This Academy member benefit temporarily has been made public to allow all practitioners access to content that may assist in patient care during the national pandemic response. Click here for information on joining the Academy. 

Health Disparities

HD: Food Security (2011)

Citation:

Pempek TA, Calvert SL. Tipping the balance: Use of advergames to promote consumption of nutritious foods and beverages by low-income African American children. Arch Pediatr Adolesc Med. 2009 Jul; 163(7): 633-637.

PubMed ID: 19581546
 
Study Design:
Cross-Sectional Study
Class:
D - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
  • To determine whether playing an advergame that promoted less healthy foods, such as those typically seen in food advertisements directed at children, could affect children's behavior, as measured by what children selected and ate as a snack
  • To determine whether playing an advergame could promote healthier food choices and consumption patterns.
Inclusion Criteria:
  • Inclusion criteria not specified
  • Based on participant description:
    • African American
    • Third or fourth grade students 
    • Attended one of five metropolitan elementary schools in Washington, DC.
Exclusion Criteria:

None provided.

Description of Study Protocol:

Recruitment

Description of recruitment methods is not provided.

Design

Participants randomized to one of three groups:

  • Healthier advergame:
    • Rules of advergame explained
    • Played advergame twice
    • Answered questionnaire
    • Chose snack and beverage after playing advergame (snack and beverage choices were the same as the foods in the advergame)
  • Less healthy advergame:
    • Rules of advergame explained
    • Played advergame twice
    • Answered questionnaire
    • Chose snack and beverage after playing advergame (snack and beverage choices were the same as the foods in the advergame)
  • Control group:
    • Chose snack and beverage (snack and beverage choices were the same as the foods in the advergame)
    • Played healthier version of advergame
    • Answered questionnaire.

Blinding Used

Participants were not told the purpose of study until after they had completed the intervention.

Intervention

Advergame (based on Pac-Man arcade game):

  • Version one: Healthier food
    • Player was awarded 10 points for each nutritious snack eaten by Pac-Man character (nutritious snacks included orange juice, bananas, apple, baby carrots)
    • Player was penalized 10 points for each less nutritious snack eaten by Pac-Man character (less nutritious snacks included soda, potato chips, chocolate chip cookie, chocolate candy bar)
  • Version two: Less healthy food:
    • Player was awarded 10 points for each less nutritious snack eaten by Pac-Man character (less nutritious snacks included soda, potato chips, chocolate chip cookie, chocolate candy bar)
    • Player was penalized 10 points for each nutritious snack eaten by Pac-Man character (nutritious snacks included orange juice, bananas, apple, baby carrots).

Statistical Analysis

  • Three by two (condition x sex) between-subjects analysis of variance with Bonferroni post-hoc tests; summary score of healthier food and beverage as dependent measure
  • Chi-square analysis to compare number of healthier snacks chosen by condition (healthier advergame or less healthy advergame).
Data Collection Summary:

Timing of Measurements

  • Treatment groups: Three questions about the advergame and four questions about computer use were asked after participants played the advergame twice
  • Control group: Four questions about computer use were asked after participants played the advergame.

Dependent Variables

  • Choice of healthier food and beverage
  • Answer to question about what Pac-Man wanted them to eat.

Independent Variables

  • Treatment
  • Gender.
Description of Actual Data Sample:
  • Initial N: 30 children
    • 15 girls
    • 15 boys
  • Attrition (final N): 30 children
    • 15 girls
    • 15 boys
  • Age: Nine years, six months ± 11 months (mean ± standard deviation)
  • Ethnicity: African American
  • Other relevant demographics:
    • Third and fourth grade students
    • Resided in low-income area
  • Location:
    • Five public metropolitan elementary schools
    • Washington, DC.
Summary of Results:

Key Findings

  • Two-factor analysis of variance computed on snack selections yielded a main effect of condition (treatment), F2,24 = 6.23, P=0.007 (observed power of 0.85)
  • Children in the healthier advergame treatment selected and ate a greater number healthier snacks than those in the less healthy game condition [1.40 (0.24) vs. 0.20 (0.24), two-factor analysis of variance]
    • Nine participants in healthier advergame treatment vs. one participant in the less healthy advergame treatment vs. six participants in the control group chose at least one healthier snack (Χ2 = 13.38, P=0.01)
    • Nine participants in the healthier advergame treatment chose at least one healthier snack vs. one participant in the less healthy advergame treatment (Χ2 = 13.07, P=0.001)
  • When asked what Pac-Man wanted them to eat, 25 of 28 children answered correctly
  • When asked what Pac-Man wanted them to drink, 27 of 28 children answered correctly.

Other Findings

  • Two-factor analysis of variance computed on snack selections yielded no main effect of gender
  • The number of healthier snacks selected and eaten by children in the control group fell between the two treatment groups and did not significantly differ from either group [0.90 (0.24)]
  • Participants played the game an average of nine minutes, 32 seconds (SD, two minutes, 22 seconds)
  • There was no significant difference in how much participants enjoyed playing the game
  • There was no significant difference in how challenging participants thought the game was
  • 27 participants reported they "really liked" the game; two participants reported they "liked" the game
  • 19 participants reported that the level of difficulty was "just right"; five participants reported that the level of difficulty was "easy"; five participants reported that the level of difficulty was "hard"
  • Computer activities online (allowed to select more than one choice)
    • Play games: 26 participants
    • Schoolwork or visit site of TV program they watch: 11 participants
    • Send instant messages: Five participants
    • Send e-mail: Five participants
    • Visit Web site of food they liked: Five participants
  • Girls were more likely than boys to visit food Web sites (Χ2 = 6.09, P=0.01)
  • Frequency of computer use:
    • Weekly basis: 27 participants
      • "Just about every day": 10 participants
      • "A few times a week": 11 participants
      • "About once a week": Six participants
    • Did not use the Internet: Two participants.
Author Conclusion:
  • With only 10 minutes of exposure, the results revealed that participants selected and ate whatever snacks were being marketed by the advergame, healthy or not
  • Advergames can be used to promote healthy food choices
  • This low-income population indicated weekly Internet usage with the most popular activity being gaming
  • 36% of the girls visited food Web sites compared to 0% of the boys, indicating that girls may be more at risk for exposure to marketing practices that promote foods that can lead to obesity and poor health.
Funding Source:
University/Hospital: Reflective Engagement in the Public Interest grant from Georgetown University
Reviewer Comments:
  • Although the study was approved by the Georgetown University IRB, the method of recruiting the participants is not provided in the study description, so there is no way to know if participant selection was biased
  • Inclusion criteria were implied, not specifically stated, and exclusion criteria were not provided, which also contributes to lack of knowledge of any bias in participant selection
  • Had the authors provided anthropometric data on the participants, their claim that the girls were more at risk for exposure to marketing practices that promote foods that can lead to obesity and poor health might carry more weight.
Quality Criteria Checklist: Primary Research
Relevance Questions
  1. Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies) Yes
  2. Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about? Yes
  3. Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice? Yes
  4. Is the intervention or procedure feasible? (NA for some epidemiological studies) Yes
 
Validity Questions
1. Was the research question clearly stated? Yes
  1.1. Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified? Yes
  1.2. Was (were) the outcome(s) [dependent variable(s)] clearly indicated? Yes
  1.3. Were the target population and setting specified? Yes
2. Was the selection of study subjects/patients free from bias? ???
  2.1. Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study? No
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? ???
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  3.3. Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.) Yes
  3.4. If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis? ???
  3.5. If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.) ???
  3.6. If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")? N/A
4. Was method of handling withdrawals described? Yes
  4.1. Were follow-up methods described and the same for all groups? Yes
  4.2. Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  4.5. If diagnostic test, was decision to perform reference test not dependent on results of test under study? N/A
5. Was blinding used to prevent introduction of bias? Yes
  5.1. In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate? Yes
  5.2. Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.) No
  5.3. In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded? No
  5.4. In case control study, was case definition explicit and case ascertainment not influenced by exposure status? N/A
  5.5. In diagnostic study, were test results blinded to patient history and other test results? N/A
6. Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described? Yes
  6.1. In RCT or other intervention trial, were protocols described for all regimens studied? N/A
  6.2. In observational study, were interventions, study settings, and clinicians/provider described? N/A
  6.3. Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect? Yes
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? Yes
  6.5. Were co-interventions (e.g., ancillary treatments, other therapies) described? N/A
  6.6. Were extra or unplanned treatments described? N/A
  6.7. Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups? Yes
  6.8. In diagnostic study, were details of test administration and replication sufficient? N/A
7. Were outcomes clearly defined and the measurements valid and reliable? Yes
  7.1. Were primary and secondary endpoints described and relevant to the question? Yes
  7.2. Were nutrition measures appropriate to question and outcomes of concern? Yes
  7.3. Was the period of follow-up long enough for important outcome(s) to occur? Yes
  7.4. Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures? Yes
  7.5. Was the measurement of effect at an appropriate level of precision? Yes
  7.6. Were other factors accounted for (measured) that could affect outcomes? Yes
  7.7. Were the measurements conducted consistently across groups? Yes
8. Was the statistical analysis appropriate for the study design and type of outcome indicators? Yes
  8.1. Were statistical analyses adequately described and the results reported appropriately? Yes
  8.2. Were correct statistical tests used and assumptions of test not violated? Yes
  8.3. Were statistics reported with levels of significance and/or confidence intervals? Yes
  8.4. Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)? N/A
  8.5. Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)? No
  8.6. Was clinical significance as well as statistical significance reported? N/A
  8.7. If negative findings, was a power calculation reported to address type 2 error? N/A
9. Are conclusions supported by results with biases and limitations taken into consideration? Yes
  9.1. Is there a discussion of findings? Yes
  9.2. Are biases and study limitations identified and discussed? Yes
10. Is bias due to study's funding or sponsorship unlikely? Yes
  10.1. Were sources of funding and investigators' affiliations described? Yes
  10.2. Was the study free from apparent conflict of interest? Yes