nongame use of computers, and 2.3 hours watching television
or other passive leisure.1 On weekend days, they spend 0.75
hours per day playing video games, 0.35 hours in nongame
computer use, and 3.5 hours watching television or other pas-
sive leisure.1 Much of this media use involves programming
that discourages physical activity and promotes unhealthy
dietary practices.2,3 Recently, efforts have been made to use
electronic media to promote healthy eating, physical activ-
ity, and weight control among children. Although electronic
media have been shown to increase knowledge in regard
to diet, physical activity, and obesity,4 promoting behavior
change is substantively more challenging than increasing
knowledge alone.5 electronic procedures for behavior change
can be classified into five general categories: (1) Web-based
educational/therapeutic programs (et), (2) tailored message
(tM) systems, (3) data monitoring and feedback (DMF)
systems, (4) active video games (AVG), and (5) interactive
multimedia involving games (iMG).
hildren are heavy users of electronic media. On week-
days, children 5–9 years old spend an average of 0.5
hours per day playing video games, 0.25 hours in
Types of Electronic Media
for Child Health Promotion
Web-based et programs take programs commonly
designed for delivery in individual or group education or
therapy sessions and place them on the web where par-
ticipants can read the text online. such a program allows
participants to engage the materials at their own times and
paces. et programs may employ e-mail reminders, but
otherwise minimize the multimedia and data-processing
capabilities of the internet. sb2-beD was a 16-week-long
internet program delivered to overweight or obese high
school students that incorporated principles of cognitive
behavior therapy, educational weight loss, awareness of
satiety, emotional regulation, and self-control procedures
(e.g., behavior self-monitoring, goal setting).6 Participants
(in comparison to a wait-list control) experienced mod-
est reductions in bMi at the end of the program and at a
5-month follow-up.6 effects might have been greater if
there had been greater participation in the online activities
(only 27% of participants used some online component
for 8 weeks or more), suggesting participants were not
February 2012 | Volume 8, Number 1
© Mary Ann Liebert, Inc.
United States Department of Agriculture Agricultural Research Service (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics,
Baylor College of Medicine, Houston, TX.
Most children, including lower socioeconomic status and ethnic minority children, play video games, use computers, and have
cell phones, and growing numbers have smart phones and electronic tablets. they are comfortable with, even prefer, electronic
media. Many expect to be entertained and have a low tolerance for didactic methods. thus, health promotion with children needs to
incorporate more interactive media. interactive media for weight control and health promotion among children can be broadly clas-
sified into web-based educational/therapeutic programs, tailored motivational messaging systems, data monitoring and feedback
systems, active video games, and diverse forms of interactive multimedia experiences involving games. this article describes the
primary characteristics of these different technological methods; presents the strengths and weaknesses of each in meeting the needs
of children of different ages; emphasizes that we are in the earliest stages of knowing how best to design these systems, including
selecting the optimal requisite behavioral change theories; and identifies high-priority research issues. Gaming and technology offer
many exciting, innovative opportunities for engaging children and promoting diet and physical activity changes that can contribute
to obesity prevention and weight loss maintenance. Research needs to clarify optimal procedures for effectively promoting change
with each change procedure.
Let’s Get Technical!
Gaming and Technology for Weight Control
and Health Promotion in Children
Tom Baranowski, PhD and Leslie Frankel, PhD
CHI 8.1 Feb 12 v8.indd 341/23/12 3:11 PM
CHILDHOOD OBESITY February 2012
motivated to maintain engagement in this type of online
program. Given the self-paced structure of the interven-
tion6 and the broad-based and sophisticated skills required
of participants, it appears unlikely that such a program
could be developmentally appropriately designed for chil-
dren younger than high school.
tM systems were among the first behavior change pro-
grams that used computing capabilities. tM asked ques-
tions about what behavior a participant usually did, and
why or why not. Using an “expert system,” tM then pro-
vided messages encouraging a particular health behavior
that person indicated she would most likely do, using rea-
sons that would be most persuasive for her,7 and suggesting
actions for overcoming problems she identified. initially,
tM involved text messages on paper or computer screens,8
but tailored video-based messages are being developed,9
and tM has subsequently been incorporated into many
other types of systems. tM for children has been devel-
oped as text messaging on cell phones to enhance weight
control among adolescents,10 and as tailored story books to
encourage dietary change among 7–10 year olds.11 Adoles-
cents wanted only positive encouraging messages, because
they reported that even mention of the undesired behaviors
would seriously tempt them to do it.10 tM systems are
believed to have their effects on health behavior because
the information is specific to an individual, and thereby
should be more personally relevant, more likely read and
cognitively processed.7 tMs appear less likely to work
among children than adults,12 but the reasons are not clear.
the next steps in tM for children will be to distinguish
which behavioral theories are most appropriate at what
ages, and how best to craft developmentally appropriate
motivating messages at each age.
DMF systems have also been called self-control, self-
regulation, self-management, and adaptive e-learning
systems.13 DMF involves a participant recording data
into a computerized system (e.g., dietary intake, physical
activity), often over several days, and then submitting that
to a software system that processes the information and
provides feedback to the participant in terms of descrip-
tions of patterns in the behavior and/or options or sugges-
tions for behavior enhancement. the feedback component
could provide tailored messages or something else.13 to
date, DMF systems have resulted in small changes.13
One study successfully modified obesity-related dietary
practices, but adversely affected physical activity, with no
influence on adiposity among adolescents.14 A key issue
for DMF systems is the design of prompts/reminders15
and feedback to optimize child participant attention and
behavior change,16 especially among those at high risk.17
AVG, also called exergames, are video games designed
primarily to make a profit, but they also happen to require/
facilitate physical activity by players. examples of this
genre include Dance, Dance Revolution,18 and Wii.19
the research in this area has clearly shown that children
or adults can get a moderate [3+ metabolic equivalents
(Mets)] or even vigorous (6+ Mets) workout under
the right circumstances.20 there have been some mostly
short-term increases in physical activity when participants
have been instructed in how frequently to use the AVG.20
A recent randomized clinical trial that gave two AVG to
treatment group children and two inactive video games to
control group children, detected no difference in level of
activity over the ensuing 12 weeks.19 this suggests there is
no public health benefit from simply having AVG available
in homes. Additional research in this area needs adequately
powered studies to identify the effective procedures and
circumstances under which AVG can be used to increase
physical activity and maintain that activity over extended
time intervals, detect at what ages these effects can be
achieved, assess the processes by which changes may
occur,21 and assess impact on adiposity. For example, AVG
play may be maintained when played socially,18 but snack-
ing occurs during AVG play,22 which may have countervail-
ing influences on child adiposity. stories (narrative) have
been behavior change components of other video games,23
but have only recently appeared in AVG. tests are needed
to address whether stories enhance initial and maintained
change in physical activity from AVG.
iMG are disc- or web-based experiences, usually
involving cut scenes of a story and component video
games, designed to engage the participant and promote
behavior change (e.g., diet or physical activity).23 in
2009, news media reported that spending on videogames
exceeded that on cinematic features, indicating the
breadth and depth of video game playing. Diverse types
of iMG have appeared: 26 of 27 published iMG studies
had some positive outcome, which is promising.23 Prin-
ciples of gamification have been proposed,24 but frankly,
understanding how to design video games to maximize
their health behavior–enhancing effects is in the earliest
stages.25 Principles of story immersion and self-determi-
nation theory26 have been proposed to understand how
games induce their effects. simulations of parent–child
interactions are being programmed as games for parents
of preschoolers to help them learn how to more effec-
tively enable their child to eat vegetables. A key challenge
in this area is how to have participants generalize what is
learned within the game to their real life circumstances.
Goal setting has been used as an effective procedure
among adults,27 but may be problematic among children.28
Media sophistication and use patterns differ by age.
Although toddlers interact with iPads and watch tV, chil-
dren need to be older to use media (at least in its current
forms) to promote behavior change. technology for chil-
dren needs to be developmentally appropriate. A recent
report identified the kinds of games children of different
ages would or could play, up to 8 years of age.29 this
work needs to be peer-reviewed and extended at least
through the teen years. in our experience, even a year can
differentiate children who will play only technically high-
CHI 8.1 Feb 12 v8.indd 351/23/12 3:11 PM
quality action video games from those willing to tolerate
more pedestrian fare. it is likely that differences in cogni-
tive and emotional development underlie some of these
differences in game acceptance and possibly effective-
ness; however, these influences and how to use them for
health behavior change need to be better understood.
there is little consensus on what behavior change pro-
cedures work best among adults30 or children,31 or even
how diet or physical activity change occurs in children.32
incorporating theory-based procedures into electronic
programs appears to offer the most promise.33 A variety
of priority issues need to be addressed to facilitate rapid
development in this area: What aspects of a story or nar-
rative are critical to immersing the participant in a game;
what aspects of environments need to be captured in
virtual realities to maximize the perceived fidelity and
effectiveness of simulations34; what aspects of an avatar
are necessary to optimize learning35; how to capitalize on
the recent advances in voice recognition technology (e.g.,
siRi on the iPhone) with artificial intelligence to sim-
plify and enhance all forms of technological approaches
to behavior change.36 electronic-based procedures (both
replicating-adapting procedures tested in other channels
and innovative procedures only possible in electronic
media) need to be developed and explored to enhance
change outcomes and contribute to the understanding of
when and how change occurs.25
this work is a publication of the United states Depart-
ment of Agriculture Agricultural Research service
(UsDA/ARs) Children’s Nutrition Research Center,
Department of Pediatrics, baylor College of Medicine,
Houston, texas, and had been funded in part with federal
funds from the UsDA/ARs under Cooperative Agree-
ment No. 58-6250-6001. the contents of this publication
do not necessarily reflect the views or policies of the
UsDA, nor does mention of trade names, commercial
products, or organizations imply endorsement from the
Author Disclosure Statement
the authors have no conflicts of interest in regard to this manuscript.
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Address correspondence to:
Tom Baranowski, PhD
Professor of Pediatrics
USDA/ARS Children’s Nutrition Research Center
Department of Pediatrics
Baylor College of Medicine
1100 Bates Street
Houston, TX 77030-2600
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