Source: UTAH STATE UNIVERSITY submitted to
THE FIT GAME PROGRAM: A GAME-BASED APPROACH OBESITY PREVENTION IN CHILDREN
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
TERMINATED
Funding Source
Reporting Frequency
Annual
Accession No.
1009720
Grant No.
(N/A)
Project No.
UTA-01284
Proposal No.
(N/A)
Multistate No.
(N/A)
Program Code
(N/A)
Project Start Date
Jul 1, 2016
Project End Date
Jun 30, 2021
Grant Year
(N/A)
Project Director
Wengreen, HE.
Recipient Organization
UTAH STATE UNIVERSITY
(N/A)
LOGAN,UT 84322
Performing Department
Nutrition, Dietetics and Food Sciences
Non Technical Summary
Childhood obesity is a current Challenge Area Focus of the USDA's Agriculture and Food Research Initiative. Helping children to develop habits that support a healthy body weight including eating fruits and vegetables and being more physically active should be a national priority. School-based interventions may offer a solution as they are an efficient means to target children and families of children. We propose a novel low-cost game-based approach to school-wide obesity prevention we call the FIT Game Program. We will test the efficacy of the FIT Game program to increase fruit and vegetable intake and physical activity in pilot studies and then in a randomized trial design. If effective, the FIT Game program will be offered to public schools at no or low cost and may be an important obesity prevention resource that has the potential to decrease risk of obesity for many children.
Animal Health Component
0%
Research Effort Categories
Basic
0%
Applied
70%
Developmental
30%
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
70360101010100%
Knowledge Area
703 - Nutrition Education and Behavior;

Subject Of Investigation
6010 - Individuals;

Field Of Science
1010 - Nutrition and metabolism;
Goals / Objectives
Objective 1. Develop a low-cost and effort school-based intervention, known as the FIT Game, aimed at increasing children's consumption of fruits and vegetables and involvement in physical activity both in and away from school.Goal 2. Implement and assess the intervention in public schools. Implementation will occur first in a single-school pilot study and then, if the pilot study demonstrates success, in a multi-school randomized controlled trial. Assessment will include measurable outcomes indicating change in FV intake and physical activity at the group (school-wide) level.Goal 3. Develop training material that would allow the intervention to be implemented with fidelity by school staff independent of involvement from the USU research team.
Project Methods
The efficacy of the FIT Game will be tested in at least one pilot study using a time series design where FV intake and physical activity will be measured at a baseline condition, then again while the game is being played, then again at a baseline condition. If FV and physical activity measures increase during the assessments taken while the Game is being played this will provide evidence that the Game is producing the desired outcomes.In phase 2 of the project we will test the efficacy of the game in a randomized trial design where four schools will be recruited to the study; 2 will be randomly selected to play the FIT Game and 2 will serve as controls.During both the time-series and randomized trial FV intake will be measured at the school-level using an aggregate plate-waste method. Physical activity will be measured at the school-level using an observational method known as SOPLAY. In this work we will adapt the existing SOPLAY method to a digital format such that observations of physical activity will be captured using mobile digital devices (aka, cell phones).Children and parents of children may also be asked to provide additional information about their individual behaviors regarding eating fruits and vegetables and being physically active.

Progress 07/01/16 to 06/30/21

Outputs
Target Audience:Children and caregivers attending 8 elementary schools in Granite, Weber, Logan, Cache School Districts. Changes/Problems:The COVID pandemic prevented us from following-up with the public schools regarding the pilot work that was done regarding implementing the game with more real-world conditions. It would be difficult to continue this research given the current conditions related to the pandemic. What opportunities for training and professional development has the project provided?Research staff associated with this project met with the teachers and food service staff of each school and delivered education about the importance of vegetable and fruit consumption and training on how to collect the outcome measures necessary for this research. How have the results been disseminated to communities of interest?Results of each school-based study were shared with administrators, teachers, staff, and parents of each school. Results of the pilot studies and randomized trials were presented at national conferences including the Food and Nutrition Conference and Expo, the Society of Nutrition Education and Behavior, and the American Society of Nutrition. In addition several papers were published in peer-reviewed journals. What do you plan to do during the next reporting period to accomplish the goals?Because this is the final report on this project, and because we found that public schools were not able to successfully implement the FIT Game program on their own, we are not planning to continue development of the FIT Game program.

Impacts
What was accomplished under these goals? A low-cost and effort, school-based intervention, known as the FIT Game program, aimed at increasing elementary children's consumption of fruits and vegetables and involvement of physical activity both at and away from school was developed. The FIT Game program includes a science-fiction odyssey narrative featuring fictional teenage heroes known as the FITs (Field-Intensive Trainees), who endeavor to find and capture three villaims, collectively known as the VAT (Vegetable Annihilation Team). The characters of the FIT Game narrative were modified to represent diversity in skin color and other traits of children. A training manual describing the process of implementation of this program in public schools was created. A digital application known as Foodphoto was also created to aid the process of collecting photos of what children selected to eat and disgarded after eating in the cafeteria. This application was used to collect critical data on food selection and consumption in a new method of data collection developed for the purpose of this research. The FIT Game program was implemented and assessed in 10 public schools in the Logan, Cache, Davis, and Granit school districts. This assessment included a randomized four-school study that was conducted in the Logan and Cache School districts. The data collected in this study provided evidence that the FIT Game program increased children's intake of vegetables and fruits at school and that this behavior of eating more vegetables and fruits was maintained for a period of three months following the end of the programing at school. In follow-up studies testing the feasibility of public schools implementing the game on their own, we found that public schools were not able to implement the program with the precision necessary to demonstrate outcomes that were produced in the randomized trial.

Publications

  • Type: Other Status: Other Year Published: 2016 Citation: Aguilar, S., & Wengreen, H. (2016). Foodphoto. [Computer software].
  • Type: Conference Papers and Presentations Status: Other Year Published: 2017 Citation: Presentations Joyner, D. (Presenter & Author), Aguilar, S. (Author Only), Wengreen, H. (Author Only), Society of Nutrition Education and Behavior, annual meeting, "Associations between elementary school children's self efficacy for eating fruit and vegetables adn intake of fruits and vegetables and skinc arotenoid scores.," Washington, DC. (July 2017)


Progress 10/01/19 to 09/30/20

Outputs
Target Audience:Children and caregivers attending 2 elementary schools in Granite School District and 2 elementary schools in Weber School District. Changes/Problems:This project is nearing completion and will end June 30, 2021. The COVID pandemic made it impossible for us to continue our work in schools in 2020. We had planned to revisit schools in spring of 2020 to collect follow-up data and interviews regarding the feasibility of the study with school administrators and food service staff, but this did not occur. What opportunities for training and professional development has the project provided?One graduate student was mentored by the faculty member on techniques related to data collection, cleaning, and analysis. How have the results been disseminated to communities of interest?Administrators of the schools received a one-page handout about the health benefits of eating fruits and vegetables as well as the results of the FIT Game in other schools compared to the results of the FIT Game at their school. A presentation on the effectiveness of the FIT Game Healthy Eating program was given at the annual conference of the Nutrition Society in May of 2020. One peer-reviewed paper was submitted for publication. Wengreen H, Aguilar S, Lockhart G, Madden. A randomized control trial evaluating the efficacy of the FIT Game. Academy of Nutrition and Dietetics. What do you plan to do during the next reporting period to accomplish the goals?The plan of work in 2021 is to complete the analysis of the study conducted at the two schools in the Granite and 2 schools in the Weber School Districts and submit this as a poster, presentation, and peer-reviewed paper. In addition, we will revise and resubmit the paper listed above for publication.

Impacts
What was accomplished under these goals? Objective 1. Develop a low-cost and effort school-based intervention, known as the FIT Game, aimed at increasing children's consumption of fruits and vegetables and involvement in physical activity both in and away from school. No new accomplishments occurred in 2020. Goal 2. Implement and assess the intervention in public schools. Implementation will occur first in a single-school pilot study and then, if the pilot study demonstrates success, in a multi-school randomized controlled trial. Assessment will include measurable outcomes indicating change in FV intake and physical activity at the group (school-wide) level. School-level data was collected on the amount of fruits and vegetables served and wasted at two schools in the Granite School District and 2 schools in the Weber School District. We ran Simulating Model Analysis on the measured amount of fruits and vegetables served and wasted at each school each day. We observed little evidence that playing the FIT Game at these four schools resulted in children eating more vegetables or fruit at school during the period of time that they played the game. Goal 3. Develop training material that would allow the intervention to be implemented with fidelity by school staff independent of involvement from the USU research team. Training material was developed and adapted to fit the individual needs of schools. Namely, measures were put in place to insure that school coordinators that were hired from the community had the appropriate background checks and food handler's permits to be allowed to work with food and children in the school cafeterias. However, the precision of measurements needed to demonstrate the effectiveness of this program was difficult to obtain from trained and paid community members. The measurements needed to implement this program take place in the school cafeteria and would require minimal time from school food service personnel, however, school food service personnel are often unwilling to invest the amount of time and effort needed to do this.

Publications

  • Type: Conference Papers and Presentations Status: Other Year Published: 2020 Citation: Presentations Wengreen, H., American Society of Nutrition, "Does the FIT Game Healthy Eating Program Increase Children's Skin Carotenoid Concentrations?," American Society of Nutrition, virtual. (June 2020 - Present)


Progress 10/01/18 to 09/30/19

Outputs
Target Audience:Children and caregivers attending East Midvale and Copperview elementary schools in Midvale, Utah and South Clearfield and Wasatch elementary schools in Clearfield, Utah. Changes/Problems:We have identified several challenges with our current methods when the program is being run at a distance and with the help of community members instead of undergraduate or graduate students. Often schools do not want us taking weights of vegetables in the cafeteria and offer to provide these weights to us, however, when left to the cafeteria staff, the weights are often not accurate. This has led us to explore alternative methods of data collection as mentioned above. What opportunities for training and professional development has the project provided?One graduate student was mentored by a faculty member to gain the skills needed to oversee the implementation of this program in public schools. Two community members were trained on the skills needed to collected the waste based outcome measures. How have the results been disseminated to communities of interest?One public press news article was written about the project being implemented in the Canyon School district. One peer-reviewed paper was published. Joyner D, Wengreen H, Aguilar S, Madden. Effects of the FIT Game on Physical Activity in Sixth Graders: A Pilot Reversal Design Intervention Study. JMIR Serious Games. 2019;18;7(2):e13051. What do you plan to do during the next reporting period to accomplish the goals?In 2020 we plan to write up the description of our four school randomized trial for publication in a peer-reviewed paper. This work will also likely be submitted as an abstract for presentation at a national conference (Society of Nutrition Education and Behavior, July 2020). In addition, we will analyze the data from the four school pilot of the pre-programmed version of the game. The direction of this project will be informed by the outcome of this ongoing work. In spring of 2020 we will also explore alternative methods of data collection in at least one school in Logan or Cache County school district. We are exploring methods of data collection that would allow us to measure the number of children selecting and eating vegetables, in addition to the total amount of vegetable consumed by the school. We are also exploring additional funding sources for the future of this project and are looking at adding a stronger home component to the program that would help parents to support vegetable consumption of family members at home.

Impacts
What was accomplished under these goals? Objective 1. Develop a low-cost and effort school-based intervention, known as the FIT Game, aimed at increasing children's consumption of fruits and vegetables and involvement in physical activity both in and away from school. The FIT Game was reviewed by administrators in the Canyon and Davis school districts and minor modifications were made to the narrative of the game to remove language that was deemed as inappropriate for the audience by these school administrators. For example, the word stupid was removed as was the visual depiction of a potato launcher, which was deemed to be similar to a gun. Goal 2. Implement and assess the intervention in public schools. Implementation will occur first in a single-school pilot study and then, if the pilot study demonstrates success, in a multi-school randomized controlled trial. Assessment will include measurable outcomes indicating change in FV intake and physical activity at the group (school-wide) level. Four additional schools were recruited to implement the game in fall of 2019. This included East Midvale and Copperview elementary schools in the Canyon's School District and South Clearfield and Wasatch elementary schools in the Davis School District. These schools represented urban schools with greater ethnic diversity than was observed in the schools in Cache County School District were the game had previously been implemented. The method of the game was modified from previous implementations such that for three of the four schools a pre-programmed schedule was followed instead of allowing the game to progress in accordance with whether or not the children at the school met or didn't meet the daily vegetable consumption goals. Our hypothesis was that individual children are not aware of how their contribution contributes to the school-wide goal, so that it may not be necessary to base the daily progress on the game on these daily results. If we find that playing the FIT Game still results in increased vegetable consumption at the schools where we implement the pre-programmed schedule, it may not be necessary to measure vegetable consumption and waste each day that the game is played. Measuring vegetable and fruit consumption at less frequent intervals during the implementation of the game would make it less burdensome for schools to implement. Goal 3. Develop training material that would allow the intervention to be implemented with fidelity by school staff independent of involvement from the USU research team. The methods of the game and training materials were adapted to fit the needs of these additional schools. Namely, measures were put in place to insure that school coordinators that were hired from the community had the appropriate background checks and food handler's permits to be allowed to work with food and children in the school cafeterias.

Publications

  • Type: Journal Articles Status: Published Year Published: 2019 Citation: Joyner, D., Wengreen, H., Aguilar, S., & Madden, G. (2019, June). Effects of the FIT Game on Physical Activity in Sixth Graders: A Pilot Reversal Design Intervention Study. JMIR Serious Games, 7(2), e13051.


Progress 10/01/17 to 09/30/18

Outputs
Target Audience:Children and caregivers of children attending Bridger and Woodruff Elementary in spring of 2018. Changes/Problems:We are working on a strategy that would make the game easier for schools to run on their own, but we need to assess the efficacy of the FIT Game under these new parameters. We have previously worked in most of the Cache Valley schools that expressed interest in collaborating with us, so we need to find connections to schools in other areas that may be willing to help us implement the game remotely from USU. We are hoping that the USU Extension faculty will be willing to help us in this regard and have started these discussions. What opportunities for training and professional development has the project provided?One PhD student and one MS student worked with the PIs of the FIT Game studies to analyze the data collected from children and parents of the FIT Game studies. Both students successfully defended their dissertation/thesis. How have the results been disseminated to communities of interest?The findings of our studies in 2017-2018 were shared with administrators and parents of the schools involved in the form of a newsletter and email. In addition, this work was published in the form of Damon Joyner's dissertation titled "Incentivizing Fruit, Vegetable, and Physical Activity Level Change: Expansion and Evaluation of the FIT Game Program for Healthy Behavior Change in Elementary Schools", and Hali Obray successfully defended her thesis titled "Development, Implementation, and Assessment of a Home Component to the FIT Game Healthy Eating Program". One poster-presentation titled "A randomized 4-school trial of the FIT Game Healthy Eating Program" was presented at the Food and Nutrition Conference and Expo in Washington, DC in October of 2018. What do you plan to do during the next reporting period to accomplish the goals?In 2019 we plan to seek additional funding that would allow our team to continue work in this area. We plan to submit a small grant to the USU Extension program to work with Extension Faculty to implement the FIT Game in a school outside of Cache Valley, with little assistance from the research team. In addition, we are planning to write an NIH proposal to allow us to examine the efficacy of playing the FIT Game using a design that wouldn't depend on daily waste measurements. We are also working with a statistician on the analysis of the data that was collected in our 4 school study that was conducted in 2016-2018. We plan to disseminate our findings in one or more peer-reviewed publications.

Impacts
What was accomplished under these goals? Objective 1: The FIT Game narrative was further adapted to target the behavior of physical activity in addition to fruit and vegetable intake and was lengthened from 6 weeks to ~ 8 weeks (39 days). Four newsletters were developed as a way to provide information to parents about the progress of the FIT Game at their child's school and to encourage parents to help their children to eat more vegetables at home. The newsletters provided parents with evidence-based behavior tips for making vegetable more accessible to children and provided recipes with challenges for families to try recipes together. We are currently working on a strategy for implementing the FIT Game that would require less effort to run. In this strategy, we would pre-program the progression of the game to match the progression that we've seen in our previous implementations. Doing this would mean that though we would collect fruit and vegetable waste from students every day, we would not need to measure the waste, nor program the game according to that number on a daily basis. Making this change would make it easier for schools to implement the game on their own. Goal 2: An additional two schools (Bridger and Woodruff Elementary schools) were recruited to participate in our 4 school experimental trial (n= approximately 600 children) and in 2018, these two schools were re-assessed to determine whether or not there were any lasting effects on fruit and vegetable intake at school three months after the game was played. In fall of 2018 I began working with Brittany Bingeman, a county Extension faculty, on recruiting a school or schools in the SLC area to allow us to implement the FIT Game in 2019. We are looking to recruit schools that have more diversity in their student populations than we've seen at the Cache Valley schools that we've previously implemented the program in. Goal 3: Changes were made to the training manual that was created in the summer of 2017 to reflect the changes in the implementation of the game.

Publications

  • Type: Book Chapters Status: Published Year Published: 2018 Citation: Madden, G., Price, J., & Wengreen, H. (2018). Change and maintaining change in school cafeterias: Economic and behavioral economic approaches to increasing fruit and vegetable consumption. Change and Maintaining Change. (pp. 101-125). Lincoln, NE: University of Nebraska Press.
  • Type: Conference Papers and Presentations Status: Other Year Published: 2018 Citation: Hauch, K. (Presenter & Author), Joyner, D. (Author Only), Wengreen, H. (Author Only), Undergraduate research symposium, "What does self-reported likability for fruit and vegetable intake tell us about skin carotenoid levels?," UTAH STATE UNIVERSITY, Logan, Utah. (April 2017 - Present)
  • Type: Conference Papers and Presentations Status: Other Year Published: 2018 Citation: Wengreen, H., Joyner, D. (Author Only), Aguilar, S. (Author Only), Madden, G., Obray, H. (Author Only), Food and Nutrition Conference and Expo, "A randomized 4-school trial of the FIT Game Healthy Eating Program," Academy of Nutrition and Dietetics, Washington, DC. (October 2018)


Progress 10/01/16 to 09/30/17

Outputs
Target Audience:Children and caregivers of children attending Nibley Elementary and Wilson Elementary in fall of 2016 and Bridger and Woodruff Elementary in fall of 2017. Changes/Problems:The size of the effect we have observed in the four school study is less than we hypothesized. In addition, there are other barriers within the U.S. school system, such as school lunch staff being reluctant to provided the measures needed to run the program, that may prevent this program from being adopted for use by U.S. schools. What opportunities for training and professional development has the project provided?One graduate student worked with a faculty member in Applied Economics who has expertise in moderating focus groups. This graduate student gained greater proficiency in the skills needed to moderate focus group activites. How have the results been disseminated to communities of interest?The findings of our studies in 2016-2017 and 2017-2018 were shared with administrators and parents of the schools involved in the form of a newsletter and email. What do you plan to do during the next reporting period to accomplish the goals?In 2018 we plan to collect one additional point of long-term follow-up data in our four school study. Much of the effort in this year will be in cleaning and analyzing the data to examine the effect of the FIT Game program in increasing childrens vegetable intake and level of physical activity in schools. Although we have consistently observed small but statistically significant increases in vegetable intake among children while participating in the FIT Game at school, the magnitude of the effect is less than we had hypothesized. Following the commencement of our studies in spring of 2018 our research group will be deciding on whether or not we will be pursuing this effort into the future. The effort needed to implement the studies may not justify the magnitude of the effects that we observe.

Impacts
What was accomplished under these goals? Objective 1: The FIT Game narrative was further adapted to target the behavior of physical activity. The FIT characters in the narrative of the game modeled being physcially active along with eating vegetables throughout the narrative. A focus group was conducted with 12 parents of Wilson elementary school in the summer of 2017. The information from the focus group was used to inform our development of newsletters targeted at providing information to parents to support their effort of helping children to eat more vegetables at home. Goal 2: An additional two additional schools (Bridger and Woodruff Elementary schools) were recruited to participate in our 4 school experimental trial (n= approximately 600 children). The implementation of the FIT Game program in the intervention school began in September of 2016 and commenced in December of 2016. In addition, a one grade pilot study was implemented in a 6th grade classroom at Providence elementary to further assess whether or not the FIT Game method could be used to target other healthy behaviors, such as physical activity. The pilot physical activity study began in September of 2016 and ended in December of 2016. Goal 3: In summer of 2017 a training manual was created to document the steps needed to take the measurements on the amount of fruits and vegetables served during lunch each day. This measurement is critical to the implementation of the game. This manual was shared with study research assistants in the fall of 2017 and could be shared with school personnel if the FIT Game is implemented by schools without the help of USU researchers.

Publications

  • Type: Journal Articles Status: Published Year Published: 2017 Citation: Joyner, D., Anderson, L., Madden, G., Wengreen, H. (2017). The FIT Game III: Reducing the operating expenses of a game-based approach to increasing healthy eating in elementary schools. Games for Health Journal., 6(2), 111-118.
  • Type: Conference Papers and Presentations Status: Other Year Published: 2017 Citation: Hauch, K. (Presenter & Author), Joyner, D. (Author Only), Wengreen, H. (Author Only), Undergraduate research symposium, "What does self-reported likability for fruit and vegetable intake tell us about skin carotenoid levels?," UTAH STATE UNIVERSITY, Logan, Utah. (April 2017 - Present)
  • Type: Conference Papers and Presentations Status: Other Year Published: 2017 Citation: Joyner, D. (Presenter & Author), Aguilar, S. (Author Only), Wengreen, H. (Author Only), Society of Nutrition Education and Behavior, annual meeting, "Associations between elementary school children's self efficacy for eating fruit and vegetables adn intake of fruits and vegetables and skinc arotenoid scores.," Washington, DC. (July 2017)


Progress 07/01/16 to 09/30/16

Outputs
Target Audience:Target Audience Children and caregivers of children attending Nibley Elementary and Wilson Elementary in fall of 2016. Changes/Problems:Changes/Problems No changes or problems have been identified in this reporting period. What opportunities for training and professional development has the project provided?Opportunities No training or professional development occurred during this period for the PI. Approximately 10 undergraduate research students receive training on the assessment of vegetables consumption in children including plate waste, digital visual observations, and skin carotenoid measurements. How have the results been disseminated to communities of interest?Dissemination Parents of children attending Wilson elementary where the FIT Game was implemented were provided with 3 monthly newsletters informing them about the importance of encouraging their children to eat more vegetables and be more physically active. One story on what the FIT Game does was written and published in the Herald Journal, the local newspaper. In addition, the PI gave one invited presentation to the students and faculty of the Nutrition and Food Sciences department at Brigham Young University on school-based interventions designed to increase fruit and vegetable consumption among children, including the group's experience with the implementation of the FIT Game program. What do you plan to do during the next reporting period to accomplish the goals?Plan of Work In spring of 2017 we will be working to organize, clean, and analyze the data we collected in fall 2016. In spring and summer of 2017 we will recruit an additional 2 schools to participate in a randomized trial of the FIT Game program, just as we did in fall of 2016. In summer of 2017 we will work on the development of the training material that would allow the intervention to be implemented with fidelity by school staff independent of involvement from the USU research team.

Impacts
What was accomplished under these goals? Accomplishments Objective 1. Development of the FIT Game. The PI and research team worked on the narrative and gaming components of the FIT Game. Additional content was developed to lengthen the game from approximately 20 days to approximately 50 days. Gaming elements were added to model and encourage children to be more physically active in addition to eating more vegetables. The Research team worked with a professional artist to enhance the visual presentation of the game narrative. High quality game material is important as it should enhance the children's interest in the Game and thus promote further increases in vegetable consumption. Goal 2. Implement and assess the Fit Game intervention. Two schools were recruited to participate in a randomized trial design testing the efficacy of the longer 50 day version of the game. The game was implemented in one school randomly assigned to implement the Fit Game. We assessed school-wide and individual level vegetable consumption at two periods among children in both the intervention (n=350) and control schools (n=250). In addition, school-level physical activity methods were assessed on 4 days at the intervention school. Goal 3. No progress was made on this objective during this period.

Publications