Background: Games and game components have become a major trend in the realm of digital health research and practice as they are assumed to foster behavior change and thereby improve patient-reported and clinical outcomes for patients with type 2 diabetes.
Objective: The aim of this systematic review was to summarize and evaluate the current evidence on the effectiveness of digital health interventions containing game components on behavioral, patient-reported, and clinical outcomes for patients with type 2 diabetes.
Methods: An electronic search was conducted in MEDLINE and PsycINFO in April 2020; updated in April 2022; and supplemented by additional searches via Google Scholar, Web of Science (which was used for forward citation tracking), and within the references of the included records. Articles were identified using predefined inclusion and exclusion criteria. In total, 2 reviewers independently conducted title, abstract, and full-text screening and then individually performed a critical appraisal of all the included studies using the Cochrane risk-of-bias tool version 2. A consensus was reached through discussion.
Results: Of 2325 potentially relevant titles (duplicates excluded), 10 (0.43%) randomized controlled trials were included in this review. Quality assessment revealed a high risk of bias for all randomized controlled trials except for 10% (1/10), with performance bias due to the lack of blinding being the major source of bias. There is evidence suggesting that digital health interventions containing game components can substantially improve motivation for physical activity (1/1, 100% of the studies dealing with PA motivation), exercise intensity (3/5, 60%), dietary behavior (4/4, 100%), health literacy (1/3, 33%), mental quality of life (2/2, 100%), glycated hemoglobin level (2/6, 33%), BMI (1/3, 33%), fasting plasma glucose level (1/2, 50%), waist circumference (1/1, 100%), and aerobic capacity (1/1, 100%).
Conclusions: Published studies indicated that digital health interventions containing game components might improve health behavior patterns, quality of life, and clinical outcomes in patients with type 2 diabetes. However, the intervention types and outcomes studied were heterogeneous, and study quality was mostly low, which translates to ambiguous results. Future research should focus on sound methodology and reporting as well as on identifying game components that contribute to significant positive effects.
Trial Registration: PROSPERO CRD42020209706; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=209706
According to the 2021 and most recent Diabetes Atlas provided by the International Diabetes Federation, diabetes affects 537 million people worldwide, which equals a share of almost 7% of the world’s total population . Compared with the data provided in the 2019 Atlas, this is an increase in diabetes prevalence of almost 16% within 2 years [ ]. The vast majority of people diagnosed with diabetes (95%) live with type 2 diabetes [ , ].
Apart from genetic predispositions and a higher probability of having a diabetes diagnosis at an older age, several risk factors of type 2 diabetes are lifestyle-related, such as physical inactivity; malnutrition; and, correspondingly, overweight and obesity . Therefore, several clinical practice guidelines on the treatment of type 2 diabetes focus not only on pharmacological interventions but also on a comprehensive self-management regimen that includes theory-based behavior change [ - ]. Measures for the latter warranted by the so-called Diabetes Self-Management and Education (DSME) regimen defined by the American Diabetes Association (ADA) include education on symptoms, etiology of and coping with diabetes, the adoption of a healthy (ie, high fiber- and fruit- and vegetable-based) diet, and the uptake of regular physical activity (PA) as a means to achieve weight loss [ , ]. Apart from the education component, continuous monitoring of blood glucose values, food intake, and frequency and intensity of PA is a requirement of DSME [ ].
The potential of digital health applications, such as telemedicine, for supporting patients regarding DSME is well documented for patients with a more recent diabetes diagnosis, especially for applications that enable continuous glucose self-monitoring or health care provider feedback on the values recorded .
Recently, interest has spiked in digital health applications containing game components as they are expected to offer aid in behavior change , which, for many patients, is a necessary precondition for successful DSME [ ]. Game components such as scoring systems, trophies, and leaderboards have been shown to be effective in increasing the motivation for uptake of healthy behaviors in a number of chronic conditions [ ] as well as a measure of health promotion. However, the methodological quality of the evidence is still moderate to low [ ]. Educational games often rely on storytelling elements such as coherent narratives and episodes, which generate a so-called transportation effect where players immerse themselves completely in the narrative world, which loosens reluctance toward behaviors perceived as laborious or unpleasant, such as PA [ , ]. Exergames stimulate PA by challenging the players’ abilities and rewarding success [ ].
A moderating role of the regulatory mode can be assumed in the relationship between gaming and behavior change. According to theory, either individuals can assess the situation they are in and then develop the most adequate strategy to reach a behavioral aim (assessment) or they can just initiate the behavior for which they strive (locomotion). Locomotion is associated with higher intrinsic motivation, whereas assessment is associated with anticipating failure and, therefore, procrastination .
In 2016, a meta-analysis including both types of game-based interventions (educational games and exergames) for patients with diabetes (type 1 and 2) showed no effect on blood glucose values (glycated hemoglobin [HbA1c]) but showed an effect on quality of life, balance, and muscle strength . Theng et al [ ] found that videogames were useful tools for diabetes education independent of diabetes type. However, the analyses are outdated (both searches were conducted in 2014) given the substantial increase in the availability of gamified health interventions, as evidenced by a recent overview of gamified interventions used in the context of diabetes [ ], half of which were launched after 2016. The median survival time of reviews is 5.5 years before they are outdated [ ]. In addition, patient populations and the measures taken to deal with type 1 and type 2 diabetes differ greatly [ ], and so do the effective components of digital health applications [ ]. Therefore, targeted game-based interventions are necessary as well. Furthermore, given the complex requirements of DSME, focusing the analysis solely on clinical outcomes and neglecting behavioral outcomes as well as patient-reported outcomes (PROs), as did Martos-Cabrera et al [ ] and Kaihara et al [ ], is limited in perspective.
Therefore, the questions to be answered were as follows: (1) Do digital game-based interventions have an effect on the health behavior of patients with type 2 diabetes? and (2) Do digital game-based interventions have an effect on clinical outcomes and PROs in patients with type 2 diabetes?
The protocol for this systematic review was published beforehand in PROSPERO (CRD42020209706) and followed during the conduct of the review. Reporting of the results adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement .
Study Inclusion and Exclusion
The inclusion and exclusion criteria were defined according to the population, intervention, control, outcome, and study design scheme (and ). For this purpose, digital health interventions containing game components were defined as the intervention group, whereas usual care or the use of digital health interventions without a game component were defined as the control group.
Study inclusion criteria.
- Participants with type 2 diabetes (no age restriction)
- Use of digital health applications containing game components identified in previous reviews [ , ] (such as virtual reality, serious gaming, or exergaming)
- Use of digital health applications without game components or standard or usual care
- Primary outcomes:
- Behavioral outcomes such as physical activity or dietary behavior
- Secondary outcomes:
- Patient-reported outcomes such as self-efficacy, patient empowerment, and quality of life
- Clinical parameters such as glycated hemoglobin (blood sugar value), BMI, and systolic blood pressure or diastolic blood pressure
- Randomized controlled trials
- Nonrandomized studies (only when n>10)
Study exclusion criteria.
- Participants without diabetes or with type 1 or gestational diabetes
- No treatment or intervention
- No treatment or intervention
- Neither behavioral outcomes nor patient-reported outcomes or clinical parameters studied
- Cross-sectional studies, qualitative studies, reviews, and meta-analyses
Only studies published in English or German were included.
An electronic database search was conducted in MEDLINE (via PubMed) and PsycINFO to cover both medical and psychological research. The initial search was conducted in April 2020 and updated in April 2022 with no restrictions on start time. The search string () included terms covering type 2 diabetes (population), including Medical Subject Heading terms and synonyms for game and gaming (intervention) as well as game components, and was piloted in previous research [ ]. Population and intervention terms were linked with the operator AND. No restrictions were imposed on the outcome category of the search string to avoid accidentally excluding relevant effects of gamified interventions.
Additional searches were conducted within the references of the included studies (backward citation tracking) as well as on Google Scholar and Web of Science, where publications citing the included studies were checked (forward citation tracking) in July 2022.
Screening and Data Extraction
The screening of relevant records was a 2-step process. First, 2 independent reviewers screened the titles and abstracts of all records found by the database and hand searches. If deemed relevant by at least one reviewer, the full text was assessed for eligibility by both reviewers as well. The reference manager EndNote (Clarivate Analytics) was used for both screening and duplicate removal.
Data were extracted according to the population, intervention, control, outcome, and study design scheme, aiming at allowing for a comparison of the effects of different gamified intervention types on the aforementioned outcome domains. In addition, the following information was extracted from each study: (1) bibliographic information, (2) population characteristics, (3) the allocation of the study participants to the intervention and control group or control groups, (4) treatment or interventions applied to the control group (as a means to account for plausible confounding factors), (5) inclusion and exclusion criteria of each applicable study (as a means to account for plausible confounding factors), and (6) outcome measures (to inform quality assessment).
The data extraction sheet was piloted by 2 researchers on 2 of the included studies, which were randomly selected, and subsequently slightly adjusted by including the category “outcome measures.” Data extraction was performed using a Microsoft Excel (Microsoft Corp) spreadsheet.
For a visual representation, HbA1c values at baseline and after intervention completion were extracted in percentage or mmol/mol depending on the data available in the included studies, along with the SD. Δ HbA1c was computed, and statistical significance was extracted from the included studies. The threshold for statistically significant effects was set at P<.05. No assumptions were made if information was missing; this was labeled as “not reported” instead. All study results were tabulated. Apart from the tabulation and visualization of HbA1c results, the presentation of the results is narrative.
The randomized controlled trials (RCTs) found were assessed for study quality by applying the Cochrane risk-of-bias tool version 2 (RoB 2) , whereas cohort studies, if included, were assessed using the corresponding Critical Appraisal Skills Programme (CASP) cohort study checklist [ ]. Case-control studies were assessed using the corresponding checklist also provided by the CASP [ ]. The RoB 2 covers bias within an outcome resulting from the randomization process (selection bias); blinding of participants, assessors, and analysts; deviations from intervention delivery (performance bias); changes in participants’ adherence to the intervention (attrition bias); modalities of outcome measurement; or selective reporting (reporting bias). RoB 2 assessment was performed for each relevant study outcome according to our inclusion criteria. According to the RoB 2 manual, the overall risk of bias within a study was deemed high if 1 study outcome had a high risk of bias. Both records by Höchsmann et al [ , ] were treated as 1 study with several outcomes. CASP checklists for nonrandomized studies cover the same categories except for randomization and blinding while also putting an emphasis on practical implications of the study results. In contrast to the RoB 2, CASP checklists were applied to the entire study instead of to selected outcomes. The RoB 2 deems studies to be at a low risk of bias when a low risk of bias is detected for all relevant domains. Some concerns regarding the risk of bias within an outcome can be assumed when some concerns are raised for at least one domain. A high risk of bias can be assumed when multiple domains raise some concerns or a high risk of bias is detected for at least one domain [ ]. With the CASP, overall risk of bias is assessed by answering the following question: “Do you believe the results?”
Quality assessment was performed for the effect of both assignment to the intervention (ie, the intention-to-treat effect) and adherence to the intervention (ie, the per-protocol effect).
All steps of the review—screening of titles and abstracts and full texts, data extraction, and quality assessment—were performed by at least 2 researchers independently (LO, LH, or PT in the first search period and LH and TH in the second search period) to minimize bias. Differences in inclusion, extraction, and quality assessment were resolved through discussion with a third person not involved in the screening process (SD).
Diversions From the Protocol
Contrary to the protocol registered with PROSPERO, research question 2 was adapted so that it clearly addressed PROs. Furthermore, we refrained from performing a search in key journals as these were all listed in MEDLINE.
Results of the Search Process
Both database searches (2020 and 2022) taken together yielded 2325 results. A total of 7 additional potentially relevant publications were identified via additional searches, but excluded after full text assessment. In total, 2087 publications remained after duplicates were removed, 2034 (97.5%) of which were removed after title and abstract screening. The full texts of the remaining 53 publications were assessed for eligibility. This process led to the exclusion of 25% (13/53) of the studies as they addressed a population outside this review’s scope, such as patients with type 1 or prediabetes [- ]. Another 40% (21/53) of the studies were excluded as the interventions studied did not have a game component [ - ]. A total of 15% (8/53) of the studies were excluded as they used 1-armed designs or did not study any of the prespecified outcomes but solely patient experiences, such as satisfaction with the application [ - ]. A complete list of the excluded studies with reasons for exclusion can be found in [ - ]. Finally, 10 studies were included in the qualitative data analysis [ , , - ]. Höchsmann et al [ , ] reported results from the same study in 2 records. The process of study selection is depicted in .
Descriptive Statistics of the Populations Studied
All the included studies (10/10, 100%) were RCTs. However, Kempf and Martin  and Brinkmann et al [ ] applied a crossover design in which participants in the control group received the intervention later during the study period. The study samples ranged from 8 participants [ ] to 465 participants [ ]. The lowest mean age was 44 (SD 7.9) years [ ] and the highest mean age was 68 (SD 5.8) years [ ]. Brinkmann et al [ ] only reported the age span of the study participants, which was 67 to 75 years. Overall, 533 female participants and 1061 male participants were included. The intervention duration ranged from 30 minutes (exergame) [ ] to 36 weeks (self-management app with quiz component) [ ]. In total, 30% (3/10) of the RCTs performed follow-up analyses after the intervention period, with follow-up times ranging from 7 days [ ] to 48 weeks [ ]. A complete overview of the population characteristics of the included RCTs can be found in .
|Study, year, title, journal, and country||Study design||Study duration||Follow-up time||Population characteristics|
|Sample size, n||Age (years)||Sex||Inclusion criteria||Exclusion criteria|
|Brinkmann et al , 2017, “Effects of Cycling and Exergaming on Neurotrophic Factors in Elderly Type 2 Diabetic Men—A Preliminary Investigation”/Experimental and Clinical Endocrinology & DiabetesExp Clin Endocrinol Diabetes, Germany||Individually randomized crossover trial||30 min once||None||8||Ranging from 67 to 75||8 male participants|
|Dugas et al , 2018, “Individual Differences in Regulatory Mode Moderate the Effectiveness of a Pilot mHealth trial for Diabetes Management among older Veterans”/PLOS ONEa, United States||Individually randomized controlled trial||13 weeks||None||27||Mean 67.8 (SD 6.1)||Not reported|
|Glasgow et al , 2010, “Outcomes of Minimal and Moderate Support Versions of an Internet-Based Diabetes Self-Management Support Program”/Journal of General Internal Medicine, United States||Individually randomized controlled trial||16 weeks||None||463||Mean 58.4 (SD 9.2)||233 male and 230 female participants|
|Grewal et al , 2015, “Sensor-Based Interactive Balance Training with Visual Joint Movement Feedback for Improving Postural Stability in Diabetics with Peripheral Neuropathy: A Randomized Controlled Trial”/Gerontology, United States||Individually randomized controlled trial||45 min twice a week for 4 weeks||None||39||Mean 63.7 (SD 8.2)||20 male and 19 female participants|
|Höchsmann et al [, ], 2019, “Effectiveness of a Behavior Change Technique–Based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Patients With Type 2 Diabetes: Randomized Controlled Trial”/JMIR Serious Games and “Novel Smartphone Game Improves Physical Activity Behavior in Type 2 Diabetes”/American Journal of Preventive Medicine, Switzerland||Individually randomized controlled trial||24 weeks||None||36||Mean 57 (SD 5.5)||19 male and 17 female participants|
|Kempf and Martin , 2013, “Autonomous Exercise Game Use Improves Metabolic Control and Quality of Life in Type 2 Diabetes Patients—a Randomized Controlled Trial”/BMC Endocrine Disorders, Germany||Crossover individually randomized controlled trial||30 min per day for 12 weeks||None||220||Mean 62 (SD 11; [intervention group]) and 60 (SD 9; [control group])||119 female and 101 male participants|
|Kerfoot et al , 2017, “A Team-Based Online Game Improves Blood Glucose Control in Veterans With Type 2 Diabetes: A Randomized Controlled Trial”/Diabetes Care, United States||Individually randomized controlled trial||24 weeks||48 weeks||465||Mean 59.5 (SD 9.9)||28 female and 428 male participants|
|Koohmareh et al , 2020, “Effect of Implementing a Mobile Game on Improving Dietary Information in Diabetic Patients”/Medical Journal of The Islamic Republic of Iran, Iran||Individually randomized controlled trial||15 min per day for 6 weeks||None||60||Mean 44.1 (SD 7.9; control group) and 43.9 (SD 9.0; intervention group)||32 female and 28 male participants|
|Maharaj et al , 2021, “Comparing Two Commercially Available Diabetes Apps to Explore Challenges in User Engagement: Randomized Controlled Feasibility Study”/JMIR Formative Research, Australia and New Zealand||Individually randomized controlled trial||2 weeks||None||89||Mean 53.2 (SD 11.1; control group) and 52.6 (SD 13.0; intervention group)||31 female and 58 male participants|
|Turnin et al , 2021, “Impact of a Remote Monitoring Programme Including Lifestyle Education Software in Type 2 Diabetes: Results of the Educ@dom Randomised Multicentre Study”/Diabetes Therapy, France||Individually randomized controlled multicenter study||48 weeks||None||263||Mean 59.6 (SD 9.6)||57 female and 166 male participants|
aPLOS ONE: Public Library of Science ONE.
bHbA1c: glycated hemoglobin (blood sugar value).
cCVD: cardiovascular disease.
dPA: physical activity.
eDPP-4: dipeptidyl peptidase 4
Results of the Quality Assessment
Applying the RoB 2, a high risk of bias was detected in 90% (9/10) of the included RCTs [, - ]. A total of 10% (1/10) of the studies had a low risk of bias [ ]. For 40% (4/10) of the RCTs, multiple reasons for a high risk of bias were detected [ , , , ], whereas for 30% (3/10) of the studies, only 1 reason was found [ , , ]. The allocation sequence was random in all but 10% (1/10) of the cases [ ]. Major sources of bias were the blinding of study participants and personnel to the allocation to either the intervention or the control group [ , , , , , ] and, to a smaller degree, inadequate (ie, nonreliable or nonvalidated) measures for outcome assessment [ , - , , ], both of which translate to detection bias. Most of the included RCTs (7/10, 70%) conducted per-protocol analyses [ , , , , , , , ], whereas another study did not specify the type of analysis [ ]. As such, the effect estimate was potentially biased by dropouts in all but 20% (2/10) [ , ] of the included RCTs (attrition bias). Glasgow et al [ ] and Kerfoot et al [ ] performed an intention-to-treat analysis, whereas the remaining authors all performed per-protocol analyses except for Koohmareh et al [ ], for whom the type of analysis could not be discerned. Bias because of selective reporting was detected by comparing the outcomes described in the Methods sections and those reported in the Results sections [ , ]. The results of the quality assessment can be found in .
Game Types and Components Analyzed in the Included RCTs
Of the 10 included RCTs, 4 (40%) focused on an exergame [, , , , ], one (25%) of which reported first behavioral and then clinical results of the same exergame intervention studied with the same population [ , ]. A total of 20% (2/10) of the studies reported on the effects of game components within digital self-management applications for diabetes [ , ]. In 40% (4/10) of the RCTs, the authors analyzed quiz games with DSME content [ , , , ]. The digital intervention studied by Brinkmann et al [ ] combined an exergame with a game for cognitive problem-solving.
Within the exergames, virtual reality components such as virtual race tracks were used [, , ]. Scoring systems awarding trophies to winners or when individualized scores were achieved were used in 60% (6/10) of the interventions [ , , , , , , ]. Storytelling features were part of 20% (2/10) of the interventions studied [ , ], and 10% (1/10) of the interventions applied a team-based approach to the game [ ].
Among the 4 RCTs in which the authors reported on the matter [, , , ], intervention intensity varied between 30 minutes once (equal to intervention duration) [ ], 15 minutes per day for 6 weeks [ ], 30 minutes per day for 12 weeks [ ] and 45 minutes twice a week for 4 weeks [ ].
A complete overview of the intervention types and game components studied in the included RCTs can be found in.
|Study, year||Intervention group||Control group||Intervention|
|Brinkmann et al , 2017||30 minutes||30 minutes|
|Dugas et al , 2018||13 weeks||Not reported|
|Glasgow et al , 2010||16 weeks||Not reported|
|Grewal et al , 2015||4 weeks||45 minutes twice a week|
|Höchsmann et al [, ], 2019||24 weeks||Not reported|
|Kempf and Martin , 2013||12 weeks||>30 minutes per day for 12 weeks|
|Kerfoot et al , 2017||24 weeks||Not reported|
|Koohmareh et al , 2020||6 weeks||15 minutes per day for 6 weeks|
|Maharaj et al , 2021||2 weeks||Not reported|
|Turnin et al , 2021||48 weeks||Not reported|
aDSME: Diabetes Self-Management and Education.
Effects of Gamified Health Interventions on Health Behavior
Exercise intensity and adherence were studied in 50% (5/10) of the included studies [, , - , ]. A total of 40% (4/10) of the studies reported on nutritional behavior [ , , , ], and 20% (2/10) of the studies reported on medication adherence [ , ].
Positive effects on behavioral PA outcomes were reported in several of the included RCTs (4/10, 40%). A total of 50% (2/4) of the exergames studied led to an increased intensity of PA (measured as step count, caloric expenditure, and self-report) in the study participants [, , ], and so did the quiz component nested within the DSME website studied by Glasgow et al [ ]. However, the latter was only effective when the website was supplemented with follow-up calls by study staff as a supportive measure in handling the website and group meetings with other study participants [ ]. Only Höchsmann et al [ ] reported on PA adherence and found no substantial effect of their exergame on PA adherence, where PA exercises were nested within a coherent narrative. However, the intervention statistically significantly increased intrinsic motivation for PA (P<.001), whereas intrinsic motivation decreased in the control group (1-time lifestyle counseling and structured exercise plan) during the study period. Between-group effects were significant. The authors also found a significant positive relationship between time spent doing the in-game exercises and PA motivation (P=.01) [ ].
Dugas et al  found no overall intervention effect of any of the intervention arms studied on adherence as a whole (quantified using an in-app rating system; ), but they found a statistically significant interaction effect (in regression analysis) of time spent using the self-management app with game elements and assessment (P=.01). They also found a statistically significant interaction effect of time and locomotion on weekly exercise adherence (P<.05) [ ].
In 40% (4/10) of the RCTs, the authors found significant positive effects on nutrition behavior. Glasgow et al  reported a significant decrease in fat intake in the intervention group compared with that in the control group (P value for intergroup differences=.006). Koohmareh et al [ ] found that participants using their educational game on glycemic index and calorie intake paid significantly more attention to the glycemic levels and calorie count of their food (P value for intergroup differences=.001). Maharaj et al [ ] showed that participants using the mySugr app with the reward system could significantly reduce their high-fat food consumption, whereas no significant changes were found in the control group using a self-management app without a game component (P value for intergroup differences=.052). Interaction effects of time and assessment as well as of time and locomotion were found by Dugas et al [ ] for nutrition adherence (quantified using an in-app rating system) as well. The authors also found a significant positive effect of locomotion on nutritional adherence (P<.05) but none of assessment (P value not reported) [ ].
Glasgow et al  found no significant effect of the intervention on medication adherence or on eating habits other than fat intake (P value for intergroup differences=.006). Dugas et al [ ] found an interaction effect of time spent using the intervention and assessment on medication adherence (P=.04).
A total of 40% (2/5) of the exergames studied had no effect on PA intensity [, ]. Overall, positive effects of digital health interventions with game components could be found on motivation for and intensity of PA as well as on eating habits.
|Study, year||Outcome (outcome measure)||Results||Study quality according to RoB 2a|
|Brinkmann et al , 2017|
|Dugas et al , 2018|
|Glasgow et al , 2010|
|Grewal et al , 2015|
|Höchsmann et al [, ], 2019|
|Kempf and Martin , 2013|
|Kerfoot et al , 2017|
|Koohmareh et al , 2020|
|Maharaj et al , 2021|
|Turnin et al , 2021|
aRoB 2: Cochrane risk-of-bias tool version 2.
bBDNF: brain-derived neurotrophic factor.
cVEGF: vascular endothelial growth factor.
dIGF-1: insulin-like growth factor–1.
eHbA1c: glycated hemoglobin (blood sugar value).
fPA: physical activity.
gBMI: body mass index
hPRO: patient-reported outcome.
iFES-I: Falls Efficacy Scale–International.
jVPT: vibration perception threshold.
kSF-12: Short Form Health Survey.
lLDL-C: low-density lipoprotein cholesterol.
mHDL-C: high-density lipoprotein cholesterol.
nSBP: systolic blood pressure.
0DBP: diastolic blood pressure.
pFPG: fasting plasma glucose.
qPAID: Problem Areas in Diabetes Scale.
rWHO-5: 5-item World Health Organization Well-Being Index.
sADS-L: Allgemeine Depressionsskala long version (German).
tDPP-4: dipeptidyl peptidase 4.
uPPR: patient-pill ratio.
vAmoo: diabetes test designed by Koohmareh et al .
wSDSCA: Summary of Diabetes Self-Care Activities.
Effects of Gamified Health Interventions on PROs
In the included RCTs, data were provided on health literacy in general [, , ], quality of life [ , ], diabetes-related impairment [ , ], and subjective well-being [ ].
Concerning health literacy, Koohmareh et al  found a significant positive effect of their educational game on knowledge concerning a diet adequate for patients with diabetes (measured on a self-developed scale; P=.001). Maharaj et al [ ] found no significant median differences in illness beliefs (measured using the Brief Illness Perception Questionnaire) between the gamified mySugr and the self-management app without any game components (P value for intergroup differences=.05). Glasgow et al [ ] used health literacy as a moderating variable in a multivariate analysis of covariance to measure the effects of their self-management website with quiz elements but found no interaction effects (P value not reported).
In the domain of quality of life, Grewal et al  found a significant improvement in mental well-being because of the virtual balance training they studied (P value for intergroup differences=.04) but no effect of said intervention on physical well-being (P value for intergroup differences=.64; both measured using the Short Form 12 Health Survey). The same effect was demonstrated by Kempf and Martin [ ], who studied Wii Fit Plus games, using both the Short Form 12 Health Survey and a German depression scale. Subjective well-being, measured using the 5-item World Health Organization Well-Being Index scale, improved significantly in the study by Kempf and Martin [ ] as well (P value for intergroup differences=.004).
Grewal et al  and Kempf and Martin [ ] studied the effects of gamified interventions on diabetes-related impairment both using the Problem Areas in Diabetes Scale. Although the latter found a positive effect of the Wii Fit Plus games (P value for intergroup differences=.03) [ ], the former found no effect of virtual balance training (P value not reported) [ ]. In terms of impairment, Grewal et al [ ] found no effect of the virtual balance training on fear of falling (P value for intergroup differences=.31).
Overall, sparse positive effects of digital health interventions with game components could be found on health literacy and diabetes-related impairment, whereas substantial evidence was found for the improvement of subjective mental well-being.
Effects of Gamified Health Interventions on Clinical Outcomes
The clinical outcome studied most often in the included RCTs was HbA1c [, , , - ]. Furthermore, 30% (3/10) of the included studies analyzed changes in BMI [ , , ], whereas Höchsmann et al [ ], Glasgow et al [ ], and Kempf and Martin [ ] also analyzed lipid outcomes and blood pressure values. Fasting plasma glucose (FPG) was studied twice [ , ], and so was the heart rate of the participants [ , ]. Brinkmann et al [ ] studied cognitive parameters in conjunction with lactate values, and Grewal et al [ ] analyzed postural stability.
The effects of the gamified interventions on HbA1c levels studied in 60% (6/10) of the RCTs are depicted in, where asterisks mark significant changes in HbA1c. Only Kerfoot et al [ ] (P value for intergroup differences=.048) and Kempf and Martin [ ] (P value for intergroup differences.001) found significant positive effects of a mobile, team-based DSME quiz and Wii Fit Plus games, respectively, on HbA1c levels in terms of a reduction in the intervention group and significant between-group effects. Dugas et al [ ] found a significant effect of time spent using the self-management app with an award system on HbA1c levels in a regression analysis (P.01), as well as an interaction effect of total adherence score (additive score of exercise, nutrition, and medication adherence; P.01).
Kempf and Martin  also found significant positive effects of the intervention on BMI (P value for intergroup differences=.008); however, Glasgow et al [ ] (P value for intergroup differences=.20) and Turnin et al [ ] (P value for intergroup differences=.08), also studying DSME software with quiz components, did not. Significant effects on FPG after using the same software were also reported by Kempf and Martin [ ] (P value for intergroup differences=.008) but not by Koohmareh et al [ ] (P value for intergroup differences=.63), who studied the same intervention type. Significant effects were not found on lipid outcomes and blood pressure values [ , , ] or on cognitive outcomes and lactate values [ ]. Grewal et al [ ] found their exergame, including a virtual obstacle course, to have a positive effect on postural stability when compared with usual care (P value for intergroup differences=.009).
Turnin et al  found a significant reduction in waist circumference in the intervention group when compared with the control group both before and after adjusting for confounding factors such as baseline HbA1c levels, age, sex, or obesity (P value for intergroup differences=.04). The authors also reported an increased effect on waist circumference in those with a higher frequency of use (P=.008).
No significant effects were found on heart rate [, ], blood pressure (systolic or diastolic) [ , ], or lipid values (ie, on total cholesterol, triglycerides, low-density lipoprotein cholesterol, or high-density lipoprotein cholesterol) [ , ] in any of the RCTs that reported on these values.
Brinkmann et al  studied the vascular endothelial growth factor as an indicator of diabetes retinopathy but found no effect of the Wii Fit exergame they studied (P value not reported). Furthermore, they found no effect of the intervention on insulin-like growth factor–1 as a proxy for poorly adjusted diabetes (P value not reported).
Brinkmann et al  found improved lactate values in the intervention group (P=.04) but not in the control group (P value not reported), which used a stationary bicycle, thus indicating higher fitness levels owing to the exergame. Improved fitness because of an exergame was also demonstrated by Höchsmann et al [ ] using aerobic capacity as an indicator (P.001). Grewal et al [ ] found improved postural stability to be an effect of the virtual balance training they studied (P=.009).
As Brinkmann et al  aimed to also improve cognitive functioning of the study participants by adding cognitive challenges to the exergame, they studied the brain-derived neurotrophic factor as an indicator of learning and memory capacity and found no significant effect of the intervention (P value not reported).
Overall, sparse positive effects of digital health interventions with game components could be found on clinical outcomes, with fitness-related outcomes improving the most.
A complete overview of the effects found in the included RCTs can be found in. If not stated otherwise, differences in outcomes are reported between the intervention and control group(s) before and after the study in .
Despite heterogeneity in the effects of the gamified applications studied in this review on behavioral, clinical, and patient-reported outcomes, certain patterns emerged. Exergames had the tendency to improve fitness-related and, to a smaller extent, clinical values (as shown in 4/10, 40% of the RCTs [, - ]), whereas educational games affected disease-related knowledge and especially nutrition behavior (as shown in 4/10, 40% of the RCTs [ , , , ]). In addition, exergames had a potential to improve outcomes related to self-reported well-being such as quality of life and diabetes-related impairment (as shown in 2/10, 20% of the RCTs [ , ]).
Comparison With Prior Work
The results confirm those of a meta-analysis by DeSmet et al , who showed significant positive effects of serious games on health behavior independent of any diagnosis and its theory-based determinants and significant but much smaller effects on various clinical outcomes. As for nutrition behavior, which improved according to 40% (4/10) of the RCTs included in this review solely because of self-management applications with quiz elements, Ledoux et al [ ] found similar effects of a serious game for young patients with type 1 diabetes.
Somewhat surprisingly, self-efficacy was not among the outcomes studied in the included RCTs despite existing evidence that both exergames and serious games can increase the feeling of being able to actively affect one’s health outcomes [, ]. A precondition derived from behavior change theories is the option for goal setting by the intervention participants themselves as opposed to behavioral goals predefined by the intervention developers [ ]. This precondition was met by all the gamified interventions studied in this review that used a reward or scoring system as these game components allow for the autonomous setting of target values that the users aim to achieve and, thus, generate intrinsic motivation [ ].
A coherent narrative as an instrument of storytelling was used in only 20% (2/10) of the included interventions; however, it aided in producing positive effects on behavioral, knowledge-related [, ], and clinical outcomes [ ]. As such, the results confirm observations made for narrative health communication messages when delivered in a digital manner [ ].
Physical fitness because of an increase in PA owing to interventions with game components is an especially promising result as PA is one of the primary target behaviors of diabetes self-management. The same is true for dietary behavior . As such, these results underline once more the potential of digital interventions for DSME, acknowledged also by the ADA and the European Association for the Study of Diabetes in a joint statement [ ].
The relatively high mean age of the study participants is surprising insofar as the traditional target group for digital health applications of all sorts is usually younger people . Christensen et al [ ], in sensitivity analyses, also found a positive effect of game-based interventions only for people aged 18 years. Especially regarding exergaming, the positive effects for older people because of high engagement have already been proven elsewhere [ ]. Given the fact that most of the gamified interventions studied in this review (7/10, 70%) were designed for mobile devices, the high penetration of such devices in all age groups might play an important role in overcoming the digital health divide because of age [ ]. Therefore, the results need to be considered in light of demographic changes and a rise in the demand for health care, especially for chronic diseases [ ].
With intervention duration varying widely (), statements on its relevance have to be made with caution. However, the results show that effects on clinical outcomes can be achieved via digital health interventions with game components after at least 12 months [ , ], which corresponds to the concept of DSME as a continuous, long-term intervention [ , ]. However, even 36 weeks of intervention duration did not guarantee significant effects on BMI and HbA1c [ ], hinting at a washout in intervention fidelity common in digital health applications [ ].
The fact that generally positive effects of digital health interventions of any kind are biased because of low overall study quality also mirrors findings of recent evidence syntheses [, ]. The methodological issues concerning the quality of obtainable evidence raised in the joint statement by the ADA and the European Association for the Study of Diabetes [ ] persist in this review even though all the included studies (10/10, 100%) were RCTs or had adaptive RCT designs. The issue of blinding of study participants and personnel to the allocation is common in digital health trials as the fact that one did not receive a gamified health application is easily uncovered [ ]. Therefore, the study conducted by Maharaj et al [ ] is a positive example of comparing 2 digital health applications whereby one is augmented with game components. The issue of missing outcome data because of dropouts, well known to researchers in multiple fields, is also common in digital health research [ ] and is linked to the issue of intervention fidelity. The reasons as to why trial participants may lose interest in the use of digital health applications can be numerous [ ]. Therefore, participatory design is an important precondition for gamified applications as well [ ]. Nonvalidated outcome measures, another major source of bias in the included RCTs, point to the need to develop core outcome sets for digital health applications with or without game components.
Strengths and Limitations
Robust and reproducible systematic review methods were used to identify the best available evidence, and the results were reported according to the PRISMA checklist ([ ]). Owing to the fact that all steps taken in this review were performed by 2 researchers independently and checked by a third researcher, it is highly unlikely that relevant records were overlooked or incorrectly discarded as irrelevant. The same is true for information in the included records relevant to the quality assessment.
The focus on research published in German or English is a limitation. Owing to the diverse intervention types (with intervention durations varying widely) and outcomes studied in the rather large number of included RCTs (compared, eg, with the meta-analysis by Christensen et al ), a meta-analysis especially of clinical outcomes was not deemed feasible. Rather, the broad realm of outcomes studied allows for a holistic overview of the potential effects of digital health interventions with game components.
Some of the included RCTs (3/10, 30%) had a considerable loss to follow-up, which would have required intention-to-treat analyses. However, most studies (7/10, 70%) conducted per-protocol analyses instead. Furthermore, the reasons for dropout were not always reported.
Little to no follow-up time after the intervention period limits the comparability of the gamified interventions studied in the included RCTs with other digital or analog behavior change interventions that have demonstrated sustainable effects over time . However, according to both theory and evidence, sustainable and long-lasting behavior change over a time span of at least 6 months is necessary to achieve improved health outcomes and still not easily achieved [ ]. Owing to limited reporting of intervention intensity, no discernible patterns regarding effectiveness could be found. Moreover, effective components of gamified health interventions regarding both clinical outcomes and behavior change have not been identified yet [ ].
This systematic review provided a thorough analysis of the effectiveness of digital health interventions with game components for the self-management of type 2 diabetes. The included RCTs analyzing exergames showed positive effects on fitness-related outcomes and, albeit only in 1 case, also on HbA1c. Educational games improved dietary habits and subjective mental health and well-being. However, the evidence base was ambiguous and further limited because of the considerable risk of bias in the study designs of most of the included RCTs (9/10, 90%). Nevertheless, the results imply that digital health interventions with game components can help improve PA, dietary habits, and well-being. Therefore, these applications, when developed based on theory and evaluated rigorously, can help achieve the behavioral goals mentioned in several guidelines for DSME. Given the mostly low quality of the included RCTs, the presented evidence allows for nothing more than the suggestion of digital health interventions with game components as a supplement to traditional DSME, which corresponds to the statement by Fleming et al . The main results of this review are summarized in .
Main results of the review.
- The variety of game components used in digital health interventions for type 2 diabetes ranges from quiz components over storytelling elements to full-scale exergames.
- Digital health interventions containing game components might improve the health behavior patterns, quality of life, and clinical outcomes of patients with type 2 diabetes.
- The methodological quality was low in most of the included randomized controlled trials.
Further research should compare digital health interventions that contain game components with those that do not rather than comparing the former with usual care and, as such, risking bias because of high dropout rates. Furthermore, longer follow-up assessments are crucial to detect whether the effects of gamified interventions are sustainable. Adaptive study designs such as microrandomization, where individuals are randomized to several intervention components or treatments for the study duration , could be used to determine which game components have an effect on which outcome domain (behavioral, PROs, or clinical). Larger sample sizes would allow for more detailed subgroup analyses [ ] to determine which user groups, in addition to those defined by age, profit the most from digital health interventions containing game components. Finally, but importantly, a comparison of the effects of digital health interventions with game components for patients with type 1 and 2 diabetes is bound to provide further insights.
The work for this review was partly funded by the county of Saxony, Germany.
LO and LH devised the study design and conducted the literature search, study selection process, quality assessment, and data extraction together with TH. SD and PT were involved in the consensus process during study selection, data extraction, and quality assessment. PT, OS, and MS analyzed the extracted data and derived points for discussion and implications. LH drafted the manuscript, which was critically revised for important intellectual content and approved by all the authors.
Conflicts of Interest
Unrelated to this study, OS served as a consultant for Novartis. Unrelated to this study, JS reports institutional grants for investigator-initiated research from the German Federal Joint Committee, Federal Ministry of Health, Federal Ministry of Education and Research, European Union, Federal State of Saxony, Novartis, Sanofi, Allergologisk Laboratorium København (ALK), and Pfizer. He also participated in advisory board meetings as a paid consultant for Sanofi, Lilly, and ALK. JS serves the German Ministry of Health as a member of the Sachverständigenrat Gesundheit und Pflege (expert advisory board on health and care).
Database-specific search strings for PubMed and PsycINFO.DOCX File , 71 KB
List of excluded studies with reasons.DOCX File , 19 KB
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist.DOCX File , 314 KB
- IDF Diabetes Atlas 10th edition. Brussels, Belgium: International Diabetes Federation; 2021.
- Khan MA, Hashim MJ, King JK, Govender RD, Mustafa H, Al Kaabi J. Epidemiology of type 2 diabetes - global burden of disease and forecasted trends. J Epidemiol Glob Health 2020 Mar;10(1):107-111 [FREE Full text] [CrossRef] [Medline]
- Diabetes. World Health Organization. URL: https://www.who.int/news-room/fact-sheets/detail/diabetes [accessed 2023-05-09]
- Beck J, Greenwood DA, Blanton L, Bollinger ST, Butcher MK, Condon JE, 2017 Standards Revision Task Force. 2017 national standards for diabetes self-management education and support. Diabetes Care 2017 Oct;40(10):1409-1419. [CrossRef] [Medline]
- Cosentino F, Grant PJ, Aboyans V, Bailey CJ, Ceriello A, Delgado V, ESC Scientific Document Group. 2019 ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD. Eur Heart J 2020 Jan 07;41(2):255-323. [CrossRef] [Medline]
- Haas L, Maryniuk M, Beck J, Cox C, Duker P, Edwards L, 2012 Standards Revision Task Force. National standards for diabetes self-management education and support. Diabetes Care 2014 Jan;37 Suppl 1(Suppl 1):S144-S153 [FREE Full text] [CrossRef] [Medline]
- Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD). Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2012 Jun;35(6):1364-1379 [FREE Full text] [CrossRef] [Medline]
- Timpel P, Oswald S, Schwarz PE, Harst L. Mapping the evidence on the effectiveness of telemedicine interventions in diabetes, dyslipidemia, and hypertension: an umbrella review of systematic reviews and meta-analyses. J Med Internet Res 2020 Mar 18;22(3):e16791 [FREE Full text] [CrossRef] [Medline]
- Kahol K. Integrative gaming: a framework for sustainable game-based diabetes management. J Diabetes Sci Technol 2011 Mar 01;5(2):293-300 [FREE Full text] [CrossRef] [Medline]
- Hood KK, Hilliard M, Piatt G, Ievers-Landis CE. Effective strategies for encouraging behavior change in people with diabetes. Diabetes Manag (Lond) 2015;5(6):499-510 [FREE Full text] [Medline]
- Sardi L, Idri A, Fernández-Alemán JL. A systematic review of gamification in e-Health. J Biomed Inform 2017 Jul;71:31-48 [FREE Full text] [CrossRef] [Medline]
- Johnson D, Deterding S, Kuhn K, Staneva A, Stoyanov S, Hides L. Gamification for health and wellbeing: a systematic review of the literature. Internet Interv 2016 Nov;6:89-106 [FREE Full text] [CrossRef] [Medline]
- Bassin SR, Kohm K, Fitzgerald N, Cohen DA. An assessment of nutrition education in endocrinology fellowship programs in the United States. Endocr Pract 2022 Mar;28(3):310-314. [CrossRef] [Medline]
- Green MC, Brock TC. The role of transportation in the persuasiveness of public narratives. J Personality Soc Psychol 2000 Nov;79(5):701-721. [CrossRef]
- Lyons EJ. Cultivating engagement and enjoyment in exergames using feedback, challenge, and rewards. Games Health J 2015 Feb;4(1):12-18 [FREE Full text] [CrossRef] [Medline]
- Amato C, Garcia D. Regulatory mode. In: Encyclopedia of Personality and Individual Differences. Cham: Springer; 2020.
- Christensen J, Valentiner LS, Petersen RJ, Langberg H. The effect of game-based interventions in rehabilitation of diabetics: a systematic review and meta-analysis. Telemed J E Health 2016 Oct;22(10):789-797. [CrossRef] [Medline]
- Theng Y, Lee JW, Patinadan PV, Foo SS. The use of videogames, gamification, and virtual environments in the self-management of diabetes: a systematic review of evidence. Games Health J 2015 Oct;4(5):352-361. [CrossRef] [Medline]
- Asadzandi S, Sedghi S, Bigdeli S, Sanjari M. A systematized review on diabetes gamification. Med J Islam Repub Iran 2020 Oct 30;34:168 [FREE Full text] [CrossRef] [Medline]
- Shojania KG, Sampson M, Ansari MT, Ji J, Doucette S, Moher D. How quickly do systematic reviews go out of date? A survival analysis. Ann Intern Med 2007 Aug 21;147(4):224-233 [FREE Full text] [CrossRef] [Medline]
- Martos-Cabrera MB, Membrive-Jiménez MJ, Suleiman-Martos N, Mota-Romero E, Cañadas-De la Fuente GA, Gómez-Urquiza JL, et al. Games and health education for diabetes control: a systematic review with meta-analysis. Healthcare (Basel) 2020 Oct 14;8(4):399 [FREE Full text] [CrossRef] [Medline]
- Kaihara T, Intan-Goey V, Scherrenberg M, Falter M, Frederix I, Akashi Y, et al. Impact of gamification on glycaemic control among patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J Open 2021 Nov;1(3):oeab030 [FREE Full text] [CrossRef] [Medline]
- Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 2009 Jul 21;6(7):e1000097 [FREE Full text] [CrossRef] [Medline]
- Harst L, Timpel P. Systematische Übersicht zum Einsatz von Gamification-basierten Interventionen für Typ II Diabetes. In: Gesundheitskommunikation und Digitalisierung: Zwischen Lifestyle, Prävention und Krankheitsversorgung. Baden-Baden: Nomos; 2020.
- Sterne JA, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ 2019 Aug 28;366:l4898 [FREE Full text] [CrossRef] [Medline]
- Spittlehouse C, Acton M, Enock K. Introducing critical appraisal skills training in UK social services: another link between health and social care? J Interprofessional Care 2009 Jul 06;14(4):397-404. [CrossRef]
- CASP checklist: 11 questionsto help you make sense of a case control study. Critical Appraisal Skills Programme. URL: https://www.unisa.edu.au/contentassets/72bf75606a2b4abcaf7f17404af374ad/4a-casp_case-control_appraisal_checklist.pdf [accessed 2023-05-09]
- Höchsmann C, Infanger D, Klenk C, Königstein K, Walz SP, Schmidt-Trucksäss A. Effectiveness of a behavior change technique-based smartphone game to improve intrinsic motivation and physical activity adherence in patients with type 2 diabetes: randomized controlled trial. JMIR Serious Games 2019 Mar 13;7(1):e11444 [FREE Full text] [CrossRef] [Medline]
- Höchsmann C, Müller O, Ambühl M, Klenk C, Königstein K, Infanger D, et al. Novel smartphone game improves physical activity behavior in type 2 diabetes. Am J Prev Med 2019 Jul;57(1):41-50 [FREE Full text] [CrossRef] [Medline]
- Saiyed S, Joshi R, Khattab S, Dhillon S. The rapid implementation of an innovative virtual diabetes boot camp program: case study. JMIR Diabetes 2022 Jan 14;7(1):e32369 [FREE Full text] [CrossRef] [Medline]
- Owolabi EO, Goon DT, Ajayi AI. Impact of mobile phone text messaging intervention on adherence among patients with diabetes in a rural setting: a randomized controlled trial. Medicine (Baltimore) 2020 Mar;99(12):e18953 [FREE Full text] [CrossRef] [Medline]
- Graham SA, Stein N, Shemaj F, Branch OH, Paruthi J, Kanick SC. Older adults engage with personalized digital coaching programs at rates that exceed those of younger adults. Front Digit Health 2021 Aug 6;3:642818 [FREE Full text] [CrossRef] [Medline]
- Birse CE, Shiffman D, Satish A, Fragala MS, Arellano AR, Sweet CM, et al. Impact of a digital diabetes prevention program on risk factors for chronic disease in a workforce cohort. J Occup Environ Med 2020 Dec;62(12):1040-1045. [CrossRef] [Medline]
- Kumar VS, Wentzell KJ, Mikkelsen T, Pentland A, Laffel LM. The DAILY (Daily Automated Intensive Log for Youth) trial: a wireless, portable system to improve adherence and glycemic control in youth with diabetes. Diabetes Technol Ther 2004 Aug;6(4):445-453. [CrossRef] [Medline]
- Turnin MC, Tauber MT, Couvaras O, Jouret B, Bolzonella C, Bourgeois O, et al. Evaluation of microcomputer nutritional teaching games in 1,876 children at school. Diabetes Metab 2001 Sep;27(4 Pt 1):459-464. [Medline]
- Wang J, Baranowski T, Lau P, Buday R, Gao Y. Story immersion may be effective in promoting diet and physical activity in Chinese children. J Nutr Educ Behav 2017 Apr;49(4):321-9.e1 [FREE Full text] [CrossRef] [Medline]
- Allsop S, Green BP, Dodd-Reynolds CJ, Barry G, Rumbold PL. Comparison of short-term energy intake and appetite responses to active and seated video gaming, in 8–11-year-old boys. Br J Nutr 2016 Jan 28;115(6):1117-1125. [CrossRef]
- Brown SJ, Lieberman DA, Germeny BA, Fan YC, Wilson DM, Pasta DJ. Educational video game for juvenile diabetes: results of a controlled trial. Med Inform (Lond) 1997 Jul 12;22(1):77-89. [CrossRef] [Medline]
- Dring K, Cooper S, Morris J, Sunderland C, Foulds G, Pockley A, et al. Cytokine, glycemic, and insulinemic responses to an acute bout of games-based activity in adolescents. Scand J Med Sci Sports 2019 Apr;29(4):597-605 [FREE Full text] [CrossRef] [Medline]
- Garde A, Umedaly A, Abulnaga SM, Robertson L, Junker A, Chanoine JP, et al. Assessment of a mobile game ("Mobilekids monster manor") to promote physical activity among children. Games Health J 2015 Apr;4(2):149-158. [CrossRef] [Medline]
- Howorka K, Pumprla J, Wagner-Nosiska D, Grillmayr H, Schlusche C, Schabmann A. Empowering diabetes out-patients with structured education: short-term and long-term effects of functional insulin treatment on perceived control over diabetes. J Psychosom Res 2000 Jan;48(1):37-44 [FREE Full text] [CrossRef] [Medline]
- Klaassen R, Bul KC, Op den Akker R, van der Burg GJ, Kato PM, Di Bitonto P. Design and evaluation of a pervasive coaching and gamification platform for young diabetes patients. Sensors (Basel) 2018 Jan 30;18(2):402 [FREE Full text] [CrossRef] [Medline]
- Fundoiano-Hershcovitz Y, Hirsch A, Dar S, Feniger E, Goldstein P. Role of digital engagement in diabetes care beyond measurement: retrospective cohort study. JMIR Diabetes 2021 Feb 18;6(1):e24030 [FREE Full text] [CrossRef] [Medline]
- Anderson D, Sturt J, McDonald N, White C, Porter-Steele J, Rogers R, et al. International feasibility study for the Women's Wellness with Type 2 Diabetes Programme (WWDP): an eHealth enabled 12-week intervention programme for midlife women with type 2 diabetes. Diabetes Res Clin Pract 2021 Jan;171:108541. [CrossRef] [Medline]
- Timurtas E, Inceer M, Mayo N, Karabacak N, Sertbas Y, Polat MG. Technology-based and supervised exercise interventions for individuals with type 2 diabetes: randomized controlled trial. Prim Care Diabetes 2022 Feb;16(1):49-56. [CrossRef] [Medline]
- Guo M, Meng F, Guo Q, Bai T, Hong Y, Song F, et al. Effectiveness of mHealth management with an implantable glucose sensor and a mobile application among Chinese adults with type 2 diabetes. J Telemed Telecare 2021 Jun 21:1357633X2110202. [CrossRef]
- Gupta U, Gupta Y, Jose D, Mani K, Jyotsna VP, Sharma G, et al. Effectiveness of a video-based lifestyle education program compared to usual care in improving HbA1c and other metabolic parameters in individuals with type 2 diabetes: an open-label parallel arm randomized control trial (RCT). Diabetes Ther 2020 Mar 31;11(3):667-679 [FREE Full text] [CrossRef] [Medline]
- Liu H, Guan H, Tan X, Jiang Y, Li F, Sun-Waterhouse D, et al. Enhanced alleviation of insulin resistance via the IRS-1/Akt/FOXO1 pathway by combining quercetin and EGCG and involving miR-27a-3p and miR-96-5p. Free Radic Biol Med 2022 Mar;181:105-117. [CrossRef] [Medline]
- Jiwani R, Wang J, Berndt A, Ramaswamy P, Mathew Joseph N, Du Y, et al. Changes in patient-reported outcome measures with a technology-supported behavioral lifestyle intervention among patients with type 2 diabetes: pilot randomized controlled clinical trial. JMIR Diabetes 2020 Jul 24;5(3):e19268 [FREE Full text] [CrossRef] [Medline]
- Lazo-Porras M, Bernabe-Ortiz A, Taype-Rondan A, Gilman RH, Malaga G, Manrique H, et al. Foot thermometry with mHeath-based supplementation to prevent diabetic foot ulcers: a randomized controlled trial. Wellcome Open Res 2020;5:23 [FREE Full text] [CrossRef] [Medline]
- Li J, Sun L, Hou Y, Chen L. Cost-effectiveness analysis of a mobile-based intervention for patients with type 2 diabetes mellitus. Int J Endocrinol 2021;2021:8827629 [FREE Full text] [CrossRef] [Medline]
- Lukkahatai N, Soivong P, Li D, Jaiman P, Thamkaew S, Chaiwong D, et al. Feasibility of using mobile technology to improve physical activity among people living with diabetes in asia. Asian Pac Isl Nurs J 2021;5(4):236-247 [FREE Full text] [CrossRef] [Medline]
- Martin M, Patterson J, Allison M, O'Connor BB, Patel D. The influence of baseline hemoglobin a1c on digital health coaching outcomes in adults with type 2 diabetes: real-world retrospective cohort study. JMIR Diabetes 2021 Jun 16;6(2):e24981 [FREE Full text] [CrossRef] [Medline]
- Pelletier C, Gagnon M, Alméras N, Després JP, Poirier P, Tremblay A, et al. Using an activity tracker to increase motivation for physical activity in patients with type 2 diabetes in primary care: a randomized pilot trial. Mhealth 2021;7:59 [FREE Full text] [CrossRef] [Medline]
- Sittig S, Wang J, Iyengar S, Myneni S, Franklin A. Incorporating behavioral trigger messages into a mobile health app for chronic disease management: randomized clinical feasibility trial in diabetes. JMIR Mhealth Uhealth 2020 Mar 16;8(3):e15927 [FREE Full text] [CrossRef] [Medline]
- Tu Y, Chang Y, Chiou H, Lai K. The effects of continuous usage of a diabetes management app on glycemic control in real-world clinical practice: retrospective analysis. J Med Internet Res 2021 Jul 15;23(7):e23227 [FREE Full text] [CrossRef] [Medline]
- Whittemore R, Vilar-Compte M, De La Cerda S, Delvy R, Jeon S, Burrola-Méndez S, et al. A self-management randomized controlled pilot trial for low-income adults with type 2 diabetes in mexico city. Curr Dev Nutr 2020 May;4(5):nzaa074 [FREE Full text] [CrossRef] [Medline]
- Yasmin F, Nahar N, Banu B, Ali L, Sauerborn R, Souares A. The influence of mobile phone-based health reminders on patient adherence to medications and healthy lifestyle recommendations for effective management of diabetes type 2: a randomized control trial in Dhaka, Bangladesh. BMC Health Serv Res 2020 Jun 08;20(1):520 [FREE Full text] [CrossRef] [Medline]
- Ruiz JG, Andrade AD, Anam R, Lisigurski M, Karanam C, Sharit J. Computer-based programmed instruction did not improve the knowledge retention of medication instructions of individuals with type 2 diabetes mellitus. Diabetes Educ 2014 Oct 29;40(1):77-88. [CrossRef] [Medline]
- Zeidi IM, Morshedi H, Alizadeh Otaghvar H. A theory of planned behavior-enhanced intervention to promote health literacy and self-care behaviors of type 2 diabetic patients. J Prev Med Hyg 2020 Dec;61(4):E601-E613 [FREE Full text] [CrossRef] [Medline]
- Bai LL, Wang J, Zhang L, Jang HY, Yao R. Using guessing game to increase complication awareness of patients with newly diagnosed type 2 diabetes. Acta Endocrinol (Buchar) 2018;14(3):401-407 [FREE Full text] [CrossRef] [Medline]
- Del Pozo-Cruz J, Alfonso-Rosa R, Ugia J, McVeigh J, Pozo-Cruz B, Sañudo B. A primary care-based randomized controlled trial of 12-week whole-body vibration for balance improvement in type 2 diabetes mellitus. Arch Phys Med Rehabil 2013 Nov;94(11):2112-2118 [FREE Full text] [CrossRef] [Medline]
- Wieland ML, Njeru JW, Hanza MM, Boehm DH, Singh D, Yawn BP, et al. Pilot feasibility study of a digital storytelling intervention for immigrant and refugee adults with diabetes. Diabetes Educ 2017 Aug 07;43(4):349-359 [FREE Full text] [CrossRef] [Medline]
- Dehghani Zahedani A, Shariat Torbaghan S, Rahili S, Karlin K, Scilley D, Thakkar R, et al. Improvement in glucose regulation using a digital tracker and continuous glucose monitoring in healthy adults and those with type 2 diabetes. Diabetes Ther 2021 Jul;12(7):1871-1886 [FREE Full text] [CrossRef] [Medline]
- Ruggiero L, Moadsiri A, Quinn LT, Riley BB, Danielson KK, Monahan C, et al. Diabetes island: preliminary impact of a virtual world self-care educational intervention for African Americans with type 2 diabetes. JMIR Serious Games 2014;2(2):e10 [FREE Full text] [CrossRef] [Medline]
- Senior H, Henwood T, DE Souza D, Mitchell G. Investigating innovative means of prompting activity uptake in older adults with type 2 diabetes: a feasibility study of exergaming. J Sports Med Phys Fitness 2016 Oct;56(10):1221-1225. [Medline]
- Wood FG, Alley E, Baer S, Johnson R. Interactive multimedia tailored to improve diabetes self-management. Nurs Clin North Am 2015 Sep;50(3):565-576. [CrossRef] [Medline]
- Mounié M, Costa N, Gourdy P, Latorre C, Schirr-Bonnans S, Lagarrigue J, Educ@dom Study Group. Cost-effectiveness evaluation of a remote monitoring programme including lifestyle education software in type 2 diabetes: results of the Educ@dom study. Diabetes Ther 2022 Apr;13(4):693-708 [FREE Full text] [CrossRef] [Medline]
- Debong F, Mayer H, Kober J. Real-world assessments of mySugr mobile health app. Diabetes Technol Ther 2019 Jun;21(S2):S235-S240. [CrossRef] [Medline]
- Álvarez-Barbosa F, Del Pozo-Cruz J, Sañudo B, Alfonso-Rosa RM. Is the Wii balance board a valid and reliable instrument to assess postural stability in older adults with type 2 diabetes mellitus? Diabetes Res Clin Pract 2020 Aug;166:108313. [CrossRef] [Medline]
- Cuevas H, Carter S. Online cognitive training: an adaptation of the memory, attention, and problem solving skills for persons with diabetes intervention. Comput Inform Nurs 2020 Aug 10;39(3):162-169. [CrossRef] [Medline]
- Brinkmann C, Schäfer L, Masoud M, Latsch J, Lay D, Bloch W, et al. Effects of cycling and exergaming on neurotrophic factors in elderly type 2 diabetic men - a preliminary investigation. Exp Clin Endocrinol Diabetes 2017 Jul 25;125(7):436-440. [CrossRef] [Medline]
- Dugas M, Crowley K, Gao GG, Xu T, Agarwal R, Kruglanski AW, et al. Individual differences in regulatory mode moderate the effectiveness of a pilot mHealth trial for diabetes management among older veterans. PLoS One 2018 Mar 7;13(3):e0192807 [FREE Full text] [CrossRef] [Medline]
- Glasgow RE, Kurz D, King D, Dickman JM, Faber AJ, Halterman E, et al. Outcomes of minimal and moderate support versions of an internet-based diabetes self-management support program. J Gen Intern Med 2010 Dec 17;25(12):1315-1322 [FREE Full text] [CrossRef] [Medline]
- Grewal GS, Schwenk M, Lee-Eng J, Parvaneh S, Bharara M, Menzies RA, et al. Sensor-based interactive balance training with visual joint movement feedback for improving postural stability in diabetics with peripheral neuropathy: a randomized controlled trial. Gerontology 2015 Feb 19;61(6):567-574 [FREE Full text] [CrossRef] [Medline]
- Kerfoot BP, Gagnon DR, McMahon GT, Orlander JD, Kurgansky KE, Conlin PR. A team-based online game improves blood glucose control in veterans with type 2 diabetes: a randomized controlled trial. Diabetes Care 2017 Sep 08;40(9):1218-1225. [CrossRef] [Medline]
- Turnin M, Gourdy P, Martini J, Buisson J, Chauchard M, Delaunay J, Educ@dom Study Group. Impact of a remote monitoring programme including lifestyle education software in type 2 diabetes: results of the Educ@dom Randomised Multicentre study. Diabetes Ther 2021 Jul;12(7):2059-2075 [FREE Full text] [CrossRef] [Medline]
- Kempf K, Martin S. Autonomous exercise game use improves metabolic control and quality of life in type 2 diabetes patients - a randomized controlled trial. BMC Endocr Disord 2013 Dec 10;13:57 [FREE Full text] [CrossRef] [Medline]
- Koohmareh Z, Karandish M, Hadianfard AM. Effect of implementing a mobile game on improving dietary information in diabetic patients. Med J Islam Repub Iran 2021 Apr 30;35:68 [FREE Full text] [CrossRef] [Medline]
- Maharaj A, Lim D, Murphy R, Serlachius A. Comparing two commercially available diabetes apps to explore challenges in user engagement: randomized controlled feasibility study. JMIR Form Res 2021 Jun 16;5(6):e25151 [FREE Full text] [CrossRef] [Medline]
- Kruglanski AW, Thompson EP, Higgins ET, Atash MN, Pierro A, Shah JY, et al. To "do the right thing" or to "just do it": locomotion and assessment as distinct self-regulatory imperatives. J Pers Soc Psychol 2000 Nov;79(5):793-815. [CrossRef] [Medline]
- DeSmet A, Van Ryckeghem D, Compernolle S, Baranowski T, Thompson D, Crombez G, et al. A meta-analysis of serious digital games for healthy lifestyle promotion. Prev Med 2014 Dec;69:95-107 [FREE Full text] [CrossRef] [Medline]
- Ledoux T, Griffith M, Thompson D, Nguyen N, Watson K, Baranowski J, et al. An educational video game for nutrition of young people: theory and design. Simul Gaming 2016 Aug 17;47(4):490-516 [FREE Full text] [CrossRef] [Medline]
- Patel MS, Benjamin EJ, Volpp KG, Fox CS, Small DS, Massaro JM, et al. Effect of a game-based intervention designed to enhance social incentives to increase physical activity among families: the be FIT randomized clinical trial. JAMA Intern Med 2017 Nov 01;177(11):1586-1593 [FREE Full text] [CrossRef] [Medline]
- Schwarzer R, Lippke S, Luszczynska A. Mechanisms of health behavior change in persons with chronic illness or disability: the Health Action Process Approach (HAPA). Rehabil Psychol 2011 Aug;56(3):161-170. [CrossRef] [Medline]
- Shen F, Sheer VC, Li R. Impact of narratives on persuasion in health communication: a meta-analysis. J Advert 2015 May 05;44(2):105-113. [CrossRef]
- Fleming GA, Petrie JR, Bergenstal RM, Holl RW, Peters AL, Heinemann L. Diabetes digital app technology: benefits, challenges, and recommendations. A consensus report by the European association for the study of diabetes (EASD) and the American diabetes association (ADA) diabetes technology working group. Diabetes Care 2020 Jan;43(1):250-260. [CrossRef] [Medline]
- Sun X, Yan W, Zhou H, Wang Z, Zhang X, Huang S, et al. Internet use and need for digital health technology among the elderly: a cross-sectional survey in China. BMC Public Health 2020 Sep 11;20(1):1386 [FREE Full text] [CrossRef] [Medline]
- Larsen LH, Schou L, Lund HH, Langberg H. The physical effect of exergames in healthy elderly-a systematic review. Games Health J 2013 Aug;2(4):205-212. [CrossRef] [Medline]
- Mackert M, Mabry-Flynn A, Champlin S, Donovan EE, Pounders K. Health literacy and health information technology adoption: the potential for a new digital divide. J Med Internet Res 2016 Oct 04;18(10):e264 [FREE Full text] [CrossRef] [Medline]
- Lapão L. The future of healthcare: the impact of digitalization on healthcare services performance. In: The Internet and Health in Brazil. Cham: Springer International Publishing; 2018.
- Reinhardt G, Schwarz PE, Harst L. Non-use of telemedicine: a scoping review. Health Informatics J 2021 Oct 26;27(4):14604582211043147 [FREE Full text] [CrossRef] [Medline]
- Shiau CW, Lim SM, Cheng LJ, Lau Y. Effectiveness of game-based self-management interventions for individuals with diabetes: a systematic review and meta-analysis of randomized controlled trials. Games Health J 2021 Dec 01;10(6):371-382. [CrossRef] [Medline]
- Olivier C, Middleton S, Purington N, Shashidhar S, Mahaffey KW, Turakhia M. Abstract 189: why digital health trials can fail: lessons learned from the SmartGUIDE randomized trial of virtual cardiac rehabilitation. Circulation Cardiovascular Quality Outcome 2019 Apr;12(Suppl_1):A189. [CrossRef]
- Harst L, Wollschlaeger B, Birnstein J, Fuchs T, Timpel P. Evaluation is key: providing appropriate evaluation measures for participatory and user-centred design processes of healthcare IT. Int J Integr Care 2021 Jun 21;21(2):24 [FREE Full text] [CrossRef] [Medline]
- Cui M, Wu X, Mao J, Wang X, Nie M. T2DM self-management via smartphone applications: a systematic review and meta-analysis. PLoS One 2016;11(11):e0166718 [FREE Full text] [CrossRef] [Medline]
- Priesterroth L, Grammes J, Holtz K, Reinwarth A, Kubiak T. Gamification and behavior change techniques in diabetes self-management apps. J Diabetes Sci Technol 2019 Sep;13(5):954-958 [FREE Full text] [CrossRef] [Medline]
- Walton A, Nahum-Shani I, Crosby L, Klasnja P, Murphy S. Optimizing digital integrated care via micro-randomized trials. Clin Pharmacol Ther 2018 Jul;104(1):53-58 [FREE Full text] [CrossRef] [Medline]
- Bachmann LM, Puhan MA, Riet GT, Bossuyt PM. Sample sizes of studies on diagnostic accuracy: literature survey. BMJ 2006 Apr 20;332(7550):1127-1129. [CrossRef]
|ADA: American Diabetes Association|
|CASP: Critical Appraisal Skills Programme|
|DSME: Diabetes Self-Management and Education|
|FPG: fasting plasma glucose|
|HbA1c: glycated hemoglobin|
|PA: physical activity|
|PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses|
|PRO: patient-reported outcome|
|RCT: randomized controlled trial|
|RoB 2: Cochrane risk-of-bias tool version 2|
Edited by G Eysenbach, N Zary; submitted 17.11.22; peer-reviewed by T Karagiannis, S Guo; comments to author 25.01.23; revised version received 02.03.23; accepted 12.03.23; published 01.06.23Copyright
©Linda Ossenbrink, Tina Haase, Patrick Timpel, Olaf Schoffer, Madlen Scheibe, Jochen Schmitt, Stefanie Deckert, Lorenz Harst. Originally published in JMIR Serious Games (https://games.jmir.org), 01.06.2023.
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