Can Video Games Help with Eating Disorders? Exploring the Evidence

In my years of writing articles, I’ve had the pleasure of writing about the different ways that video games can help with mental and physical health. My interest piqued recently when I came across a review of research on video games and eating disorders. As a bright-eyed undergrad student, I wrote several of my assignments on eating disorders as I was fascinated by the misinformation surrounding the topic.

As a bleary-eyed researcher, it’s my pleasure to return to the topic and share this information with you all. This article will explore the peer-reviewed academic article “The Role of Serious Video Games in the Treatment of Disordered Eating Behaviors: A Systematic Review” by Tang et al. So can video games help with symptoms of eating disorders? Let’s find out together.

Please note that this article discusses eating disorders, disordered eating, eating habits, food purging, Body Mass Index (BMI) and topics of this nature; you may wish to skip this article if you do not wish to read about these topics. As usual, there will be a summary at the end if you do not wish to read everything.

Contents

1. 1. Introduction
   2. Methods
   3. Results
   4. Discussion
   5. Summary
   6. Credits
   7. References

Introduction

The article begins by laying out information on eating disorders that you may or may not be familiar with. Perhaps the most common piece of knowledge about eating disorders is that they most commonly affect adolescents and young adults [1-2]. Information that may be less familiar is the relatively high mortality risk associated with eating disorders when compared with other mental health disorders [3].

While anorexia and bulimia are the most well-known eating disorders, the authors raise awareness of the term ‘disordered eating’ that can include a wider range of dangerous and restrictive eating behaviours. Disordered eating is a complex phenomenon influenced by factors such as poor body image and struggles with control which can manifest in restricting and/or bingeing food.

Treating disordered eating can be challenging for multiple reasons. Research suggests that disordered eating is actually underdiagnosed as people can fail to understand that their eating behaviours are unhealthy, or they may feel too ashamed to seek help [4-6]. If you do seek help, treatment can require what is called a multidisciplinary approach. This means that you can be treated by a team of experts as psychologists, medical doctors, dieticians and more work together to provide you with the best treatment. This is a lot of people to admit your vulnerabilities and insecurities to. This, combined with factors such as not wanting to relinquish control of eating behaviours, can lead to high treatment dropout rates of up to 50%  [7-8].

Due to the relatively high mortality rate of eating disorders, it is imperative for people with these difficulties to enter and stay in treatment. If you’ve read any of my articles on physical health, you will know that video games are a popular method of keeping people enrolled in healthcare that is otherwise considered monotonous and repetitive. It will come as no surprise to you that the authors are interested in whether video games can keep people enlisted in treatment for disordered eating.

However, they also note additional benefits that gamified treatments can have. Through narrative encounters and gameplay, participants can practice new skills and behaviours in a safe environment [9-10]. This is particularly useful for practicing things like food choices as it’s a decision we could be confronted with dozens of times a day. The authors also praise video games for being educational tools with difficulty levels that can constantly challenge players and encourage them to grow [10-11]. Finally, they are interested in the potential for video games to help participants’ impulse control and emotional regulation [12-13], aspects of wellbeing that are crucial for managing bingeing.

Methods

Before moving on to the results, I’ll quickly describe what type of research paper this is. As the title shows, this paper is a systematic review. A systematic review is when researchers use very detailed and organised search terms to try to find as much research related to their chosen topic as possible.

When planning out systematic reviews, it is important to have clear instructions for what type of research to include. This paper chose to include only peer-reviewed randomised controlled trials or studies with a quasi-experimental research design. I appreciate that those words can be confusing, so to describe it as simply as possible, they only selected research that aimed to be as scientific and controlled as possible.

This paper examined a variety of video games, ranging from commercial video games like The Sims to what we call ‘serious video games’. Serious video games is a term commonly used to describe video games that have been commissioned and created as a specific health and wellbeing tool. For example, I have previously covered EndeavorRx which is a game that can be prescribed to children to help manage symptoms of ADHD. However, the authors decided to exclude any type of gaming or intervention that took place using virtual reality (VR). This is a fair decision as VR can add a novelty factor to the intervention, and the authors described how they are interested in isolating the effects of games versus VR novelty as much as possible.

Studies will be looking to find a statistically significant change before and after taking part in the gamified treatment. As a reminder, statistical significance refers to the probability that a finding happened due to a specific cause, most likely the result of the treatment programme. Studies usually consider findings to be statistically significant if p<.05. This means that we can be at least 95% sure that a finding was not due to chance or coincidence.

Results

So what types of games did they use? What did the studies find? Let’s get right into it.

The researchers identified 11 studies that used video games to help with components of eating disorders and disordered eating. You might be sad to know that only one commercially available video game was used in research. The Sims 4 was used to practice impulse control and lifestyle behaviours by acting out daily routines using their sim.

The remainder of the games were serious video games that were specifically designed for an intended purpose. These purposes included:

• Emotional regulation: Emotional regulation is highly related to disordered eating due to the connection between emotional state and eating behaviours. Serious video games such as PlayMancer: Islands were designed to help players regulate and manage their emotions.
• Approach-avoidance training: Games like Mindtastic were designed to help participants pay close attention to positive things about their body and discouraged them from dwelling on negative thoughts.
• Conditioning: Games were designed using tenets of conditioning such as pairing objects with a positive response (known as classical conditioning). For example, games rewarded players for rating a variety of body types as beautiful and rewarded players for not classifying people as ‘fat’.
• Inhibitory control: Multiple games were designed using the Go-No-Go principle of inhibitory control. While the prompts were different between games, the main idea was to show a ‘No Go’ prompt around high calorie, unhealthy foods that participants may reach for in moments of emotional difficulty, and a ‘Go’ prompt around healthy food. This aimed to promote and practice the idea that junk food isn’t the best solution for their problems or their body.

So what did studies using these types of games find? Let’s keep it simple and organise it by category:

• Six studies explored symptoms of an eating disorder as measured by eating disorder questionnaires such as the Eating Disorder Inventory. Four studies showed statistically significant improvements in eating disorder symptoms, but the positive findings of half of these studies reduced over time.
• Four studies used video games as a way of helping participants who struggled with food binges to lose weight. Two studies found significant weight loss after taking part, and this loss was higher for men than in women.
• Five studies explored behavioural outcomes related to disordered eating such as frequency of food binges. While two studies did not find significant effects on eating behaviours (this sadly includes the study using The Sims), the remaining studies found benefits such as reducing calorie intake during cravings, swapping out unhealthy foods for healthy foods, and reducing symptoms of food addiction. However, the positive effects of the food addiction study reduced over time.
• Three studies looked at the dropout rate of the treatment. These findings were a bit mixed as while one study found that gaming treatments had a dropout rate that was less than half the size of the non-gaming treatment, another study didn’t find a significant difference in dropout rates.
• Two studies explored body dissatisfaction, and both of them found statistically significant reductions in participants disliking their bodies.
• As a final point, it was noted by researchers that women showed higher levels of enjoyment for gamified disordered eating treatment than males.

Discussion

This review identified a range of ways that video games designed with specific purposes could help with disordered eating. This included reducing symptoms of eating disorders listed in diagnostic criteria, reducing food binges, reducing calorie intake, increasing healthy eating, and reducing body dissatisfaction. Using video games had the potential to reduce treatment dropout rates, and it was found that women particularly enjoyed gamified aspects of disordered eating treatments.

The authors discuss further merits of gamified treatment and why it may have led to positive findings. They detail how PlayMancer: Islands is able to capture biomarkers of mood such as heart and respiratory rate. They argue that traditional therapies such as Cognitive Behavioural Therapy (CBT) may not be well-equipped to tackle disordered eating traits such as emotion regulation and impulsivity. Biomarkers helped the game to monitor the player’s mood, something which they could usually hide from a therapist. Interestingly, the game increased the difficulty when it identified negative moods. The rationale behind this was that the game wanted to encourage emotional self-control and get players to work towards reaching a state of calm in the game’s safe environment. Because of PlayMancer: Island’s ability to reduce eating disorder symptoms and keep participants involved in treatment, the authors recommend pairing it with CBT to provide those in need with as much help as possible.

An additional benefit of pairing CBT with gamified treatments is that it can overcome the trust limitation of traditional talking therapies. As those with disordered eating may have challenges with trust and control, building rapport with a therapist can take time and they may ultimately hide things from them or not take their advice. As gamified treatments are often a solo experience, this means that people can learn techniques such as self-control and emotional regulation while they build a rapport with their therapist.

As no study or body of research is perfect, the discussion points out some flaws of the research and what future studies can do to improve. I’ve also identified my own critiques while reading through the research, so I’m going to try to acknowledge which critiques are mine and which are the authors’ so that our critiques aren’t misattributed to one another.

Critiques

• The authors are critical that the samples used in these studies might limit our knowledge. For example, both studies looking at body dissatisfaction used a sample of university students, so the findings may not be as applicable to younger or even older people. I’ll take this critique further and point out how some studies only used one particular type of sample. For example, studies which measured changes in body weight exclusively used participants classified as overweight. While healthy weight loss is definitely important, it would be interesting to see if games can help with healthy weight gain.
• The authors mention that gamified treatments could theoretically complicate a person’s recovery. Disordered eating, particularly restrictive eating, can be influenced by feelings of control and competitiveness. There are concerns that a person competing with themselves to eat fewer and fewer calories could transfer this to trying to score higher and higher in the game. While this doesn’t sound all that bad, previous research shows that competing for high scores can reduce the likelihood of paying attention to lessons and messages from the game [14].
• The final two critique points are primarily my own critiques. Firstly, I would love to see future research try to utilise more commercially available video games. Nearly all of the studies in this review used serious video games. Unfortunately, serious video games can be inaccessible to the general public and can even require a prescription from a doctor. It would be great to have more accessible tools to help people with their own eating behaviours. Increasing access to these tools could also help overcome some of the limitations of these studies as the benefits of some studies wore off over time. Wouldn’t it be great to be able to practice with these tools and reinforce their lessons after the study is over?
• Finally, only 3/11 studies shared their dropout rates. I’ve seen myself in research areas such as stroke rehabilitation how beneficial gamified treatment can be in keeping people interested and engaged in their health. I would love for future research to disclose this information more often to see if the same benefits can be seen for disordered eating research.

Overall, I think this is an interesting and exciting field of research that I’m definitely eager to keep an eye on!

Summary

• The paper begins by sharing information such as the health and mortality risks associated with eating disorders. Helping people with eating disorders can be challenging as they can struggle with lack of control and may have to discuss their vulnerabilities to a range of people, leading to high treatment dropout rates.
• Video games have a history of being used to keep people engaged with health care. The authors explored whether video games can be used to reduce symptoms of eating disorders, whether games can keep people in treatment for disordered eating, and whether they can teach people new skills and behaviours in a safe environment.
• The researchers identified 11 studies that used video games to help with components of eating disorders and disordered eating. These studies identified a range of ways that video games could help. This included significantly reducing symptoms of eating disorders, reducing food binges, reducing calorie intake, increasing healthy eating, and reducing body dissatisfaction. Using video games had the potential to reduce treatment dropout rates, and it was found that women particularly enjoyed gamified aspects of disordered eating treatments.
• Future improvements to the world of video games and disordered eating can explore using games to encourage healthy weight gain rather than loss, can use more commercially available video games, and can disclose treatment dropout rates more frequently to further our understanding of this.

Credits

A big thank you to DECosmic for designing my header image and to LoopyGc for drawing the header art.

This hard work would not be possible without the support of my wonderful Patrons. I would particularly like to thank my Platinum Patrons: Albert S Calderon, Kyle T, redKheld, Austin Enright, NotGac, Shaemus, DarrenIndeed, Thomas Meszaros, Mulgar, Tobias Svensson, Gamma Ray Garrett and Pot. Thank you!

 

References

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[2] Javaras, K. N., Runfola, C. D., Thornton, L. M., Agerbo, E., Birgegård, A., Norring, C., … & Bulik, C. M. (2015). Sex‐and age‐specific incidence of healthcare‐register‐recorded eating disorders in the complete Swedish 1979–2001 birth cohort. International Journal of Eating Disorders, 48(8), 1070-1081.

[3] van Hoeken, D., & Hoek, H. W. (2020). Review of the burden of eating disorders: mortality, disability, costs, quality of life, and family burden. Current Opinion in Psychiatry, 33(6), 521.

[4] Hudson, J. I., Hiripi, E., Pope Jr, H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358.

[5] Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating disorders in men: underdiagnosed, undertreated, and misunderstood. Eating Disorders, 20(5), 346-355.

[6] Ogg, E. C., Millar, H. R., Pusztai, E. E., & Thom, A. S. (1997). General practice consultation patterns preceding diagnosis of eating disorders. International Journal of Eating Disorders, 22(1), 89-93.

[7] Wallier, J., Vibert, S., Berthoz, S., Huas, C., Hubert, T., & Godart, N. (2009). Dropout from inpatient treatment for anorexia nervosa: critical review of the literature. International Journal of Eating Disorders, 42(7), 636-647.

[8] Kaplan, A. S., & Garfinkel, P. E. (1999). Difficulties in treating patients with eating disorders: A review of patient and clinician variables. The Canadian Journal of Psychiatry, 44(7), 665-670.

[9] Fitzgerald, M., & Ratcliffe, G. (2020). Serious games, gamification, and serious mental illness: a scoping review. Psychiatric Services, 71(2), 170-183.

[10] Ferguson, C., Van den Broek, E. L., & Van Oostendorp, H. (2020). On the role of interaction mode and story structure in virtual reality serious games. Computers & Education, 143, 103671.

[11] Hamari, J., Shernoff, D. J., Rowe, E., Coller, B., Asbell-Clarke, J., & Edwards, T. (2016). Challenging games help students learn: An empirical study on engagement, flow and immersion in game-based learning. Computers in human Behavior, 54, 170-179.

[12] Crepaldi, M., Colombo, V., Mottura, S., Baldassini, D., Sacco, M., Cancer, A., & Antonietti, A. (2020). The use of a serious game to assess inhibition mechanisms in children. Frontiers in Computer Science, 2, 34.

[13] Mena-Moreno, T., Fernández-Aranda, F., Granero, R., Munguía, L., Steward, T., López-González, H., … & Jiménez-Murcia, S. (2021). A serious game to improve emotion regulation in treatment-seeking individuals with gambling disorder: A usability study. Frontiers in Psychology, 12, 621953.

[14] Mekler, E. D., Brühlmann, F., Tuch, A. N., & Opwis, K. (2017). Towards understanding the effects of individual gamification elements on intrinsic motivation and performance. Computers in Human Behavior, 71, 525-534.