevent obesity in children by modifying dietary intake or 'activity' levels, or a combination of both, on changes in BMI, zBMI score and serious adverse events.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was February 2023.

SELECTION CRITERIA

Randomised controlled trials in children (mean age 5 years and above but less than 12 years), comparing diet or 'activity' interventions (or both) to prevent obesity with no intervention, usual care, or with another eligible intervention, in any setting. Studies had to measure outcomes at a minimum of 12 weeks post baseline. We excluded interventions designed primarily to improve sporting performance.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our outcomes were body mass index (BMI), zBMI score and serious adverse events, assessed at short- (12 weeks to < 9 months from baseline), medium- (9 months to < 15 months) and long-term (≥ 15 months) follow-up. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

This review includes 172 studies (189,707 participants); 149 studies (160,267 participants) were included in meta-analyses. One hundred forty-six studies were based in high-income countries. The main setting for intervention delivery was schools (111 studies), followed by the community (15 studies), the home (eight studies) and a clinical setting (seven studies); one intervention was conducted by telehealth and 31 studies were conducted in more than one setting. Eighty-six interventions were implemented for less than nine months; the shortest was conducted over one visit and the longest over four years. Non-industry funding was declared by 132 studies; 24 studies were funded in part or wholly by industry. Dietary interventions versus control Dietary interventions, compared with control, may have little to no effect on BMI at short-term follow-up (mean difference (MD) 0, 95% confidence interval (CI) -0.10 to 0.10; 5 studies, 2107 participants; low-certainty evidence) and at medium-term follow-up (MD -0.01, 95% CI -0.15 to 0.12; 9 studies, 6815 participants; low-certainty evidence) or zBMI at long-term follow-up (MD -0.05, 95% CI -0.10 to 0.01; 7 studies, 5285 participants; low-certainty evidence). Dietary interventions, compared with control, probably have little to no effect on BMI at long-term follow-up (MD -0.17, 95% CI -0.48 to 0.13; 2 studies, 945 participants; moderate-certainty evidence) and zBMI at short- or medium-term follow-up (MD -0.06, 95% CI -0.13 to 0.01; 8 studies, 3695 participants; MD -0.04, 95% CI -0.10 to 0.02; 9 studies, 7048 participants; moderate-certainty evidence). Five studies (1913 participants; very low-certainty evidence) reported data on serious adverse events: one reported serious adverse events (e.g. allergy, behavioural problems and abdominal discomfort) that may have occurred as a result of the intervention; four reported no effect. Activity interventions versus control Activity interventions, compared with control, may have little to no effect on BMI and zBMI at short-term or long-term follow-up (BMI short-term: MD -0.02, 95% CI -0.17 to 0.13; 14 studies, 4069 participants; zBMI short-term: MD -0.02, 95% CI -0.07 to 0.02; 6 studies, 3580 participants; low-certainty evidence; BMI long-term: MD -0.07, 95% CI -0.24 to 0.10; 8 studies, 8302 participants; zBMI long-term: MD -0.02, 95% CI -0.09 to 0.04; 6 studies, 6940 participants; low-certainty evidence). Activity interventions likely result in a slight reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.18 to -0.05; 16 studies, 21,286 participants; zBMI: MD -0.05, 95% CI -0.09 to -0.02; 13 studies, 20,600 participants; moderate-certainty evidence). Eleven studies (21,278 participants; low-certainty evidence) reported data on serious adverse events; one study reported two minor ankle sprains and one study reported the incident rate of adverse events (e.g. musculoskeletal injuries) that may have occurred as a result of the intervention; nine studies reported no effect. Dietary and activity interventions versus control Dietary and activity interventions, compared with control, may result in a slight reduction in BMI and zBMI at short-term follow-up (BMI: MD -0.11, 95% CI -0.21 to -0.01; 27 studies, 16,066 participants; zBMI: MD -0.03, 95% CI -0.06 to 0.00; 26 studies, 12,784 participants; low-certainty evidence) and likely result in a reduction of BMI and zBMI at medium-term follow-up (BMI: MD -0.11, 95% CI -0.21 to 0.00; 21 studies, 17,547 participants; zBMI: MD -0.05, 95% CI -0.07 to -0.02; 24 studies, 20,998 participants; moderate-certainty evidence). Dietary and activity interventions compared with control may result in little to no difference in BMI and zBMI at long-term follow-up (BMI: MD 0.03, 95% CI -0.11 to 0.16; 16 studies, 22,098 participants; zBMI: MD -0.02, 95% CI -0.06 to 0.01; 22 studies, 23,594 participants; low-certainty evidence). Nineteen studies (27,882 participants; low-certainty evidence) reported data on serious adverse events: four studies reported occurrence of serious adverse events (e.g. injuries, low levels of extreme dieting behaviour); 15 studies reported no effect. Heterogeneity was apparent in the results for all outcomes at the three follow-up times, which could not be explained by the main setting of the interventions (school, home, school and home, other), country income status (high-income versus non-high-income), participants' socioeconomic status (low versus mixed) and duration of the intervention. Most studies excluded children with a mental or physical disability.

AUTHORS' CONCLUSIONS

The body of evidence in this review demonstrates that a range of school-based 'activity' interventions, alone or in combination with dietary interventions, may have a modest beneficial effect on obesity in childhood at short- and medium-term, but not at long-term follow-up. Dietary interventions alone may result in little to no difference. Limited evidence of low quality was identified on the effect of dietary and/or activity interventions on severe adverse events and health inequalities; exploratory analyses of these data suggest no meaningful impact. We identified a dearth of evidence for home and community-based settings (e.g. delivered through local youth groups), for children living with disabilities and indicators of health inequities.

Effect of a Technology-Integrated Curriculum on Sugary Drink and Snack Intake of Elementary-Aged Youth Experiencing Low Income

OBJECTIVE

To describe the results of a technology-integrated intervention on sugar-sweetened beverage (SSB) and energy-dense snack intake with third graders experiencing low income.

DESIGN

A 2 × 2 quasi-randomized cluster-block, parallel-group experimental research design.

SETTING

Low-income schools in Rhode Island.

PARTICIPANTS

Two-hundred seventeen intervention and 242 control third-grade students in low-income (89.6% and 88.2% free/reduced meals, respectively), ethnically and racially diverse (63% Hispanic/20% Black and 62% Hispanic/18% Black, respectively) schools.

INTERVENTION(S)

A 13-week in-school program held once per week for 1 hour. The hands-on, technology-integrated program used a modified version of the Body Quest: Food of the Warrior curriculum.

MAIN OUTCOME MEASURE(S)

Intake of SSB and energy-dense snacks, both salty and sweet snacks, using baseline (week 1) and postassessment (week 13) previous day self-recall.

ANALYSIS

Generalized mixed modeling with nesting.

RESULTS

Intervention students significantly reduced their SSB intake by 38% (0.5 times/d; F[1, 540] = 4.26; P = 0.04) and salty snack intake by 58% (0.8 times/d; F[1, 534] = 6.58, P < 0.01) from baseline to postassessment as compared with the control students.

CONCLUSIONS AND IMPLICATIONS

Findings suggest a technology-integrated curriculum is effective in decreasing SSB and salty snacks in elementary-aged students of low-income, minoritized populations. Improved dietary habits can potentially influence other facets of students' lives.

The Influence of Serious Games in the Promotion of Healthy Diet and Physical Activity Health: A Systematic Review

(1) Background: serious games seem to show promising strategies to promote treatment compliance and motivate behavior changes, and some studies have proven to contribute to the literature on serious games. (2) Methods: this systematic review aimed to analyze the effect of serious games in promoting healthy eating behaviors, effectively preventing childhood obesity, and improving physical activity in children. Five electronic bibliographic databases—PubMed, ACM Digital Library, Games for Health Journal, and IEEE Xplore were used to conduct a systematic literature search based on fixed inclusion and exclusion criteria. Peer-reviewed journal articles published between 2003 and 2021 were selected for data extraction. (3) Results: a total of 26 studies were identified, representing 17 games. Half of the studies tested interventions for healthy eating and physical education. Most of the intervention’s games were designed according to specific behavioral change theories, predominantly the social cognitive theory. (4) Conclusions: studies confirmed the potential of serious games for obesity prevention but considering the restrictions encountered, we exhort for novel designs with different theoretical perspectives.

Childhood obesity risk increases with increased screen time: a systematic review and dose-response meta-analysis

BACKGROUND

The role of screen time in promoting obesity among children has been reported in previous studies. However, the effects of different screen types and the dose-response association between screen time and obesity among children is not summarized yet. In the current meta-analysis we systematically summarized the association between obesity and screen time of different screen types in a dose-response analysis.

METHODS

A systematic search from Scopus, PubMed and Embase electronic databases was performed. Studies that evaluated the association between screen time and obesity up to September 2021 were retrieved. We included 45 individual studies that were drawn from nine qualified studies into meta-analysis.

RESULTS

The results of the two-class meta-analysis showed that those at the highest category of screen time were 1.2 times more likely to develop obesity [odds ratio (OR) = 1.21; confidence interval (CI) = 1.113, 1.317; I2 = 60.4%; P < 0.001). The results of subgrouping identified that setting, obesity status and age group were possible heterogeneity sources. No evidence of non-linear association between increased screen time and obesity risk among children was observed (P-nonlinearity = 0.310).

CONCLUSION

In the current systematic review and meta-analysis we revealed a positive association between screen time and obesity among children without any evidence of non-linear association. Due to the cross-sectional design of included studies, we suggest further studies with longitudinal or interventional design to better elucidate the observed associations.

Interventions to prevent obesity in school-aged children 6-18 years: An update of a Cochrane systematic review and meta-analysis including studies from 2015-2021

Background

Childhood obesity remains a global public health priority due to the enormous burden it generates. Recent surveillance data suggests there has been a sharp increase in the prevalence of childhood obesity during the COVID-19 pandemic. The Cochrane review of childhood obesity prevention interventions (0-18 years) updated to 2015 is the most rigorous and comprehensive review of randomised controlled trials (RCTs) on this topic. A burgeoning number of high quality studies have been published since that are yet to be synthesised.

Methods

An update of the Cochrane systematic review was conducted to include RCT studies in school-aged children (6-18 years) published to 30 June 2021 that assessed effectiveness on child weight (PROSPERO registration: CRD42020218928). Available cost-effectiveness and adverse effect data were extracted. Intervention effects on body mass index (BMI) were synthesised in random effects meta-analyses by setting (school, after-school program, community, home), and meta-regression examined the association of study characteristics with intervention effect.

Findings

Meta-analysis of 140 of 195 included studies (183,063 participants) found a very small positive effect on body mass index for school-based studies (SMD -0·03, 95%CI -0·06,-0·01; trials = 93; participants = 131,443; moderate certainty evidence) but not after-school programs, community or home-based studies. Subgroup analysis by age (6-12 years; 13-18 years) found no differential effects in any setting. Meta-regression found no associations between study characteristics (including setting, income level) and intervention effect. Ten of 53 studies assessing adverse effects reported presence of an adverse event. Insufficient data was available to draw conclusions on cost-effectiveness.

Interpretation

This updated synthesis of obesity prevention interventions for children aged 6-18 years, found a small beneficial impact on child BMI for school-based obesity prevention interventions. A more comprehensive assessment of interventions is required to identify mechanisms of effective interventions to inform future obesity prevention public health policy, which may be particularly salient in for COVID-19 recovery planning.

Funding

This research was funded by the National Health and Medical Research Council (NHMRC), Australia (Application No APP1153479).

Serious games for health promotion in adolescents - a systematic scoping review

Digital gaming has broad appeal globally, with a reported 2.7 billion gamers worldwide. There is significant interest in using games to enhance learning, with 'serious games' being included in classrooms to engage adolescents' learning across a range of domains. A systematic scoping review of serious games used for health promotion with adolescents was conducted to identify serious games, review the methods used to evaluate these games, and outline evidence available to support the efficacy of these games in improving knowledge, beliefs/attitudes and behaviours in the target groups. Player engagement/enjoyment was reported if assessed. A total of 21 studies were found to have met the inclusion criteria domains: 'healthy lifestyle' 'sexual health' and 'substance use'. A heterogenous approach across studies to game design and development, duration of game play, use of a control group and measurement of outcome(s) was observed. Game efficacy was difficult to assess due to broad generalisations and lack of consistent evaluation methods. Several studies demonstrate serious games can be engaging and pedagogically effective as a learning device and behaviour-change agent. Several studies, however, had less rigorous evaluation and lacked longer-term follow up. The ability for developers to demonstrate positive short- and long-term impacts of serious games with high-quality evidence is essential to the ongoing acceptance and use of these serious games as part of the school curriculum.

Feasibility of Using Games to Improve Healthy Lifestyle Knowledge in Youth Aged 9-16 Years at Risk for Type 2 Diabetes: Pilot Randomized Controlled Trial

Background

Mobile games can be effective and motivating tools for promoting children’s health.

Objective

We aimed to determine the comparative use of 2 prototype serious games for health and assess their effects on healthy lifestyle knowledge in youth aged 9-16 years at risk for type 2 diabetes (T2D).

Methods

A 3-arm parallel pilot randomized controlled trial was undertaken to determine the feasibility and preliminary effectiveness of 2 serious games. Feasibility aspects included recruitment, participant attitudes toward the games, the amount of time the participants played each game at home, and the effects of the games on healthy lifestyle and T2D knowledge. Participants were allocated to play Diabetic Jumper (n=7), Ari and Friends (n=8), or a control game (n=8). All participants completed healthy lifestyle and T2D knowledge questionnaires at baseline, immediately after game play, and 4 weeks after game play. Game attitudes and preferences were also assessed. The primary outcome was the use of the game (specifically, the number of minutes played over 4 weeks).

Results

In terms of feasibility, we were unable to recruit our target of 60 participants. In total, 23 participants were recruited. Participants generally viewed the games positively. There were no statistical differences in healthy lifestyle knowledge or diabetes knowledge over time or across games. Only 1 participant accessed the game for an extended period, playing the game for a total of 33 min over 4 weeks.

Conclusions

It was not feasible to recruit the target sample for this trial. The 2 prototype serious games were unsuccessful at sustaining long-term game play outside a clinic environment. Based on positive participant attitudes toward the games, it is possible to use these games or similar games as short-term stimuli to engage young people with healthy lifestyle and diabetes knowledge in a clinic setting; however, future research is required to explore this area.

Trial Registration

Australia New Zealand Clinical Trials Registry ACTRN12619000380190; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377123

HelperFriend, a Serious Game for Promoting Healthy Lifestyle Behaviors in Children: Design and Pilot Study

BACKGROUND

The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children.

OBJECTIVE

We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness.

METHODS

Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction.

RESULTS

Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (t14=2.01, P=.03), healthy eating (t14=3.14, P=.003), and socioemotional wellness (t14=2.75, P=.008). In addition, from T0 to T1, the intervention group improved their intention to perform physical activity (t14=2.82, P=.006), healthy eating (t14=3.44, P=.002), and socioemotional wellness (t14=2.65, P=.009); and there was a reduction in their intake of 13 unhealthy foods. HelperFriend was well received by intervention group.

CONCLUSIONS

HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend.

Digital Interventions for Universal Health Promotion in Children and Adolescents: A Systematic Review

BACKGROUND AND OBJECTIVES

Digital media has been used mostly to deliver clinical treatments and therapies; however limited evidence evaluates digital interventions for health promotion. The objective of this review is to identify digital interventions for universal health promotion in school-aged children and adolescents globally.

METHODS

Eligible articles were searched in PubMed, Embase, Medline, Ovid SP, The Cochrane Library, Cochrane Central Register of Controlled Trials, WHO regional databases, Google Scholar, and reference lists from 2000 to March 2021. Randomized controlled trials and quasi-experimental studies evaluating interventions that promote health in school-aged children and adolescents (5-19.9 years) were included. Methods were conducted in duplicate. Where possible, data were pooled with a random-effects model.

RESULTS

Seventy-four studies were included (46 998 participants), of which 37 were meta-analyzed (19 312 participants). Interventions increased fruit and vegetable consumption (servings per day) (mean difference [MD] 0.63, 95% confidence interval [CI] 0.21 to 1.04; studies = 6; P = .003; high quality of evidence), and probably reduced sedentary behavior (MD -19.62, 95% CI -36.60 to -2.65; studies = 6; P = .02; moderate quality of evidence), and body fat percentage (MD -0.35%, 95% CI -0.63 to -0.06; studies = 5; P = .02; low quality of evidence). The majority of studies were conducted in high-income countries and significant heterogeneity in design and methodology limit generalizability of results.

CONCLUSIONS

There is great potential in digital platforms for universal health promotion; however, more robust methods and study designs are necessitated. Continued research should assess factors that limit research and program implementation in low- to middle-income countries.

Nutrition education strategies to promote vegetable consumption in preschool children: the Veggies4myHeart project

OBJECTIVE

To test the efficacy of three nutrition education strategies on the intake of different vegetables in preschool children.

DESIGN

This is an experimental study conducted in four Portuguese preschools. The intervention consisted of 20-min educational sessions, once a week, for 5 weeks, with one of the following randomised educational strategies: Portuguese Food Wheel Guide (control), digital game, storybook, storybook and reward (stickers). All groups had repeated exposure to vegetables in all sessions. A pre- and post-test were conducted to determine vegetable intake, and a 6-month follow-up was realised.

SETTING

Preschools of Leiria district, Portugal.

PARTICIPANTS

A sample of 162 children aged 3 to 6 years. All eligible children attending the preschools were invited to participate.

RESULTS

All interventions tested were effective in increasing vegetable consumption both in the short and medium term, without statistically significant differences, compared to the control group. Stickers were more effective in the short term than in the medium term.

CONCLUSIONS

The nutritional education strategies associated with repeated exposure tested in this study were effective in promoting vegetable consumption in preschool children. The use of stickers may be a valid strategy to promote the consumption of vegetables less recognised by children.

A Mobile App to Increase Fruit and Vegetable Acceptance Among Finnish and Polish Preschoolers: Randomized Trial

Background

Early childhood education and care (ECEC) centers are ideal venues for food education. As smartphones and tablets are becoming increasingly popular in ECEC centers, technology can be used to deliver such pedagogical content. Evidence suggests that video games can affect fruit and vegetable (FV) consumption among 9- to 12-year-old children, but studies among preschoolers are scarce.

Objective

This paper describes the development of the Mole’s Veggie Adventures app and its effectiveness in increasing FV acceptance among Finnish and Polish preschoolers aged 3 to 6 years.

Methods

A multiprofessional team created an app to be used in ECEC centers in groups of 3 to 10 children. The app aimed to increase vegetable acceptance, and it was built using elements that support the development of self-regulation and social skills. Altogether, 7 Finnish and 4 Polish ECEC centers participated in the study. Before randomization, parents reported background factors and their children’s willingness to taste different FVs. The ECEC professionals in the intervention arm were instructed to use the app at least once a week during the 3- to 4-week intervention period. The main outcomes in this unblinded, cluster-randomized study were FV acceptance and relative FV acceptance. The first was calculated as a sum variable describing the children’s willingness to taste 25 different FVs, the second as FV acceptance divided by the number of FVs served. We used analysis of covariance to compare the FV acceptance and relative FV acceptance scores between the intervention and control groups at follow-up.

Results

A total of 221 children were included in the analysis. At follow-up, the intervention group (115/221, 52%) had higher FV acceptance scores (baseline adjusted difference of mean 7.22; 95% CI 1.41-13.03) than the control group (106/221, 48%). The intervention effect was parallel for relative FV acceptance scores (baseline adjusted difference of mean 0.28; 95% CI 0.05-0.52).

Conclusions

The Mole’s Veggie Adventures app has the potential to increase FV acceptance among preschoolers and can be a valuable tool in supporting food education in ECEC centers. Furthermore, the app can be feasibly incorporated into preschool routines in countries with different educational environments.

Trial Registration

ClinicalTrials.gov NCT05173311; https://tinyurl.com/4vfbh283

Microsimulation projections of obesity interventions on cardiometabolic health disparities in the United States

OBJECTIVE

The aim of this study was to estimate long-term impacts of health education interventions on cardiometabolic health disparities.

METHODS

The model simulates how health education implemented in the United States throughout 2019 to 2049 would lead to changes in adult BMI and consequent hypertension and type 2 diabetes. Health outcome changes by sex, racial/ethnic (non-Hispanic White, non-Hispanic Black, and Hispanic), and weight status (normal: 18.5 ≤ BMI < 25; overweight: 25 ≤ BMI < 30; and obesity: 30 ≤ BMI) subpopulations were compared under a scenario with and one without health education.

RESULTS

By 2049, the intervention would reduce average BMI of women with obesity to 27.7 kg/m2 (CI: 27.4-27.9), which would be 2.9 kg/m2 lower than the expected average BMI without an intervention. Education campaigns would reduce type 2 diabetes prevalence, but it would remain highest among women with obesity at 27.7% (CI: 26.2%-29.2%). The intervention would reduce hypertension prevalence among White women by 4.7 percentage points to 38.0% (CI: 36.4%-39.7%). For Black women in the intervention, the 2049 hypertension prevalence would be 52.6% (CI: 50.7%-54.5%). Results for men and women were similar.

CONCLUSIONS

Long-term health education campaigns can reduce obesity-related disease. All population groups benefit, but they would not substantially narrow cardiometabolic health disparities.

Feasibility and Acceptability of 'VitaVillage': A Serious Game for Nutrition Education

Computer games have previously been used to improve nutrition knowledge in children. This paper describes the acceptability and feasibility of a serious game, "VitaVillage", for improving child nutrition knowledge. VitaVillage is a farming-style game in which the player undertakes quests and completes questions aimed at increasing several aspects of nutrition and healthy eating knowledge. Children aged 9-12 years in two primary schools (control vs. intervention) completed a nutrition knowledge questionnaire at baseline (T1) and after 1 week (T2). Participants at the intervention school (n = 75) played VitaVillage for 20 minutes on two occasions. Control participants (n = 94) received no nutrition education. Likeability question scores and written feedback from intervention participants was reported qualitatively. Paired sample t-tests were used to compare T1 and T2 nutrition knowledge changes between control and intervention participants. Engagement with VitaVillage improved children's overall nutrition knowledge (Mean increase of 2.25 points between T1 and T2, Standard Deviation (SD) 6.31, p = 0.035) compared to controls. The game was liked overall (mean score 77 (SD 24.6) on scale of 0-100) and positive feedback was given. Results indicate that VitaVillage has the potential to be successful as a nutrition education tool. In the future, VitaVillage's content and gameplay will be revised, extended and evaluated for its long-term impact on eating behaviour and knowledge changes.

Promoting Navigation Health Literacy at the Intersection of Schools and Communities. Development of the Game-Based Intervention Nebolus

Emerging empirical evidence indicates a limited health literacy for a substantial proportion of children and adolescents. Although it is generally agreed upon promoting health literacy as early as possible in the lifespan, there is a lack of interventions addressing children and adolescents and their primary living environments. This article describes the development of Nebolus, a game-based intervention aiming to promote navigation health literacy at the intersection of schools and communities. Its intervention foundation lies in a socio-ecological understanding of health as well as in the Entertainment Education approach. Following an extensive literature search on health-related location-based games, a co-creation process was initiated that involved adolescents, community stakeholders, and design/IT professionals in all phases of the intervention development. The final Nebolus intervention includes three core activities: (1) a Nebolus rally app for adolescents aged 12 to 16 years, (2) an online planning tool allowing local health service providers/professionals to set up own Nebolus rallies, and (3) accompanying teaching material on health literacy in the school setting to be used before and after the Nebolus rallies. This article provides an overview of the intervention layout and discusses strengths and challenges of its development and implementation.

Hubungan Screen Based Activity dan Perilaku Makan dengan Status Gizi Anak Usia 10-12 Tahun (Studi di SDI Darush Sholihin Kabupaten Nganjuk)

ABSTRAK Latar Belakang: Anak usia sekolah mengalami peningkatan kebutuhan gizi untuk tumbuh kembang. Di usia ini, anak-anak bisa memilih makanan maupun media bermain sesuai keinginan mereka. Aktivitas menggunakan layar yang berlebih serta perilaku makan yang buruk dapat memicu terjadinya obesitas.Tujuan: Penelitian ini bertujuan untuk menganalisis hubungan Screen Based Activity (SBA) dan perilaku makan dengan status gizi anak usia sekolah.Metode: Penelitian ini merupakan penelitian observasional analitik dengan desain penelitian cross sectional. Penelitian dilakukan di SDI Darush Sholihin Kabupaten Nganjuk. Besar sampel sebanyak 48 siswa yang dipilih secara proportional random sampling. Pengumpulan data meliputi berat badan, tinggi badan, kuesioner SBA, Food Frequency Questionnaire (FFQ), serta food recall 2x24 jam. Data dianalisis menggunakan uji korelasi Spearman dan Kendall’s tau dengan nilai signifikansi 0,05.Hasil: Hasil penelitian menunjukkan bahwa tidak ada hubungan SBA (p=0,151), perilaku makan makanan pokok (p=0,101), perilaku makan lauk hewani (p=0,212), perilaku makan lauk nabati (p=0,829), perilaku makan sayuran (p=0,751) dan perilaku makan jajanan (p=0,109) dengan status gizi. Namun, terdapat hubungan perilaku makan buah (p=0,040) dengan status gizi.Kesimpulan: Konsumsi buah-buahan yang sering tanpa memperhatikan kandungan gula dan cara penyajian dapat memberikan risiko obesitas pada anak. Diperlukan pendidikan gizi kepada pihak sekolah maupun orang tua mengenai pembatasan SBA dan perilaku makan sehat terutama buah untuk mencapai tumbuh kembang yang optimal dan terhindar dari obesitas.

Active Video Gaming Using an Adapted Gaming Mat in Youth and Adults With Physical Disabilities: Observational Study

Background

A common leisure-time activity amongst youth and adults in the United States is video gameplay. Playing video games is typically a sedentary endeavor; however, to encourage an increased level of physical activity in an engaging and enjoyable way, active video gaming has become popular. Unfortunately, the accessibility of gaming controllers is often an issue for persons with disabilities. A commercial off-the-shelf (OTS) gaming mat was adapted to facilitate use by individuals with mobility impairments to address this issue.

Objective

Our study aimed to examine energy expenditure, enjoyment, and gameplay experience in youth and adults with mobility impairment during active video gaming using an OTS and adapted versions of a gaming mat.

Methods

The study used an observational design. During visit 1, physical function was assessed, and participants were given a familiarization period with the gaming system. For visit 2, based on observation during the physical function tests and discussion with the participant, it was decided whether the participant would play in a standing or seated position. For standing gameplay, the mat was placed on the floor, and for seated play, the mat was placed on a height-adjustable and tilt-adjustable tabletop. Metabolic data were collected during a 20-minute baseline and four 10-minute bouts of Wii Fit Plus gameplay, with 2 bouts on each of the mats (adapted and OTS). During gameplay, the research staff observed and rated participants’ ability to use the game controller (mat) and the quality of gameplay. At the end of each game set, participants reported their rating of perceived exertion on a scale from 0 to 10. During rest, participants completed the physical activity enjoyment scale. Participants also answered additional questions regarding the system's usability with each controller (adapted mat and OTS mat). Statistical analyses were computed using Stata 16 (version 16.1; StataCorp). Linear mixed-effects maximum likelihood regression was performed separately for individuals who could play standing and for those who played seated.

Results

A convenience sample of 78 individuals with mobility impairments between the ages of 12 and 60 years (mean 39.6, SD 15.8) participated in the study. Of the sample, 48 participants played the video games in a seated position, while 30 played the games standing. Energy expenditure and heart rate tended to be higher in the OTS mat condition for seated players, while values were similar for both conditions among standing players. However, seated participants reported greater gameplay experience, and both groups exhibited a higher quality of gameplay during the adapted mat condition.

Conclusions

Active video gaming using an adapted gaming mat provided an enjoyable exercise activity for individuals with mobility impairments. The use of the adapted controller provides a means by which this population can engage in light to moderate intensity active video gaming, thereby reducing sedentary leisure time.

Trial Registration

ClinicalTrials.gov NCT02994199; https://clinicaltrials.gov/ct2/show/NCT02994199

The Effects of Computer Game on Preschool Children’s Nutrition Knowledge and Junk Food Intake Behavior (Preprint)

Background

Objective

Methods

Results

Conclusions

Gamification for the Improvement of Diet, Nutritional Habits, and Body Composition in Children and Adolescents: A Systematic Review and Meta-Analysis

Currently, one of the main public health problems among children and adolescents is poor adherence to healthy habits, leading to increasingly high rates of obesity and the comorbidities that accompany obesity. Early interventions are necessary, and among them, the use of gamification can be an effective method. The objective was to analyse the effect of game-based interventions (gamification) for improving nutritional habits, knowledge, and changes in body composition. A systematic review and meta-analysis were performed in CINAHL, EMBASE, LILACS, MEDLINE, SciELO, and Scopus databases, following the PRISMA recommendations. There was no restriction by year of publication or language. Only randomized controlled trials were included. Twenty-three articles were found. After the intervention, the consumption of fruit and vegetables increased, as well as the knowledge on healthy food groups. The means difference showed a higher nutritional knowledge score in the intervention group 95% CI 0.88 (0.05–1.75). No significant effect of gamification was found for body mass index z-score. Gamification could be an effective method to improve nutritional knowledge about healthier nutritional habits. Promoting the development of effective educational tools to support learning related to nutrition is necessary in order to avoid and prevent chronic diseases.

Learning Impact of a Virtual Brain Electrical Activity Simulator Among Neurophysiology Students: Mixed-Methods Intervention Study

BACKGROUND

Virtual simulation is the re-creation of reality depicted on a computer screen. It offers the possibility to exercise motor and psychomotor skills. In biomedical and medical education, there is an attempt to find new ways to support students' learning in neurophysiology. Traditionally, recording electroencephalography (EEG) has been learned through practical hands-on exercises. To date, virtual simulations of EEG measurements have not been used.

OBJECTIVE

This study aimed to examine the development of students' theoretical knowledge and practical skills in the EEG measurement when using a virtual EEG simulator in biomedical laboratory science in the context of a neurophysiology course.

METHODS

A computer-based EEG simulator was created. The simulator allowed virtual electrode placement and EEG graph interpretation. The usefulness of the simulator for learning EEG measurement was tested with 35 participants randomly divided into three equal groups. Group 1 (experimental group 1) used the simulator with fuzzy feedback, group 2 (experimental group 2) used the simulator with exact feedback, and group 3 (control group) did not use a simulator. The study comprised pre- and posttests on theoretical knowledge and practical hands-on evaluation of EEG electrode placement.

RESULTS

The Wilcoxon signed-rank test indicated that the two groups that utilized a computer-based electrode placement simulator showed significant improvement in both theoretical knowledge (Z=1.79, P=.074) and observed practical skills compared with the group that studied without a simulator.

CONCLUSIONS

Learning electrode placement using a simulator enhances students' ability to place electrodes and, in combination with practical hands-on training, increases their understanding of EEG measurement.

Problematic Internet Use and Digital Gaming in Adolescents: Problems, Nursing Interventions, and Outcomes

The aim of the current study was to determine problems of adolescents with problematic internet use and digital gaming using the Omaha System and to evaluate the results by applying nursing interventions. Data were collected using the Internet Addiction Test, Digital Game Addiction Scale, and Nightingale Notes software. The sample comprised 30 adolescents selected from a total of 125 adolescents with problematic internet use and digital gaming from a high school. Results showed that problematic internet use and digital gaming rates were higher in males compared to females. Seven problems identified most frequently among adolescents were: mental health, vision, pain, sleep and rest patterns, nutrition, social contact, and physical activity. The Omaha System can be used by psychiatric-mental health nurses and school nurses to determine the problems of adolescents with problematic internet use and digital gaming, apply interventions, and evaluate health outcomes. [Journal of Psychosocial Nursing and Mental Health Services, 58(12), 51-59.].

Impact of Pediatric Mobile Game Play on Healthy Eating Behavior: Randomized Controlled Trial

BACKGROUND

Video and mobile games have been shown to have a positive impact on behavior change in children. However, the potential impact of game play patterns on outcomes of interest are yet to be understood, especially for games with implicit learning components.

OBJECTIVE

This study investigates the immediate impact of fooya!, a pediatric dietary mobile game with implicit learning components, on food choices. It also quantifies children's heterogeneous game play patterns using game telemetry and determines the effects of these patterns on players' food choices.

METHODS

We analyzed data from a randomized controlled trial (RCT) involving 104 children, aged 10 to 11 years, randomly assigned to the treatment group (played fooya!, a dietary mobile game developed by one of the authors) or the control group (played Uno, a board game without dietary education). Children played the game for 20 minutes each in two sessions. After playing the game in each session, the children were asked to choose 2 out of 6 food items (3 healthy and 3 unhealthy choices). The number of healthy choices in both sessions was used as the major outcome. We first compared the choice and identification of healthy foods between treatment and control groups using statistical tests. Next, using game telemetry, we determined the variability in game play patterns by quantifying game play measures and modeled the process of game playing at any level across all students as a Markov chain. Finally, correlation tests and regression models were used to establish the relationship between game play measures and actual food choices.

RESULTS

We saw a significant main effect of the mobile game on number of healthy foods actually chosen (treatment 2.48, control 1.10; P<.001; Cohen d=1.25) and identified (treatment 7.3, control 6.94; P=.048; Cohen d=.25). A large variation was observed in children's game play patterns. Children played an average of 15 game levels in 2 sessions, with a range of 2 to 23 levels. The greatest variation was noted in the proportion of scoring activities that were highly rewarded, with an average of 0.17, ranging from 0.003 to 0.98. Healthy food choice was negatively associated with the number of unhealthy food facts that children read in the game (Kendall τ=-.32, P=.04), even after controlling for baseline food preference.

CONCLUSIONS

A mobile video game embedded with implicit learning components showed a strong positive impact on children's food choices immediately following the game. Game telemetry captured children's different play patterns and was associated with behavioral outcomes. These results have implications for the design and use of mobile games as an intervention to improve health behaviors, such as the display of unhealthy food facts during game play. Longitudinal RCTs are needed to assess long-term impact.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04082195; https://clinicaltrials.gov/ct2/show/NCT04082195, registered retrospectively.

Quality Criteria for Serious Games: Serious Part, Game Part, and Balance

Serious games are digital games that have an additional goal beyond entertainment. Recently, many studies have explored different quality criteria for serious games, including effectiveness and attractiveness. Unfortunately, the double mission of serious games, that is, simultaneous achievement of intended effects (serious part) and entertainment (game part), is not adequately considered in these studies. This paper aims to identify essential quality criteria for serious games. The fundamental goal of our research is to identify important factors of serious games and to adapt the existing principles and requirements from game-related literature to effective and attractive serious games. In addition to the review of the relevant literature, we also include workshop results. Furthermore, we analyzed and summarized 22 state-of-the-art serious games for education and health. The selected best-practice serious games either prove their effectiveness through scientific studies or by winning game awards. For the analysis of these games, we refer to "DIN SPEC 91380 Serious Games Metadata Format." A summarized text states quality criteria for both the serious and the game part, and especially the balance between them. We provide guidelines for high-quality serious games drawn from literature analysis and in close cooperation with domain experts.

Interventions to increase the consumption of water among children: A systematic review and meta-analysis

The aim of this study was to conduct a systematic review and meta-analysis on the effectiveness of interventions to increase children's water consumption. A systematic literature search was conducted in seven electronic databases. Studies published in English before 18 February 2019 that evaluated any type of intervention that measured change in water consumption among children aged 2 to 12 years by applying any type of design were included. Of the 47 interventions included in the systematic review, 24 reported a statistically significant increase in water consumption. Twenty-four interventions (17 randomized controlled trials and seven studies with other controlled designs) were included in the meta-analysis. On average, children in intervention groups consumed 29 mL/d (confidence interval [CI] = 13-46 mL/d) more water than did children in control groups. This effect was larger in eight interventions focused specifically on diet (MD = 73 mL/d, CI = 20-126 mL/d) than in 16 interventions focused also on other lifestyle factors (MD = 15 mL/d, CI = 1-29 mL/d). Significant subgroup differences were also found by study setting and socioecological level targeted but not by children's age group, intervention strategy, or study design. In conclusion, there is evidence that, on average, lifestyle interventions can lead to small increases in children's daily water consumption. More research is needed to further understand the specific intervention elements that have the greatest effect.

An Experimental Study of Effects of Media Implication on Self-Report Symptoms Related With MP Use

Along with gradually increases in mobile phone (MP) use, the mass media has played a vital role in informing the public regarding the potential health hazards of MP use. These media warnings have prompted public worries about health. The aim of the present study is to investigate the effects of media warnings about the possible health hazards of MP use on self-reported symptoms. Participants were 703 undergraduate students who volunteered to take part in an experimental study between August 2013 and July 2015. After completing baseline questionnaires containing information on demographics, MP usage and possible confounding variables, the participants were randomly clustered assigned to a video treatment group (watching a 5-min video about the possible health hazards of MP use) or a control group. Then, they completed another set of questionnaires containing 6 self-reported physical symptoms and the Beck Depression Inventory (BDI). Chi-squared tests, Mann-Whitney U-tests and logistic regression models were applied in the data analysis. Participants in the video group reported significantly more frequent headache (P = 0.01), fatigue (P = 0.00), memory loss (P = 0.03), inattention (P = 0.00), and higher level of depression (P = 0.05) than those in the control group. Additionally, the prevalence of memory loss (β = 0.071, P = 0.03) and inattention (β = 0.110, P = 0.00) were significantly higher in participants with higher level of depression who watched the video. Media warnings about the possible health hazards of MP use promote people to report physical symptoms and psychological problems. Considering this tendency, more moderate and scientific media information is needed to alleviate public worries about MP use.

A Systematic Review of Active Video Games on Youth's Body Composition and Physical Activity

In the past decade, active video games (AVGs) have started to find their way into communities, schools, and homes as a possible solution to promote physical activity (PA) and prevent childhood obesity. However, the evidence regarding its effectiveness on body composition and objectively measured PA in youth remains inconclusive. Thus, a systematic review on this topic is needed. This review synthesizes effects of AVGs on body composition and PA in youth. The initial search yielded 260 articles from 10 databases and 18 randomized-controlled trials were included after evaluating against eligibility and removing duplicates. Overall, AVGs showed positive effects in improving body composition and PA in overweight/obese youth as compared to the control conditions with only 2 studies displaying neutral effects on these outcomes as compared to traditional PA or comparison programs. For healthy youth, more than half of the studies (n = 10) demonstrated neutral effects of AVGs on these outcomes whereas only 6 yielded positive effects compared to the control conditions. Further, one study indicated that the control condition observed greater improvement in body composition compared with an AVG intervention in healthy youth. In summary, AVGs are deemed a promising addition to promote PA and health among overweight/obese youth with the goal of fighting childhood obesity.

The Kids Obesity Prevention Program: Cluster Randomized Controlled Trial to Evaluate a Serious Game for the Prevention and Treatment of Childhood Obesity

Background

Health games provide opportunities for the treatment and prevention of childhood obesity. We developed a motion-controlled serious game for children that addresses 3 core topics of nutrition, physical activity, and stress coping. It is the first serious game that extensively targets the dietary energy density principle (DED-P) in relation to nutrition. The game is intended to provide an additional educational component for the prevention and treatment of obesity in children.

Objective

The Kids Obesity Prevention study aimed to evaluate the newly developed game and to evaluate how well children are able to understand and apply the DED-P.

Methods

This cluster randomized controlled trial collected data from 82 primary school children aged 9 to 12 years and their parents at baseline (T0), at 2 weeks after study commencement (T1), and at the 4-week follow-up (T2). The dropout rate was 3.6%. The intervention group (IG) played the game within 2 weeks (2 sessions with different game modules). One part of the game involves selection of food with the lower energy density when presented with a pair of foods. This allows assessment of whether the children have understood the DED-P and whether they can apply it to unknown foods under time pressure. The control group (CG) received a brochure about the food pyramid concept and physical activity. The primary outcome was the gain in knowledge (nutrition and stress coping) and measured with a pretested questionnaire. The secondary outcomes were the maintenance of knowledge, application of the DED-P, feelings during game play, game acceptance, and behavioral measures (physical activity, media consumption, and dietary intake).

Results

The knowledge score ranging from 0 to 100 increased from T0 (IG: 53 [SD 10], CG: 50 [SD 11]) to T1 (IG: 69 [SD 11], CG: 52 [SD 12]) in IG versus CG (P<.001). At T2, the knowledge score of IG remained at the same level as that of T1. Game data showed that after DED-P education, the classification under time pressure of unknown versus known food pairs according to their DED category was similar (hit rate around 70%). Overall, 95% of the children liked the game very much or much. No group changes were observed at the behavioral level.

Conclusions

The Kids Obesity Prevention program sustainably increased knowledge in the areas of nutrition and stress coping, and children were able to apply the DED-P.

Trial Registration

ClinicalTrials.gov NCT02551978; https://clinicaltrials.gov/ct2/show/NCT02551978

Nutritional Education and Promotion of Healthy Eating Behaviors Among Mexican Children Through Video Games: Design and Pilot Test of FoodRateMaster

Background

Childhood obesity has risen dramatically in recent decades, reaching epidemic levels. Children need guidance on and support for maintaining a healthy diet and physical activity to ensure that they grow appropriately and develop healthy eating habits. Serious video games have shown positive effects on promoting the nutritional knowledge, and eating attitudes and behaviors of children; however, research about the usefulness of such games with younger children (8-10 years old) is sparse.

Objective

The objective of this study was to design and test the serious video game FoodRateMaster targeting children between 8 and 10 years old. The game includes nutritional information and behavior change techniques to help children improve their knowledge of healthy and unhealthy foods, increase their intake of healthy food, and reduce their intake of ultraprocessed food. In addition, FoodRateMaster was designed as an active game to promote physical activity.

Methods

An interdisciplinary team developed FoodRateMaster following an iterative methodology based on a user-centered design. A total of 60 participants (mean age 9 years, SD 0.8; 53% male) completed 12 individual gaming sessions in 6 weeks. A food knowledge questionnaire and a food frequency questionnaire were completed before and after game play. In addition, 39 of the participants’ parents answered a parent perception questionnaire after the game play.

Results

Participants showed increased food knowledge from pregame (mean 56.9, SD 10.7) to postgame play (mean 67.8, SD 10.7; P<.001). In addition, there was a greater self-reported frequency in the consumption of cauliflower and broccoli (P<.001) and corn quesadillas (P<.001). They also indicated a lower self-reported intake of 10 unhealthy foods, including french fries (P=.003), candy and chocolate (P<.001), sweet soft cakes (P=.009), and soft drinks (P=.03). Moreover, most of the parents who answered the parent perception questionnaire agreed that their children showed greater interest in explaining why they should avoid some unhealthy foods (67%, 26/39), in distinguishing between healthy and unhealthy foods (64%, 25/39), and in the intake of fruits (64%, 25/39) and vegetables (59%, 23/39). Finally, 14 parents stated that they introduced some changes in their children's diet based on the comments and suggestions they received from their children.

Conclusions

In an initial evaluation, children between 8 and 10 years old indicated an increased level in nutritional knowledge and their self-reported frequency intake of two healthy foods, and a decreased level in their self-reported intake of 10 unhealthy foods after playing FoodRateMaster. Moreover, the participants’ parents agreed that FoodRateMaster positively influenced their children’s attitudes toward several healthy eating behaviors. These results support that health games such as FoodRateMaster are viable tools to help young children increase their food knowledge and improve dietary behaviors. A follow-up randomized controlled trial will be conducted to assess the medium- and long-term effects of FoodRateMaster.

Descriptive Normative Nutrition Messages to Maximize Effect in a Videogame: Narrative Review

Messages containing descriptive norms have been manipulated and tested for effects on dietary intake in a number of studies. The effects have been mostly small or nonexistent. This narrative review analyzed the structural elements of the nutrition messages most likely related to effectiveness. Elements examined included the following: source, similarity of source to the participant, reference group, identification with or evaluative significance of the reference group, delivery, salience, background, tailoring, gain-loss framing, and whether an assessment of the group norm was conducted before designing the descriptive norm message. Most studies incorporated few of the reviewed structural elements, and message manipulations appeared weak. Controlled, systematic studies are needed to examine the effect of the structural elements, singly and in combination, on behavior and its mediators. Videogames are designed to be delivered in the same way to players; therefore, they offer a controlled environment for extensively and systematically manipulating structural elements of messages and examining the resulting behavioral effects. How this might be accomplished was described. Experimental research was identified as being necessary to delineate the individual and combined element effects, thereby contributing to the body of literature on videogame design and effectiveness.

A Meta-analysis of Narrative Game-based Interventions for Promoting Healthy Behaviors

Health interventions that use serious games have become increasingly popular. However, many of these games have been designed with few immersive game features which would improve users' engagement with the persuasive messages. To address this issue, researchers have incorporated narrative elements in games to facilitate message processing and enhance behavioral change. There have been theoretical debates about whether narratives benefit these interventions; empirical evidences for their effects are slightly mixed. This meta-analysis provides a deeper understanding of the overall impact of narrative game-based interventions on health-related behaviors and their psychological determinants. Combining the results from 22 studies, this meta-analysis found that narrative game-based interventions were effective in changing behaviors, knowledge, self-efficacy, and enjoyment. These effects were moderated by factors such as the genre of the game, the genre of the story, group play, and participant age. Implications of the findings and suggestions for future design of narrative game-based interventions were discussed.

Home-Based Exergaming on Preschoolers' Energy Expenditure, Cardiovascular Fitness, Body Mass Index and Cognitive Flexibility: A Randomized Controlled Trial

PURPOSE

The effects of exergaming-based physical activity (PA) interventions on preschoolers' health outcomes and cognition remain largely unexplored. Therefore, we conducted a randomized controlled trial to discern the effectiveness of a home-based educational exergaming intervention on preschoolers' energy expenditure, fitness, body mass index, and cognition.

METHODS

Participants were 32 preschoolers (16 girls; 59.4% Asian; M_age = 4.72, SD = ±0.73) recruited from the Twin Cities area in Minnesota. During baseline testing, we measured preschooler's daily energy expenditure (EE), cardiovascular fitness, body mass index, and cognitive flexibility using validated instruments. Participants were then randomly assigned to one of two conditions: (1) the exergaming intervention condition; or (2) control condition. The intervention program requested children participate in home-based educational exergaming using the LeapTV gaming console for at least 30 min/session 5 times/week. The control condition asked children to maintain regular PA patterns without any exergaming gameplay. Each condition lasted 12 weeks. We conducted identical outcome assessments for all children at baseline and post-intervention.

RESULTS

Analysis of covariance with repeated measures yielded significant time x group interaction effects for cognitive flexibility, Wilks' Lambda = 0.81, F(1, 29) = 6.98, p = 0.01, η² = 0.19, suggesting children in the exergaming group demonstrated significantly greater increases in cognitive flexibility as compared to those in the control group over time. There were no significant differences for time x group changes between the two groups for EE, Wilks' Lambda = 0.92, F(1, 29) = 2.29, p = 0.14, η² = 0.08; cardiovascular fitness, Wilks' Lambda = 0.96, F(1, 29) = 1.07, p = 0.31, η² = 0.04; and BMI, Wilks' Lambda = 0.99, F(1, 29) = 0.05, p = 0.82, η² = 0.01. However, our data did suggest a marginal effect of time for EE, Wilks' Lambda = 0.89, F(1, 29) = 3.26, p = 0.08, η² = 0.08, indicating that children's daily EE increased from baseline to post-intervention.

CONCLUSIONS

Home-based educational exergaming may positively impact cognitive flexibility in preschoolers. Studies with larger sample sizes in multiple geographic locations are needed, with our study suggesting a longer intervention period might also be warranted.

Obesity Prevention Interventions and Implications for Energy Balance in the United States and Mexico: A Systematic Review of the Evidence and Meta-Analysis

OBJECTIVE

Obesity is preventable and yet continues to be a major risk factor for chronic disease. Multiple prevention approaches have been proposed across multiple settings where people live, work, learn, worship, and play. This review searched the vast literature on obesity prevention interventions to assess their effects on daily energy consumed and energy expended.

METHODS

This systematic review (PROSPERO registration CRD42017077083) searched seven databases for systematic reviews and studies reporting energy intake and expenditure. Two independent reviewers screened 5,977 citations; data abstraction supported an evidence map, comprehensive evidence tables, and meta-analysis; critical appraisal assessed risk of bias; and the quality of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS

Hundreds of published reviews were identified. However, few studies reported on energy intake and expenditure to determine intervention success. Ninety-nine studies across all intervention domains were identified. Few areas demonstrated statistically significant effects across studies; school-based approaches and health care initiatives reduced energy consumed, education reduced energy consumed and increased energy expended, and social-group approaches increased energy expenditure.

CONCLUSIONS

Despite the amount of research on obesity prevention interventions, very few studies have provided relevant information on energy intake and expenditure, two factors determining weight gain. Future research needs to fill this gap to identify successful public health policies.

Short-Term Effects of the Serious Game "Fit, Food, Fun" on Nutritional Knowledge: A Pilot Study among Children and Adolescents

“Serious games” are a novel and entertaining approach for nutritional education. The aim of this pilot study was to evaluate the short-term effectiveness of “Fit, Food, Fun” (FFF), a serious game to impart nutritional knowledge among children and adolescents. Data collection was conducted at two secondary schools in Bavaria, Germany. The gameplay intervention (gameplay group; GG) consisted of a 15-minute FFF gameplay session during each of three consecutive days. The teaching intervention (teaching group; TG) was performed in a classic lecture format. Nutritional knowledge was evaluated via questionnaires at baseline and post-intervention. Statistical analyses were performed using R (R Core Team, 2018). In total, baseline data were available for 39 participants in the GG and 44 participants in the TG. The mean age was 13.5 ± 0.7 years in the GG and 12.8 ± 0.9 years in the TG. There was a significant (p-value < 0.001) improvement in nutritional knowledge in both intervention groups. Moreover, a between-group difference with a significantly (p-value = 0.01) higher increase in nutritional knowledge was detected for the TG. This pilot study provides evidence for the short-term effectiveness of both educational interventions on the improvement in nutritional knowledge. Finally, the FFF game might be an adequate educational tool for the transfer of nutritional knowledge among children and adolescents.

Jogos eletrônicos na atenção à saúde de crianças e adolescentes: revisão integrativa

Resumo No contexto atual encontramos brincadeiras que envolvem tecnologias avançadas, como o uso de notebooks, smartphones e videogames, sejam no cenário hospitalar, ambulatorial, em clínicas ou em casa, esses dispositivos inovadores estão inseridos na promoção, prevenção, tratamento e recuperação da saúde. Diante do exposto, este estudo tem como objetivo descrever através de revisão integrativa a utilização de jogos eletrônicos na atenção à saúde da criança e adolescentes. Trata-se de uma revisão da literatura nacional e internacional, dos artigos publicados entre os anos de 2007 a 2017, que abordam as implicações do uso de jogos eletrônicos. A coleta de dados foi realizada no período entre janeiro e abril de 2018, por meio de consulta na Biblioteca Virtual em Saúde (BVS), selecionando-se as bases de dados (MEDLINE, LILACS e BDENF) utilizando os Descritores em Ciências da Saúde (DeCS), pela Biblioteca Virtual em Saúde (BVS). Foram utilizados os seguintes descritores: “Criança hospitalizada/ Child Hospitalized”; “Jogos de vídeo/Video Games”; “Promoção da saúde/Health Promotion”. A análise foi realizada a partir da amostra final com 11 artigos. Diante dos achados, foi possível identificar que a literatura aborda questões relacionadas na utilização de jogos eletrônicos. Temáticas relacionadas com promoção, prevenção, tratamento e recuperação da saúde em situações de doenças crônicas e o estímulo de atividades físicas, foram evidenciados no estudo. Com isso, percebe-se a relevância que os profissionais de saúde, em especial os de enfermagem, têm em saber que os jogos eletrônicos podem auxiliar no cuidado de crianças com doenças agudas ou crônicas, que estejam ou não hospitalizadas.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Food habits during treatment of childhood cancer: a critical review

Several factors can affect the nutritional status of children undergoing cancer therapy. The present review aims to describe children’s food intake during cancer treatments and to explore the contributing determinants. It also assesses the nutritional educational interventions developed for this clientele. Scientific literature from January 1995 to January 2018 was searched through PubMed and MEDLINE using keywords related to childhood cancer and nutritional intake. Quantitative and qualitative studies were reviewed: forty-seven articles were selected: thirty-eight related to food intake and parental practices and nine related to nutritional interventions. Patients’ intakes in energy, macronutrients and micronutrients were compared with those of healthy controls or with requirement standards. Generally, patients ate less energy and proteins than healthy children, but adhered similarly to national guidelines. There is a lack of consensus for standard nutrient requirement in this population and a need for more prospective evaluations. Qualitative studies provide an insight into the perceptions of children, parents and nurses on several determinants influencing eating behaviours, including the type of treatment and their side effects. Parental practices were found to be diverse. In general, savoury and salty foods were preferred to sweet foods. Finally, most interventional studies in childhood cancer have presented their protocol or assessed the feasibility of an intervention. Therefore, because of the variability of study designs and since only a few studies have presented results, their impact on the development of healthful eating habits remains unclear. A better understanding of children’s nutritional intakes and eating behaviours during cancer treatment could guide future nutritional interventions.

Nutrition Education and Dietary Behavior Change Games: A Scoping Review

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.

Healthy eating interventions delivered in the family home: A systematic review

Unhealthy eating habits have long term health implications and can begin at a young age when children still consume the majority of their meals at home. As parents are the principal agents of change in children's eating behaviours, the home environment is the logical location for the delivery of interventions targeting healthy family eating. Despite the recent proliferation of published studies of behaviour-change interventions delivered in the home, there has been little attempt to evaluate what makes such interventions successful. This review provides a systematic evaluation of all healthy eating interventions delivered to families in the home environment to date and seeks to identify the successful elements of these interventions and make recommendations for future work. Thirty nine studies are described, evaluated and synthesised. Results show that evidence- and theory-based interventions tended to be more successful than those that did not report detailed formative or evaluative work although details of theory application were often lacking. Careful analysis of the results did not show any further systematic similarities shared by successful interventions. Recommendations include the need for more clearly theoretically driven interventions, consistent approaches to measuring outcomes and clarity regarding target populations and desired outcomes.

Videogames That Encourage Healthy Behavior Did Not Alter Fasting Insulin or Other Diabetes Risks in Children: Randomized Clinical Trial

Background: Previous research indicates games for health have substantial promise in promoting change in children's diet and physical activity (PA) behavior for obesity and diabetes prevention, but the research has generally not been rigorous. The study reported here was an efficacy trial of two role-playing videogames played in sequence, "Escape from Diab" (hereinafter called Diab) and "Nanoswarm: Invasion from Inner Space" (hereinafter called Nano), on diabetes and obesity risk factors: fasting insulin and body mass index (BMI), and risk-related behaviors: diet, PA, and sedentary behavior (SB). Design: A two-group (treatment vs. wait list control) randomized clinical trial was used with baseline, immediate postintervention (∼3 months postbaseline), and 2 months postassessments. Intervention: Diab and Nano were desktop or laptop role-playing videogames with nine sessions (each episode/session lasting ∼60 minutes). Two storylines attempted to immerse players and used ethnically diverse characters to model desired behaviors. Tailored goal setting, problem solving, and motivational statements were used. Methods: A sample of 200 overweight or obese children (ages 10-12 years from 85th to 99th BMI percentile [%ile]) was recruited, primarily using a volunteer list. Fasting insulin was the primary dependent variable. BMI, fruit, vegetable and sweetened beverage intakes, PA, and SBs were secondary outcomes. Generalized linear mixed models were used to test for the treatment effects. Results: No significant differences were detected in any of the tested outcome variables. Conclusions: The lack of differences may indicate that games cannot change dietary behaviors and thereby not change-related clinical outcomes. Alternatively, there seem to have been changes in (1) the types of videogames children expect and like to play since a pilot study was conducted, (2) productization challenges, and/or (3) problems in staff management of the trial. All may have contributed to the lack of effect.

Digital Gaming for Nutritional Education: A Survey on Preferences, Motives, and Needs of Children and Adolescents

Background

Use of novel information and communication technologies are frequently discussed as promising tools to prevent and treat overweight and obesity in children and adolescents.

Objective

This survey aims to describe the preferences, motives, and needs of children and adolescents regarding nutrition and digital games.

Methods

We conducted a survey in 6 secondary schools in the southern region of Germany using a 43-item questionnaire. Questions referred to preferences, motives, and needs of children and adolescents regarding nutrition and digital games. In addition, knowledge regarding nutrition was assessed with 4 questions. We collected self-reported sociodemographic and anthropometric data. Descriptive statistical analyses were performed using SPSS.

Results

In total, 293 children and adolescents participated in the study, with ages 12-18 years (137 girls, 46.8%), weight 30.0-120.0 (mean 60.2 [SD 13.2]) kg, and height 1.4-2.0 (mean 1.7 [SD 0.1]) m. A total of 5.5% (16/290) correctly answered the 4 questions regarding nutrition knowledge. Study participants acquired digital nutritional information primarily from the internet (166/291, 57.0%) and television (97/291, 33.3%), while school education (161/291, 55.3%) and parents or other adults (209/291, 71.8%) were the most relevant nondigital information sources. Most participants (242/283, 85.5%) reported that they regularly play digital games. More than half (144/236, 61.0%) stated that they play digital games on a daily basis on their smartphones or tablets, and almost 70% (151/282, 66.5%) reported playing digital games for ≤30 minutes without any interruption. One-half of respondents (144/280, 51.4%) also stated that they were interested in receiving information about nutrition while playing digital games.

Conclusions

This survey suggests that nutrition knowledge in children and adolescents might be deficient. Most children and adolescents play digital games and express interest in acquiring nutritional information during digital gameplay. A digital game with a focus on sound nutrition could be a potential educational tool for imparting nutrition knowledge and promoting healthier nutrition behaviors in children and adolescents.

An Internet-Based Childhood Obesity Prevention Program (Time2bHealthy) for Parents of Preschool-Aged Children: Randomized Controlled Trial

Background

Electronic health (eHealth) obesity programs offer benefits to traditionally delivered programs and have shown promise in improving obesity-related behaviors in children.

Objective

This study aimed to assess the efficacy of a parent-focused, internet-based healthy lifestyle program for preschool-aged children, who are overweight or at or above the fiftieth percentile for body mass index (BMI) for their age and sex, on child BMI, obesity-related behaviors, parent modeling, and parent self-efficacy.

Methods

The Time2bHealthy randomized controlled trial was conducted in Australia, during 2016 to 2017. Participants were recruited both online and through more traditional means within the community. Parent or carer, and child (aged 2-5 years) dyads were randomized into an intervention or comparison group. Intervention participants received an 11-week internet-based healthy lifestyle program, underpinned by social cognitive theory, followed by fortnightly emails for 3 months thereafter. Intervention participants set goals and received individual feedback from a dietitian. They were also encouraged to access and contribute to a closed Facebook group to communicate with other participants and the dietitian. Comparison participants received email communication only. Objectively measured child BMI was the primary outcome. Secondary outcomes included objectively measured physical activity, parent-measured and objectively measured sleep habits, and parent-reported dietary intake, screen time, child feeding, parent modeling, and parent self-efficacy. All data were collected at face-to-face appointments at baseline, 3 months, and 6 months by blinded data collectors. Randomization was conducted using a computerized random number generator post baseline data collection.

Results

A total of 86 dyads were recruited, with 42 randomized to the intervention group and 44 to the comparison group. Moreover, 78 dyads attended the 3- and 6-month follow-ups, with 7 lost to follow-up and 1 withdrawing. Mean child age was 3.46 years and 91% (78/86) were in the healthy weight range. Overall, 69% (29/42) of participants completed at least 5 of the 6 modules. Intention-to-treat analyses found no significant outcomes for change in BMI between groups. Compared with children in the comparison group, those in the intervention group showed a reduced frequency of discretionary food intake (estimate −1.36, 95% CI −2.27 to −0.45; P=.004), and parents showed improvement in child feeding pressure to eat practices (−0.30, 95% CI 0.06 to −0.00; P=.048) and nutrition self-efficacy (0.43, 95% CI 0.10 to 0.76; P=.01). No significant time by group interaction was found for other outcomes.

Conclusions

The trial demonstrated that a parent-focused eHealth childhood obesity prevention program can provide support to improve dietary-related practices and self-efficacy but was not successful in reducing BMI. The target sample size was not achieved, which would have affected statistical power.

Trial Registration

Australian New Zealand Clinical Trials Registry ANZCTR12616000119493; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370030 (Archived by WebCite at http://www.webcitation.org/74Se4S7ZZ).

Participant Outcomes from Methods of Recruitment for Videogame Research

OBJECTIVE

The most productive methods of recruitment for a videogame for health (G4H) trial are not known. Success or failure of recruitment methods has been reported for a variety of clinical trials, but few specifically for G4H trials. This study's goal was to recruit 444 overweight or obese (body mass index percentile between the 84.5th-99.4th percentiles) children between the ages of 10-12 years. The article reports the results of different methods of participant recruitment.

MATERIALS AND METHODS

Participants had to agree to three fasting blood samples (baseline, immediately after, and 2 months later); be willing to wear an accelerometer for 7 days at each assessment; read and speak English fluently (because the games were in English); have no history of any condition that would affect what he/she could eat or how much physical activity he/she could get; and have an eligible home computer purchased in the last 5 years with high-speed internet. Hardware criteria reflected the types of computers upon which Diab-Nano could be effectively played. Recruitment was conducted over a 35-month period and included electronic media, print advertising, community recruitment, and an internal volunteer list. Respondents were guided to a web-based screening questionnaire that asked for source of hearing about the study.

RESULTS

Although diverse recruitment methods were used, slow recruitment resulted in obtaining only 45% of the recruitment goal (n = 199). Electronic media (e.g., radio, television, and internet), which reached millions of targeted parents, resulted in only 76 respondents, of whom 13 became participants; print media (e.g., magazine, newsletter/newspaper, and mail), which also reached large numbers of parents, resulted in 192 respondents, of whom 19 became participants; community recruitment (e.g., school, friend or family, doctors office, flyer, work, community program) resulted in 162 respondents, of whom 38 became participants; and the internal volunteer list resulted in 413 respondents, of whom 128 became participants.

CONCLUSION

Inclusionary and exclusionary criteria and restricted access by gatekeepers could be deterrents to successful recruitment. The documented payoff of alternative comprehensive methods of recruitment should benefit other investigations in optimally allocating their recruitment resources.

Fruits and vegetables embedded in classic video games: a health-promoting potential?

The proliferation of the video game era has increased sedentary behaviours among children and adolescents. Contemporary interventions involve the use of video games to introduce fruit and vegetable (F&V) consumption among children and adolescents. A comprehensive list of licenced video games (n = 671) released for the Nintendo Entertainment System (NES) console were reviewed for thematic content and qualitative characteristics of the game's activity relevant to F&V. Seventy-five video games were included in the study sample and categorised by release year, prevalence of F&V, and thematic content. Mild associations were found comparing release year to F&V totals (r = 0.21) and release year to theme (r = 0.19). F&V themes embedded within classic video games could serve as health-promoting lessons for forthcoming video games. Future games produced by the video gaming industry should continue to focus on nutrition-embedded messages promoting F&V. Video game development and marketing could be an avenue that incorporates healthy nutrition themes.

Serious games as an educational strategy to control childhood obesity: a systematic literature review1

Objectives:

to identify in the literature the efficacy of serious games to improve knowledge for and/or behavioral changes among overweight or obese children.

Method:

Systematic Literature Review. The Cochrane Systematic Reviews Handbook was used. The studies were collected from the following databases: Public Medline; Web Of Science; Science Direct; Latin American and Caribbean Health Sciences Literature; and the Health Game Research and Cumulative Index to Nursing & Allied Health Literature. The descriptors were video games and obesity, while the key word was serious games. Inclusion criteria were: studies classified as Randomized Clinical Trials written in English, Spanish or Portuguese and in which children were the subjects of the study.

Results:

2,722 studies were identified in the initial search and six studies remained in the final sample. The papers focused on encouraging behavioral changes in players, including physical exercise and improved eating habits. The studies report that serious games are a potential strategy to encourage positive coping with childhood obesity.

Conclusion:

research in this field is an expanding and promising strategy and serious games represent an alternative means to provide health education to children.