Abstract
Objective
This paper reviews the recent gamified interventions that focus on the dietary factor to explore the effectiveness of using gaming elements in combating the prevalence of childhood obesity.
Methods
Two electronic databases were searched (PubMed and ProQuest); to identify the relevant papers published between 2018 and 2021. The keywords that use to search the entire selected databases were gamification and obesity. There were no restrictions regarding the language. Two independent reviewers screened the titles, abstracts, and keywords for relevance.
Results
407 papers were identified initially, while only 18 articles met the inclusion criteria. Most of the included articles indicated the positive impact of gamification on changing children eating behaviors. This systematic review summarizes the theories followed in developing such interventions and suggests some other theories to use and follow. Moreover, we synthesized the main findings into six recommendations that would assist in combating the global concern regarding childhood obesity if IS/IT researchers and other implement them during the development of any IT intervention.
Conclusions
Using gamification and gaming elements in imparting nutritional knowledge to children and improving their eating habits and behaviors is considered effective generally. It provides them with the needed knowledge and promotes the acquisition of better habits within enjoyable environment.
Introduction
Childhood obesity is considered as an international concern. During the past years, the number of obese children dramatically increased. Globally, by 2025, the estimates indicate that the number of children who will be affected by obesity is around 200 million children. 1 Childhood obesity results in many burdens including economic losses and the rise of health risks. Being obese steadily increases the probability of a wide range of diseases for both children and adults. It increases the risk of heart problems, type 2 diabetes, different cancers, and many other diseases.2–4 More seriously, it also causes human losses where 2.8 million people around the world die yearly as a consequence of obesity. 5 These consequences are a call for serious action for combating this crisis, treating obesity sufferers, besides launch effective interventions to prevent it.
During this technology era, knowledge seems to be everywhere and can be accessed anytime, that considered true for nutritional information. 6 However, that information is not necessarily reached by all children, or it might be reached but come in a difficult to understand form like if it was written using complex words. However, taking into consideration the long-time children spend using mobiles, tablets, or different devices, and the enjoyment they have during playing various games. It has been clearly found that this time can be utilized for adopting good eating habits and acquiring plentiful nutrition information. IT-related interventions to reduce childhood obesity varied, it includes health education with regard to eating habits, nutrition, and/or physical activity.7,8
This article goes beyond that and reviews the recent gamified interventions that focusing on the dietary factor to explore the effectiveness of using gaming elements in combating the prevalence of childhood obesity, which is the aim of this study. The rest of the article is structured as: second section presents the methodology of the study; third section shows the results found in reviewed papers; fourth section discusses those results; finally, the conclusions are illustrated in the fifth section.
Methodology
Research questions
Using gamification or gamified tools outside the gaming context is not totally new. Gamification uses since many decades ago in various fields through numerous manners and with different aims. This article followed 9 five steps in conducting a systematic review research, which are: (a) framing the review's question; (b) identifying relevant work; (c) assessing the studies’ quality; (d) summarizing the evidence; and (e) interpreting the finding. Thus, as a first step, this research mainly answering the following questions: (a) What is the state of adopting gamification in combating or preventing childhood obesity? (b) What are the recent gamified solutions used to combat obesity regarding dietary factor? and What are their effectiveness in combating or preventing the prevalence of childhood obesity? (c) And what are the commonly used theories in designing IT solutions for combating childhood obesity related to dietary factor?
Search strategy
To identify the relevant work, this review has been conducted with the respect to systematic literature review guidelines.10,11 Two databases selected, PubMed and ProQuest based on the top recommendations of Murdoch University for best databases for conducting systematic reviews. However, Cochrane Library is ignored because it provides similar results to what was found in PubMed. Two keywords used to search the entire selected databases which are: gamification and obesity. Thus, the following search term were used: “gamification and obesity”. The review covers only the scholarly publications published between 2018 and 2021 with no language restrictions applied. After defining the timeframe and search terms, it was applied for both databases during November 2020, and updated later in June 2021. After the preliminary search, duplicate articles were removed and then a set of inclusion\exclusion criteria were defined as describes below. Results obtained from the electronic search were downloaded and managed using EndNote X8 bibliographic software.
Inclusion and exclusion criteria
A set of inclusion and exclusion criteria is defined to objectively select the articles that will be studied further. The inclusion criteria are as follows:
Conferences and journals papers. Papers published between 2018 and 2021. Papers that proposed gamified solutions to combat obesity with a focus on dietary and eating factors. Papers that discuss gamified solutions to combat obesity with a focus on dietary and eating factors.
While the exclusion criteria are:
Papers not addressing or discussing obesity gamified solutions. Papers focusing on promoting physical activity or solving other obesity factors.
Identifying relevant work and assessing quality
Firstly, focusing on titles, abstracts, and keywords two independent reviewers (ASA and HB) performed an initial screening for articles and categorized them into eligible, not eligible, or uncertain. The articles were selected based on if they met the inclusion criteria or not. To confirm the article eligibility, all articles under the eligibility and uncertain categories were fully read independently. Finally, the two reviewers met to discuss which articles to include in the final review and reached a consensus.
Results
As stated earlier, after extracting the articles from the defined databases, it has been screened and then reviewers made decision of including or excluding each one. The number of extracted articles was 407, among which 380 were extracted from PubMed and 27 from ProQuest. And 5 articles were eliminated in initial screening because of the duplication. The remaining articles were explored against inclusion\exclusion criteria. One record was excluded because it has no sufficient details, while 383 were excluded, because it violated inclusion/exclusion criteria which stated previously under Methodology section. 348 of these excluded records are out of this review scope, 20 records focused on the physical activity factor, 10 records do not propose or discuss any gamified solution, while 5 records are targeting adult rather than children. However, 18 articles were qualified to be studied deeply in this review. Figure 1 illustrates the selection process using PRISMA flow diagram.
The selection process using PRISMA flow diagram.
Table 1 summarizes all included studies, focusing on the used solution, theory, targeted age, language, and results. After that, the review results of the included articles are illustrated in detail under four subsections.
The summarization of the included studies in terms of solution description, used theory, targeted age, language, and results.
The state of adopting gamification in combating or preventing childhood obesity
This review found that many recent studies related to combat childhood obesity involved one or more gaming element. All studies (n=18; 100%) included in this review adopt at least one gaming element, but the employment method is differing from one study to another. For example, some interventions are designed as a standalone gaming environment like a serious or educational game for nutritional knowledge imparting (n=2; 11.11%)16,18; other interventions used the gaming element as supporting activity within training sessions or classes (n=3; 16.67%)13,17,21; also some studies embraced gamification in educational or coaching platforms (n=6; 33.33)12,14,15,19,20,22; the remain studies were review papers that reports the commonly used theories in related studies, exploring the consequences of adopting different gaming elements in such interventions (n=7; 38.89%)23–29; all that will be described in detail below.
The effectiveness of the recent gamified solutions used to combat obesity regarding dietary factor
As stated earlier, the studies employee gamification and gaming elements in different methods. PEGASO system is an adoption of gamification in enhancing people’s lifestyles including their dietary habits, nutritional knowledge, and other health aspects like activity rates. 12 PEGASO aims to increase user's engagement and stimulate their motivation to maintain a healthy lifestyle, which was done through rewarding good behaviors and cyclic improvements with points, coins, and badges. The effect of PEGASO on preventing the development of chronic diseases is not proven, however, the positive influence of the system on participants was very clear. Moreover, two studies concluded with the same results, where increasing the children engagement within healthy behavioral applications through gamification showed positive results.14,15 Both interventions proved that the use of gamification is boosting children motivation and help in gaining better outcomes. Another intervention is Aim2Be, which aim to improve different health indicators of participated children such as their body mass index (BMI) and enhance their eating behaviors like increasing vegetable intake and reduce sweet consumption. 19 This study is still ongoing and has no clear results until now. Gaming elements and dynamics also embraced within a mobile application that aim to impart knowledge about healthy diet and acceptable physical activity rates. 20 The results were not very reliable but even so, the positive implication of add rewarding-points cannot be ignored. Another study proposed a self-monitoring application that monitors six behaviors including (diet, physical activity rate, smoking, alcohol usage, screen time, and sleep quality) and link the related risk behaviors with chronic diseases. 22 The study results in proving that the use of notifications and rewards have a positive impact on changing poor health behaviors and therefore preventing chronic diseases like obesity.
In another way, gamification used the flipped classes concept in primary education school to motivate students about learning healthy habits and basics of the balanced diet. 13 The study is observing and investigating the development of those classes. The study indicated that students’ autonomy is enhanced, and they showed high levels of self-regulation during this experience. Another article was exploring the SI! Program. 17 SI! is an online course for children that using gaming elements including points and rewards to impart awareness about healthy lifestyles and instill sustained good behaviors. SI! covers many aspects where besides the dietary knowledge it also promotes cut-off smoking and increasing physical activity levels. In spite of the hard work spent on developing this game, it is not widely tested, so its results are still not reliable and need more analysis and proofs. Similarly, the Food Dudes program designed to enhance children's nutrition. 21 The program including classes and adopted gaming elements like rewards and scenarios has a significant positive impact on children's nutrition where they consumed more fruit and vegetables. Besides that, the children consumed lower ranges of fat and total energy.
With regard to using gamification elements within a whole gaming environment, one article expounds on the critical enhancements that resulted from developing an educational video game with regard to adherence to the Mediterranean diet and healthy nutrition. 16 The game is targeting obese children and aims to offer them the needed nutritional knowledge. Children's measurements were taken at three different phases: intervention phase, immediate follow up, and long-term follow up then the data analyzed. The analysis proved that the game is helped to increase children's adherence. Another study demonstrated the evaluation of “Fit, Food, Fun” game, which is a serious game that also aims to spread nutritional knowledge among children. 18 The evaluation results showed that the nutritional knowledge of both testing groups is significantly improved. However, the group that educated with teacher assistance gained better results.
The review articles included in this review summarized as, one pilot study was conducted to determine the impact of games on changing children eating behavior regarding fruit and vegetable consumption. 23 This study found that the use of gaming elements in introducing nutritional knowledge gets increasing attention over the past few decades. The study also proved that gamification has a positive impact on changing eating behaviors of children. While regarding the general guidelines of applying gaming elements, a review was done on games, applications, social media, and other digital tools related to nutritional information and food safety to explore the characteristics of these tools and their limitations. 24 The review described the essential rules that must be followed while designing similar applications or information and communications technology (ICT). The authors also stated that developed tools can take the advantage of using social incentives and heavy promotion to stimulate the target segment. The study also highlighted that 59% of covered tools are reported with positive implications. Another review was done and concluded with the same results. 25 The difference is the last review 25 only covered the trials that done with the aim of maintaining weight loss. Furthermore, another study suggested considering the surrounding family environment too. 26 This study indicated the role of the household environment to support the adolescents’ adherence to guidelines and encourage them during their health behaviors changing journey. Further, there is a study concluded in proving that the adoption of gaming or interactive elements in health programs could effectively improve the conditions and facilitating the achievement of the objectives. 27 Where the second round of usability tests of the application they investigate (where the gamification embraced) revealed better results than the first one. This study also highlighted five aspects that must be considered during the development of health knowledge and awareness ICTs, which are: appearance, content accuracy, navigation smoothness, and engagement level. Another study investigated the use of MyFitnessPal app in order to define the general appropriations of nutritional applications. 28 It concluded with highlighting the Normative Social Behavior and Planned Behavior theories as commonly used in designing the eating behaviors change interventions. Unexpectedly it also stated that both interactions, feedback, and competition do not always affect user's responses, although it is typically associated with health-related ICTs and interventions. A different study hypothesized that user engagement and adherence may be affected by user gender. It resulted that the use of gamification within weight loss would be stronger for men than for women. 29
The commonly used theories in designing solutions for combating childhood obesity related to dietary factor
Different theories were used as guidance for designing childhood obesity combating interventions. The developers of PEGASO system used two theories combinedly for designing their intervention, which are Behavior Change Wheel (BCW) and Capability-Opportunity-Motivation-Behavior (COM-B). 12 While 15 designed their approach for health promotion in obese children based on Self-Tracking of Data relying on quantified-self theory. Another used theory is the Change Starts from Baseline theory which is used by the developer of SI! program to design their online course. 17 In a different way, the coaching app 19 combined between three theories in designing the intervention which are Behavior Change, Social Cognitive and Self-Determination. Self-Determination theory has also been used within designing the gamified flipped classes. 13 However, the extensive review 25 indicated that Social Cognitive theory were used by most of the articles covered in their review. Moreover, the review 26 confirmed that both Social Cognitive and Self-Determination theories are commonly used in behavior modification interventions with regard to adolescent's lifestyle. Differently, the intervention of lifestyle self-monitoring 22 used the Social Influence theory for designing the proposed mobile application. Finally, the pilot study 23 proved the positive impact of gamification on changing children eating behaviors based on the Zone of Proximal Development theory.
The effectiveness of using the gamification in imparting nutritional knowledge in combating or preventing the prevalence of childhood obesity
Generally, adopting gamification proved its effectiveness in many different fields including health, education, marketing, and much more. One of the aims of this review is to examine the effectiveness of utilizing gamification or gaming elements for preventing and combating childhood obesity. Firstly, the adoption of gaming element13,16,22,23 proved its impact on changing the children’s eating behaviors positively. In addition, some studies indicated an increase in the children self-regulation and their adherence to the dietary guideline.13,16 Secondly, some studies focused on the use of cartoons and music considered as an attractive element that utilize the children's stimuli to promote the acquisition of good long-term eating habits and simplifying the nutritional knowledge imparting.18,21 That is considered also true for the use of points and other rewarding methods.20–22 As a consequence, children’s BMI and other medical parameters like blood pressure indicated an improvement, where some children recorded lower BMI and better blood pressure rates.14,15
To summarize, gamification proved its positive impact on boosting children motivation15,16 and increasing their engagement. 22 In another word, the usage of gaming elements in childhood obesity-related interventions is highly recommended for effective prevention of childhood obesity in addition to treat obese children suffer. However, the gaming elements like background music, used colors should be investigated deeper to match the targeted age, gender, and educational preferences to be more effective.
Discussion
IT solutions for combating childhood obesity varied, as well as the employment of gaming elements in those solutions differ too. This review detected that some solutions were designed basically in a gaming environment, for example serious games and educational games.16,18 Otherwise, there were solutions that employ one or more gaming element to facilitate the knowledge impartment or increase user interaction only, such as gamified courses and educational videos.13,17,21 However, some studies used a mixed approach to explore the difference.
Regarding the theories used for designing the solutions, this review found that Self-Determination13,19 and Social Cognitive19,25 were the most used theories. Moreover, the covered review articles indicate that these two theories were commonly used in many different related interventions.19,26
Each one of them has been used in three different studies. Other used theories were Zone of Proximal Development, 23 BCW and COM-B, 12 Quantified-Self, 15 Change from Baseline, 17 Behavior Change, 19 Normative Social Behavior and Planned Behavior, 28 and Social Influence. 22 Eight out of 18 reviewed studies did not mention any theory explicitly.14,16,18,20,21,24,27,29 However, specifying the used theory or model can help in promoting gamified obesity combating solutions by providing a baseline for designing, implementing, and evaluating similar interventions. Other theories that can be followed in designing an intervention for promoting a healthy habits and good eating behavior are FOGG Behavioral Model, 30 Health Belief Model, 31 and Operant Conditioning 32 since it have been used successfully in different fields and proved its effectiveness in behavior change promotion.
In addition, most of the proposed solutions reviewed are broad and targeting a wide age range while narrowing the targeted age range would lead to better results. Developing such an intervention for a specific, well-defined age frame (e.g. primary school age, middle school age, etc.) will make it more effective and provide extra advantages. By considering the reading level of the targeted age range , besides involving attention stimuli that match their preferences like cartoons and musical backgrounds. 33
Furthermore, this study also found that most of the obesity combat interventions based on dietary factor are targeting English speakers only. Ten studies were targeting English speakers,12,17,19–22 while two were designed for German.18,28 Other languages need more attention where the language considered a barrier for non-English-speaking children in such interventions. 34 That allows researchers from non-native English-speaking countries to search the field more and make real efforts regarding combating this global epidemic.
More importantly, almost all studies prove the positive implication of the usage of different gaming elements as an intervention for prevent, combat, and treating obesity suffers.13–15,18,21,22,24,25,27 Children food behavior positively changed after acquiring the needed nutritional knowledge, also their self-regulation and adherence increased.13,16,22,23 Moreover, children health parameters improved in some cases, for example some children recorded lower blood pressure ranges after being nutritionally educated.14,15 The musical background, use of cartoons, and attention stimuli like collecting points and rewards had its positive impact on encouraging children for adopting good eating habits and facilitating their nutritional education.20–22
All work done regarding childhood obesity and associated problems including IT and non-IT interventions is appreciated. However, more research and hard work need to combat this global concern. We synthesized the main findings of this systematic review into six recommendations that can be used by researchers, designers, developers, and healthcare authorities to design and develop other childhood obesity combating interventions: (1) design the intervention relying on a well proven theory, (2) narrowing down the targeted age range, (3) adding customization and tailored features, for example enabling translating to other languages, (4) applying some design features and try to address any cultural issues, (5) employing ready-made tools if there is any, and finally (6) benefiting from others work and not start from scratch.
Conclusion
This article reviewed the recent studies related to using gamification for combating and preventing childhood obesity. Only 18 articles from the 2 selected databases reviewed since these research papers matched the inclusion/exclusion criteria, other articles discussed health informatics in general, or other complex healthcare problems like psychiatry. While this review focus only on the use of dietary factor for combating the childhood obesity with excluding the analysis of general children's lifestyles or their activity levels.
The articles extracted from the selected databases were mostly discussing general healthcare problems, thus resulted in a limited number of papers to be analyzed and that considered one limitation of this review. Thus, as a future direction including other databases will aid in increasing the number of included articles, as well as having different results. Also, as a future direction more research terms will be used, such as m-health, health informatics, nutrition education, etc. The usage of more variety of terms will hopefully assist in having different articles that match the research aims.
To conclude, using gamification and gaming elements in imparting nutritional knowledge to children and improving their eating habits and behaviors is generally considered effective. It provides them with the needed knowledge and promotes the acquisition of better habits within enjoyable environment.
Footnotes
Acknowledgement
We sincerely appreciate our university for the insight, expertise and encouragement provided to us which greatly assisted the completion of this research.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Guarantor
ASA.
Contributorship
ASA contributed to the foundation of the original idea, acquisition, analysis or interpretation of data and manuscript writing. HB contributed to the foundation of the original idea, supervision, revised article critically for important intellectual content.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
