Appetite 120 (2018) 100e108

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Appetite
journal homepage: www.elsevier.com/locate/appet

Acute effects of video-game playing versus television viewing on

stress markers and food intake in overweight and obese young men: A
randomised controlled trial*
Mario Siervo a, *, Jason Gan b, Mary S. Fewtrell b, Mario Cortina-Borja c,
Jonathan C.K. Wells a, b
a
Human Nutrition Research Centre, Institute of Cellular Medicine, Newcastle University, Campus for Ageing and Vitality, Newcastle on Tyne, NE4 5PL, UK
b
Childhood Nutrition Research Centre, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
c
Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK

a r t i c l e i n f o a b s t r a c t

Article history: Background: Sedentary or near-sedentary activities are associated with overweight/obesity in epide-
Received 12 January 2017 miological studies. This has traditionally been attributed to physical activity displacement. A little-
Received in revised form explored area is whether behavioural stresses alter sensations of appetite and eating behaviour. We
17 August 2017
examined whether behaviours conducted seated (television viewing, video gaming) induce different
Accepted 18 August 2017
Available online 24 August 2017
eating patterns, associated with differential levels of stress response.
Methods and findings: We conducted a randomized controlled trial in 72 overweight/obese adult males,
assigned to three groups (24 per group): (i) non-violent television (control group); (ii) non-violent game
Keywords:
Video game playing
(FIFA); (iii) violent game (Call of Duty). Following a standardized breakfast, the 1-h intervention was
Stress followed by 25-min rest, with sweet and savoury snacks and drinks available ad libitum. Stress markers
Appetite (heart rate, blood pressure, visual analogue scale (VAS)) were measured throughout. Heart rate, systolic
Obesity blood pressure, and stress by VAS were significantly higher (p < 0.05) playing video games than watching
non-violent television, though the two game groups did not differ. Considered separately, only the vi-
olent video game group consumed more energy (D ¼ 208.3 kcal, 95%CI 16, 400), sweet foods (D ¼ 25.9 g,
95%CI 9.9, 41.9) and saturated fat (D ¼ 4.36 g, 95%CI 0.76, 7.96) than controls.
Conclusion: Playing video games in overweight/obese adult males is associated with an acute stress
response relative to watching non-violent television, associated with greater subsequent food intake.
These findings highlight the need to focus on the metabolic effects, as well as the energy costs, of ac-
tivities involving sitting in relation to obesity risk.
© 2017 Elsevier Ltd. All rights reserved.

1. Introduction energy balance. This theory is based upon fundamental thermo-

Over one third of adults worldwide are now overweight or
obese (Ng et al., 2014), constituting a public health crisis. The steep
increase in obesity prevalence over recent decades implicates a key
contribution of environmental factors, but identifying suitable
targets for public health policies has proven difficult (Goran &
Treuth, 2001; Weinsier, Hunter, Heini, Goran, & Sell, 1998).
Research into the aetiology of obesity has focused on the concept of
*
The material presented in this manuscript is original and it has not been sub-
mitted for publication elsewhere while under consideration for Appetite.
* Corresponding author.
E-mail address: mario.siervo@ncl.ac.uk (M. Siervo).
dynamic principles, which state that energy cannot be created or
destroyed by an organism, only gained or lost by the body (Hess,
1838). Application of these principles to obesity implicates
chronic over-eating and/or chronic physical inactivity (eg sitting,
sedentary behaviour), as determinants of ‘positive energy balance’,
resulting in weight gain (Wells & Siervo, 2011). Although this model
has been central to public health efforts to prevent obesity, through
the promotion of exercise and calorie counting, the success of such
schemes has been very modest, reflected in rising rates in most
countries (Ng et al., 2014). In particular, the energy balance
approach assumes that any two activities with equal caloric cost
should affect body weight to the same degree, whereas specific
behaviours might vary in their obesity risk. This unfocused

http://dx.doi.org/10.1016/j.appet.2017.08.018
0195-6663/© 2017 Elsevier Ltd. All rights reserved.
 M. Siervo et al. / Appetite 120 (2018) 100e108
approach prevents understanding of the metabolic consequences
of behaviour among adolescents and young adults (eg 18e30
years), who should be a primary target of obesity prevention
campaigns.
Sedentary behaviour has been consistently associated with
obesity. For example, television viewing is a well-established risk
factor (Robinson, 2001; Viner & Cole, 2005), and interventions to
reduce TV viewing have reduced body mass index (BMI) (Otten,
Jones, Littenberg, & Harvey-Berino, 2009). Sitting has also been
associated with obesity risk (Hu, Li, Colditz, Willett, & Manson,
2003; Kong, Lee, Kim, Sim, & Choi, 2015). Likewise, growth of
the video games industry has closely paralleled the obesity
epidemic (Wack & Tantleff-Dunn, 2009), and a number of studies
have reported associations between time spent playing video
games and BMI in children (Mota, Ribeiro, Santos, & Gomes, 2006;
Stettler, Signer, & Suter, 2004), adolescents (Schneider, Dunton, &
Cooper, 2007) and adults (Weaver et al., 2009). However, playing
video games using a hand-held joystick while seated has been
associated with greater energy expenditure, similar to mild-
intensity exercise, compared to simply sitting or standing still
(Segal & Dietz, 1991). Other studies have reported a modest in-
crease in energy expenditure when playing video games compared
to resting (Chaput et al., 2011; Mansoubi et al., 2015; Mellecker &
McManus, 2008; Wang & Perry, 2006). On this basis, television
viewing would be predicted to be a stronger risk factor for obesity
than playing video games. Recently, a formal definition of seden-
tary activity has been proposed of 1.5 METS (Metabolic Equiva-
lent Task, defined as 3.5 ml O2$kg1 min1) (Sedentary
Behaviour Research Network, 2012). Studies show that adults
playing seated Playstation-type video games typically achieve
around 1.4 METs, though there is variability between individuals
some of which reflects nutritional status assessed by BMI
(Mansoubi et al., 2015).
A less intuitive possibility is that activities while sedentary or
sitting affect appetite, and potentially in variable ways. A ran-
domized trial reported higher subsequent energy intake in video-
game players relative to controls, translating into an energy sur-
plus of 104.2 kcal over the entire day, despite no reported increases
in hunger or appetite rating (Chaput et al., 2011). Another trial
found that those playing violent video games on a playstation
subsequently felt less full and expressed greater desire to eat
sweetened foods, compared to those playing non-violent games or
watching non-violent television (Siervo, Sabatini, Fewtrell, & Wells,
2013). More generally, activities involving mental effort (Chaput &
Tremblay, 2007; Chaput, Drapeau, Poirier, Teasdale, & Tremblay,
2008; Tremblay & Therrien, 2006) and watching television
(Bellisle, Dalix, & Slama, 2004; Temple, Giacomelli, Kent,
Roemmich, & Epstein, 2007) have been reported to increase food
intake without elevating appetite.
It has been postulated that appetite increases following video
gaming may be due to stress-induced rewards or impairment in
satiety signalling (Chaput et al., 2011). A number of studies have
documented a stress response after playing video games, shown by
increased heart rate and blood pressure (Barlett & Rodeheffer,
2009; Chaput et al., 2011; Segal & Dietz, 1991), while experi-
mental studies have also linked exposure to stress with altered
patterns of food consumption. A small study (n ¼ 10) found that
exposure to stress significantly increased consumption of carbo-
hydrate, and led to non-significant increases in the consumption of
sweet foods, fatty foods and total energy (Hitze et al., 2010).
Another study demonstrated greater total energy intake after
completing difficult mental arithmetic questions compared to the
control state (230.6 vs 189.6 kcal, p < 0.01), despite no difference in
hunger; a statistically significant greater consumption of sweet
foods was also observed 169.2 vs 143.2 kcal, p < 0.03) (Rutters,
101
Nieuwenhuizen, Lemmens, Born, & Westerterp-Plantenga, 2009).
Both of these two studies indicate a tendency to consume foods rich
in glucose in response to stress (Hitze et al., 2010; Rutters et al.,
2009), as also suggested in a trial of violent video games (Siervo
et al., 2013). Finally, a study of brain metabolism demonstrated a
12% increase in global cerebral metabolic rate for glucose in
response to a behavioural stressor (Lund Madsen et al., 1995). This
increased glucose utilization persisted for 40min after termina-
tion of the stressor, despite all physiological stressors having
returned to baseline levels (Lund Madsen et al., 1995).
Collectively, these studies suggest that increased energy intake,
potentially targeting certain food types, may be an adaptive
response to satisfy the brain's demand for extra cerebral energy
during periods of stress. However, few studies (Chaput et al., 2011;
Hitze et al., 2010; Rutters et al., 2009) have directly measured food
intake, hence there is little understanding as yet of how video
games might impact eating behaviour through the stress response.
This issue can be addressed by probing in greater detail the effect of
different kinds of video games on sensations of appetite and eating
behaviour.
We aimed to examine whether behaviours conducted while
sitting (television viewing and playing different Playstation video
games) induce different patterns of eating, associated with differ-
ential levels of stress response in young overweight men. Our pri-
mary hypothesis, specified prior to the trial, was that playing
violent video games would induce a stress response, an elevation of
appetite, and a heightened consumption for sweet foods or drinks,
relative to watching non-violent television or playing a non-violent
video game. However, when analysing the data we also tested two
secondary hypotheses. First, we tested whether either of the video
game groups differed from the non-violent television control group
in stress responses, appetite and food consumption. This differs
from the primary hypothesis, which not only assumed that the
violent game would differ from the non-violent television group,
but also assumed that the non-violent game would not show such a
difference from the television group. Second, we also tested the
hypothesis that all videogame players combined into a single group
had different stress responses, appetite and food consumption
compared to those watching non-violent television. These hy-
potheses are illustrated in Supplementary online Fig. S1. We tested
these hypotheses experimentally using a randomized controlled
trial, which we undertook in overweight and obese men aged
18e30 years, as many regular video gamers are overweight (Wack
& Tantleff-Dunn, 2009).
2. Methods
A three-arm, parallel, randomized control trial was carried out
at the Childhood Nutrition Research Centre, University College
London (Clinical-Trials.gov NCT01809470). Participants were
blinded to the main aim of the study, in order to minimise any
influence of individual expectations. After the study the partici-
pants were fully informed about the outcomes that were
measured and monitored. The study was approved by the ‘UCL
Research Ethics Committee’ (0326/011), and all participants pro-
vided written informed consent. All data was anonymized and
stored in accordance with the Data Protection Act 1998. The study
was run from 18th February to 24th May 2013, and finished due to
completion. The trial registration was completed 8th March 2013,
due to delays in providing supporting information, but no changes
to the protocol were made. Funding was provided by University
College London in support of JG. The trial protocol can be accessed
as supplementary online material (S1 File). The authors confirm
that all ongoing and related trials for this intervention are
registered.
102 M. Siervo et al. / Appetite 120 (2018) 100e108
2.1. Participants
Seventy-two, overweight/obese (BMI >25.0 kg/m2), non-
smoking men aged 18e30 years were recruited. All participants
had to be video game players familiar with both FIFA and CoD.
Participants were excluded if they consumed >21 units alcohol/
week, or if they were not weight-stable (>3 kg change over the past
3 months). Participants were also excluded if they suffered from a
psychiatric disorder, uncontrolled hypertension, coronary heart
disease, heart failure, central or peripheral arteriopathies, or any
other acute or chronic medical conditions which may have inter-
fered with the primary outcomes of the study or if they were on
medications that might have interfered with the primary outcomes
of the study. There were no dietary exclusion criteria.
Participants were recruited via advertising through electronic
message boards, advertising boards all around campus, and
through contacting university societies. They were told the aim of
the study was to investigate the effects of video gaming on appetite
and metabolism, and no reference was made to the stress response.
Eligibility in terms of inclusion/exclusion criteria was assessed by
JG, through a detailed telephone interview. Eligible participants
were sent an information sheet describing the protocol. One
participant a day was subsequently invited to attend the study from
09:30e11:30am; all participants were asked to fast overnight from
9 p.m., and to avoid caffeinated drinks for at least 12 h before
arrival. Participants were compensated £10 cash, and travel was
reimbursed.
2.2. Protocol
All data were collected by JG. The study setting was a stan-
dardized room, with the video games console/TV on a desk by a
window. On arrival, after confirming fasting status, written
informed consent was obtained. Anthropometric baseline mea-
surements (height, weight, waist circumference) were taken and
BMI calculated. Baseline measurements of systolic (SBP) and dia-
stolic (DBP) blood pressure were subsequently performed in trip-
licate after a 1 min resting period. Participants were then asked to
complete a visual analogue scale (VAS) to assess mood, stress,
appetite perceptions and the desire to eat different types of food.
Participants consumed a standardized breakfast (chocolate chip
muffin, 440 kcal, 33 g sugar, 23 g fat (5 g saturates), 0.5 g salt;
200 ml water). This was subsequently followed by collection of
3 min of baseline heart rate data, and a second VAS. The participant
was then randomly assigned to one of three groups (n ¼ 24 per
group); non-violent TV (Group 1), non-violent video game (Group
2), or violent video game (Group 3). Randomisation assignments
were prepared by a member of the research team who had no
contact with the participants (MF). The randomisation sequence
was generated on computer with randomized blocks of permuted
length. Assignments were held in individually sealed opaque en-
velopes until after collection of the baseline data. After allocation,
the participant was invited to familiarize himself with the allocated
game or to watch TV. After 3 min, the protocol was started. It was
not possible for data collection (by JG) to be blinded.
The intervention lasted 1 h and after 15, 30, 45 and 60 min, the
game/TV episode was paused for 4 min to make BP and VAS
measurements. The intervention was followed by a 25 min resting
phase (reading magazines) where a selection of sweet and savoury
snacks/drinks was offered (biscuits - 86 kcal; chocolate bar -
205 kcal, nuts - 294 kcal; crisps - 132 kcal; apple - 71 kcal; banana -
103 kcal; Sprite - 145 kcal; water - 0 kcal). Heart rate was monitored
continuously throughout the duration of the intervention and rest
period. A final set of measurements (BP, VAS) were performed after
the rest period. Leftovers were counted to calculate snack food
consumption.
2.3. Interventions
Group 1, the controls, watched the same three episodes of
‘Friends’, a popular American sitcom. This was selected as a relaxing
non-violent TV programme, that could be easily standardized
through the study. Group 2 played ‘FIFA 2013’, a competitive foot-
ball game, while Group 3 played ‘Call of Duty’ (CoD) Modern
Warfare 3, a realistic first-person shooter. These were the two most
popular non-violent and violent computer games at the time of the
study.
2.4. Measurement of blood pressure and heart rate
Blood pressure was measured using an automated BP monitor
(Omron M3, Omron Europe, The Netherlands). Measurements were
taken in triplicate at each time point. Heart rate was monitored
using a Polar S-610i watch. The watch was wirelessly connected to a
counterpart attached to the participant's chest. Heart rate readings
were taken every 5 s throughout the duration of the study and
downloaded from the watch for statistical analysis.
2.5. Measurement of stress, mood, appetite perception, and the
desire to eat different types of food
These qualitative feelings were quantitatively assessed using
VAS (Stubbs et al., 2000). This instrument incorporates a 10 cm
straight line in between two opposing statements defined as ‘very
little’ to ‘very much’. Participants were asked to mark a vertical line
across the line in relation to their feelings at that moment. These
scales have been validated for repeat use within-participant under
controlled circumstances (Lund Madsen et al., 1995), and have been
used in studies very similar to our own (Chaput et al., 2011). The
scales were measured using digital callipers (Mitutoyo CD-600 CP) to
the nearest 0.01 cm.
Sweet foods comprised biscuits, fruit, chocolate, while savoury
foods comprised nuts and crisps. Food consumption was assessed
after the 25min rest period by subtracting leftover food from the
original pre-recorded amount. Subsequently, food consumption
was converted into total calories, and the intake of grams of sugar,
carbohydrates, fat, and saturated fat based on previously deter-
mined nutritional information from food packaging. We calculated
total sugar content, and also quantified artificially-added sugar
content, using manufacturer's information. The VAS also enquired
about the participant's desire to eat sweet, salty or fatty foods.
2.6. Statistical analysis
The primary outcome was blood pressure. Secondary outcomes
were heart rate, stress and appetite ratings by VAS, and food intake
in the rest period. The raw data are available as supporting
information (S1 Dataset, S2 Dataset, S3 dataset, S4 Dataset).
Building on our previous study (Siervo et al., 2013), where 16
individuals per group yielded adequate power to detect differences
in blood pressure of at least 1 standard deviation between the vi-
olent video game group and both a non-violent video group and a
non-violent TV control group, we aimed to increase the statistical
power for similar analyses in our present study. We calculated that
a sample size of 24 participants in each group would yield statistical
power of at least 90% to detect differences in blood pressure (our
primary outcome) of at most 0.86 standard deviations with a 5%
significance level, among groups (Day & Graham, 1991). This was
equivalent to ~6 mm/HG based on our previous study. All statistical
analysis was carried out using IBM SPSS Statistics version 19 and
 M. Siervo et al. / Appetite 120 (2018) 100e108
the R language and environment for statistical computing and
graphics, version 3.0.2 (R: A Language and Environment for
Statistical Computing, 2013).
We formally tested normality using the Shapiro-Wilk test. The
‘food intake’ outcomes did not satisfy this assumption and were
transformed using the Box-Cox family (Box & Cox, 1964) as
implemented in the R library MASS (Venables & Ripley, 2002). A
square root transformation was judged appropriate based on partial
log-likelihood plots; thus we fitted linear regression models
including a treatment contrastp with
ffiffiffiffi TV as the reference category to
the transformed outcomes ð Y  1Þ=2 , where Y denotes the
original food intake variable.
To compare the three groups individually, baseline characteris-
tics were compared by one-way ANOVA. We fitted linear mixed-
effects models (Pinheiro & Bates, 2000) with a random effect
term in their intercepts to account for the within-participant
repeated measurements. We used maximum likelihood estima-
tion procedures in order to satisfy the assumptions required to
perform likelihood ratio tests (LRT) in the comparisons of nested
models with and without an interaction term between time and
group identity.
For the secondary hypotheses, we analysed differences between
two groups. For secondary hypothesis A, we compared each video
game group separately against the other group (FIFA vs CoD), and
also against the non-violent television control group (FIFA vs TV;
CoD vs TV). For secondary hypothesis B, we combined Groups 2 and
3 into a single Video Game group and compared that against the
non-violent television control group. As the three hypotheses are
tested on the same data for stress markers and appetite, we cor-
rected for multiple comparisons with a Bonferroni procedure by
adjusting the level for statistical significance from a ¼ 0.05 to
a ¼ 0.0167.
Initial analyses of the secondary hypotheses indicated that only
hypothesis 2B was supported for some stress markers, and also
food intake. For this hypothesis, we additionally fitted three types
of mixed-effects models to the stress marker outcomes. Model 1
was fitted to measurements up to 60 min; it included an intercept
for each group and a common slope. Models 2 (no interaction
time:group) and 3 (including the interaction time:group) were
fitted to measurements between 60 and 85 min to analyze changes
between the end of the TV/game intervention and the end of the
resting phase. Comparisons between these two groups were con-
ducted using independent t-tests.
3. Results
A total of 477 recruits were assessed for eligibility (Supple-
mentary online Fig. S2). Seventy-two (24 per group) were subse-
quently recruited and randomized. Due to small differences
between reported weight and height values, and those measured at
the time of recruitment, a minority of individuals of each group had
BMI below 25 kg/m2. The median and range were as follows: Group
1e25.8, range 24.6e32.9; Group 2e26.4, range 24.5e29.7; Group
3e27.0, range 24.3e33.3 kg/m2. Baseline characteristics did not
statistically differ between groups by one-way ANOVA (Supple-
mentary online Table S1).
Two participants did not strictly adhere to the study protocol.
One individual refused to eat the standardized breakfast, and was
therefore given an alternative meal with similar calorie content.
Another participant arrived at the study hung-over, and was
probably dehydrated. Analysis was therefore repeated excluding
these data. The significance of the results was not altered by their
inclusion/exclusion, and the tables and figures therefore refer to the
full sample. No harm or adverse effect occurred during the study.
Fitting mixed-effects models including a random effect on the
103
individuals, and fixed effects on Time, Group and their interaction
showed no differences in SBP, DBP, heart rate or VAS between the
three groups any time point (p > 0.07), hence the violent video
game group did not show elevated stress relative to the other two
groups, our primary hypothesis (Table 1). Regarding secondary
hypothesis A, also we did not find that either the violent video
game group or the non-violent video game group differed inde-
pendently from the non-violent television group by independent
samples t-test. However, Table 1 indicated differences between the
TV and combined Video Game groups in stress markers, hence we
ran additional mixed effects models to test Secondary hypothesis B.
For SBP, there were no significant difference in slopes
(p ¼ 0.966) nor intercepts (p ¼ 0.068) between TV and combined
Video Game groups. However, these groups did differ significantly
at the beginning of the resting phase, as the combined Video Game
group was now on average 3.96 mm/Hg higher than the TV Group
(95% CI 0.50, 7.42, p ¼ 0.025) and both increased significantly at the
same rate (0.071 (mm/Hg)/min, p ¼ 0.019; LRT for interaction
p ¼ 0.947) through the rest period, indicating that this difference
was maintained after the intervention (Fig. 1). These SBP data
therefore support hypothesis 2B. However, no such differences
were found for DBP.
For heart rate the TV and combined Video Game groups had no
significant trend through the intervention (p ¼ 0.379) but there was
a significant difference in their intercepts (p ¼ 0.023) with the
combined Video Games groups being 2.71 (95% CI 0.41, 5.01) bpm
higher on average than the TV group at the beginning of the first
phase (Fig. 2). The interaction term between time elapsed and
group during the resting phase was not significant (LRT p ¼ 0.620);
the common slope in this phase was significantly different from
zero (0.221 bpm/min, p < 0.001) as was the difference in intercepts,
with participants assigned to the TV group having a lower heart
rate at the end of the rest period (2.96 bpm, 95% CI 0.02, 5.90,
p ¼ 0.047). This therefore supported our secondary hypothesis B,
that the combined video games group developed elevated heart
rate compared to the TV group during the intervention.
For VAS stress, fitting mixed-effects models including a random
effect on the individuals, and fixed effects on Time, Group and their
interaction showed differences between each of the VG groups and
the non-violent TV controls (p ¼ 0.0244 for CoD and p ¼ 0.003 for
FIFA), However, these findings did not support our secondary hy-
pothesis A, since the two video game groups did not differ from
each other (p > 0.13). Instead, the data again supported secondary
hypothesis B, showing a contrast between the combined video
games group and the TV group confirmed by independent samples
t-test (Table 1; Fig. 3). The difference in the intercepts was nearly
significant (7.20, 95% CI -0.18, 14.58, p ¼ 0.055), indicating that
although similar at baseline, the two groups differed in VAS stress
during the intervention, though this difference did not steadily
increase over the 60-min session (p ¼ 0.183). At the start of the
resting phase, the intercepts for the TV and combined Video Game
groups still differed significantly, with the combined Video Game
group having a much higher stress rating (6.75, 95% CI 2.65, 10.85,
p ¼ 0.002) and a significant negative slope (0.318 VAS units/min,
p ¼ 0.012), whilst the slope for the TV group did not differ signif-
icantly from zero (0.011, p ¼ 0.914). A t-test showed that both
groups ended at similar levels of stress after the resting period
(p ¼ 0.625), showing that the elevated VAS stress of the video-game
players relative to the television controls rapidly disappeared when
the game ended.
3.1. Food intake and desire for specific food types
There were no differences between any group in subjective
hunger rating, or subjective desire to eat any particular food type,
104 M. Siervo et al. / Appetite 120 (2018) 100e108

Table 1
Markers of stress by timepoint for each group.

Group 1 (TV) Group 2 (FIFA) Group 3 (CoD) Group 2 þ 3 Group Group Group
Mean, SD Mean, SD Mean, SD Mean, SD 1 vs 2 1 vs 3 1 vs (2 þ 3)
p-value p-value p-value

SBP (mmHg) Baseline 116.4, 8.6 115.6, 8.6 117.9, 8.1 116.7, 8.3 0.7 0.5 0.8
15 min 114.7, 9.1 115.6, 9.4 118.3, 11.4 116.9, 10.4 0.7 0.2 0.2
30 min 114.9, 10.9 117.1, 10.0 118.6, 12.4 117.8, 11.2 0.4 0.2 0.1
45 min 113.3, 10.1 117.2, 10.4 117.8, 10.5 117.5, 10.3 0.2 0.1 0.032
60 min 113.5, 11.0 117.1, 9.0 118.6, 11.5 117.8, 10.2 0.2 0.1 0.024
85 min 115.4, 9.5 119.8, 9.9 119.3, 9.4 119.7, 9.6 0.1 0.1 0.022

DBP (mmHg) Baseline 65.2, 7.7 64.6, 5.9 67.2, 7.4 65.4, 7.8 0.7 0.3 0.7
15 min 61.4, 7.8 63.3, 6.0 65.8, 9.4 64.1, 8.7 0.3 0.085 0.1
30 min 61.9, 6.7 64.8, 7.0 65.3, 9.2 64.7, 8.7 0.1 0.1 0.1
45 min 62.0, 9.8 63.8, 6.8 65.8, 7.2 64.5, 8.7 0.4 0.1 0.3
60 min 62.5, 6.8 64.5, 6.5 66.2, 6.7 65.2, 7.1 0.3 0.069 0.1
85 min 62.7, 7.8 64.9, 6.2 66.1, 8.8 65.0, 8.3 0.3 0.17 0.2

HR (bpm) Baseline 75.2, 10.6 74.6, 9.8 72.9, 9.7 73.7, 9.7 0.8 0.4 0.5
15 min 69.0, 11.3 71.7, 9.2 69.7, 8.7 70.7, 8.9 0.3 0.8 0.002
30 min 71.3, 11.6 73.2, 9.5 70.2, 7.8 71.7, 8.8 0.5 0.6 0.1
45 min 70.9, 10.9 74.2, 9.1 70.2, 7.4 72.2, 8.4 0.2 0.8 0.052
60 min 69.7, 10.8 72.8, 9.3 69.3, 7.5 71.1, 8.6 0.3 0.8 0.025
85 min 75.7, 9.7 77.7, 11.2 75.1, 7.8 76.5, 9.7 0.5 0.8 0.086

VAS (stress) Baseline 13.6, 13.7 11.8, 10.5 16.4, 18.6 14.2, 15.2 0.6 0.5 0.8
15 min 9.6, 7.6 17.0, 16.5 21.0, 14.4 19.5, 15.4 0.030 0.001 0.009
30 min 7.4, 6.0 18.2, 25.3 25.4, 17.7 21.8, 16.5 0.002 0.001 0.001
45 min 9.4, 8.4 16.4, 14.5 22.4, 19.1 19.4, 17.0 0.045 0.004 0.031
60 min 7.8, 6.8 16.1, 13.2 21.3, 20.2 18.7, 17.1 0.009 0.004 0.018
85 min 7.5, 6.3 9.3, 7.4 11.2, 9.93 10.3, 8.7 0.3 0.1 0.5

SBP e systolic blood pressure; DBP e diastolic blood pressure; HR e heart rate; bpm e beats per minute; VAS e Visual Analogue Scale; d e change from baseline; SD e standard
deviation; SE e standard error. Comparisons made by a t-test for independent samples.

Fig. 1. Change in systolic blood pressure (SBP) from baseline for the Television and
Fig. 2. Change in heart rate from baseline in Television and combined Video Games
combined Video Games groups (Hypothesis 2B). Data are mean and standard error.
groups (Secondary hypothesis B). Data are mean and standard error. The groups
The groups achieved a difference during the intervention (D ¼ 3.96 mm/Hg, p ¼ 0.025)
achieved a difference during the intervention (D ¼ 2.71 bpm, p ¼ 0.023) that persisted
that was maintained during the rest period.
through the rest period.

as measured by VAS. Thus, for subjective feelings, neither primary

video game group did not consume more food than both the other
nor secondary hypotheses were supported.
two groups. This did not support our primary hypothesis.
For food intake, comparison of the three groups by ANOVA
Regarding our secondary hypotheses, the combined Video
showed no significant differences in intake across all food cate-
Games group showed a trend towards higher total consumption of
gories (p > 0.07) (Supplementary online Table S2), thus the violent
energy (difference ¼ 172.6 kcal, 95% CI 6.8, 338.4, p ¼ 0.033), and
 M. Siervo et al. / Appetite 120 (2018) 100e108
Fig. 3. Change in stress measured by Visual Analogue Scale from baseline for the
Television and combined video games groups (Secondary hypothesis B). Data are
mean and standard error. The combined Video Games group showed elevated stress
levels compared to the Television controls during the intervention that were nearly
significant (D ¼ 7.2, p ¼ 0.055), however this difference did not persist during the rest
period.
significantly greater consumption of sweet foods
(difference ¼ 17.8 g, 95% CI 3.6, 32.0, p ¼ 0.0053), and saturated fat
(difference ¼ 3.84 g, 95% CI 0.74, 6.94, p ¼ 0.013), but not of car-
bohydrate or total fat. When considering the video groups sepa-
rately, however, the Call of Duty group consumed more energy
(difference ¼ 208.3 kcal, 95% CI 70.3, 346.3, p ¼ 0.025) and satu-
rated fat (difference ¼ 4.36 g, 95% CI 0.76, 7.96, p ¼ 0.018) and
significantly more sweet foods (difference ¼ 25.9 g, 95% CI 9.9, 41.9,
p ¼ 0.001) than the TV group, whereas the FIFA group did not differ
Fig. 4. Food intake variables (sweet, carbohydrate, fat, saturated fat, measured in g) in
the Television (TV), FIFA, CoD, and combined Video game (FIFA þ CoD) groups. Data are
mean and standard error, with all data square-root transformed. All comparisons by t-
tests for independent samples, corrected for multiple comparisons (a ¼ 0.0167).
105
from the TV group. These findings provide support for hypothesis
2A (Fig. 4). Moreover, there was a greater, though not significantly
so, consumption of sweet foods by the Call of Duty group than the
FIFA group (difference ¼ 16.0 g, 95% CI -1.4, 33.4, p ¼ 0.072. Thus,
playing a video game elevated intake in the rest period compared to
watching non-violent TV, and there was weak evidence that this
effect was stronger if the game contained violent content.
4. Discussion
Collectively, the results from this study of overweight/obese
men show that playing video games for 1 h in men is accompanied
by greater SBP, heart rate, and feelings of stress relative to watching
non-violent TV, thus indicating a difference in the stress response.
These findings did not support our primary hypothesis, which was
based on an earlier study in adult men within the normal BMI
range, where only those playing a violent video game differed
significantly from the non-violent TV controls (Siervo et al., 2013).
Instead, they supported our secondary hypothesis B. Playing video
games was also associated with elevated food consumption during
the rest period. Although this appears to support secondary hy-
pothesis B, we further found that the difference from non-violent
TV controls was disproportionately attributable to the violent
game group, which showed an elevated consumption of energy,
sweet foods, and foods containing saturated foods relative to the TV
group that was not matched by the non-violent game group. In
terms of food intake, therefore, there is weak support for secondary
hypothesis A, however a larger sample size would be required to
confirm this. Overall, our study indicates that apparently similar
activities conducted while sitting may induce different patterns of
subsequent eating, and this may help to identify specific behaviours
for emphasis in obesity prevention campaigns.
4.1. Stress response
The physiological data on SBP and heart rate indicate a modest
stress response when video gaming relative to watching non-
violent TV, consistent with hypothesis 2B, and this was supported
by the subjective VAS stress scores. The pattern of results for
physiology was that SBP and heart rate fell in the TV controls, but
either remained the same in the combined video games (SBP) or fell
less strongly (heart rate). However, the VAS marker of stress rose
significantly in both video games groups, while it remained stable
in the controls. This implies that BP and heart rate were not
indicative of relaxation when the study began, most likely because
the participants had arrived by walking at the study centre. Thus,
the effect of the trial (that the video games groups became stressed
relative to the controls) was superimposed on a general decline in
SBP and heart rate in the control group. Also, though these effects
were statistically significant, the increase in SBP and decrease in
heart rate observed in the video games group were lower than
those reported in other studies (Barlett & Rodeheffer, 2009; Chaput
et al., 2011; Segal & Dietz, 1991). The increase in heart rate and SBP
observed during the rest phase may be due to the food consump-
tion, as reported elsewhere (De Mey, Enterling, & Meineke, 1993;
Fagan, Sawyer, Gourley, Lee, & Gaffney, 1986; deMey, Enterling,
Brendel, & Meineke, 1987). This is supported by a test on the cor-
relation coefficient which was close to reaching statistical signifi-
cance (r ¼ 0.22; p ¼ 0.061) in the whole sample between calories
consumed and change in SBP between 60 and 85 min.
There was no difference in stress response between the violent
and non-violent video games groups. This can be interpreted in
three ways. First, it is possible that violent video gaming does not
elicit a greater stress response, though we have previously
observed elevated blood pressure in those playing violent
106 M. Siervo et al. / Appetite 120 (2018) 100e108
compared to non-violent video games in normal weight adult men
(Siervo et al., 2013). Second, it is possible that in response to violent
video gaming, a different and larger cerebral stress response is
taking place, but the physiological markers of stress that we
measured did not detect this. Third, the level of violence in the Call
of Duty game may have been insufficient (our previous study used
‘Grand Theft Auto’ as the violent game (Siervo et al., 2013)), or
participants did not become sufficiently involved in the game, to
elicit a greater stress response compared to playing FIFA.
Whilst our own interest is in the relationship between the stress
response and appetite perturbation, our findings also have clinical
significance in terms of the cardiovascular reactivity hypothesis,
which assumes that psychological stressors promote the develop-
ment of cardiovascular disease. Repetitive elevations of SBP
through chronic video game playing in the absence of physical
activity may affect long-term regulation of BP, potentially leading to
hypertension (Phillips & Hughes, 2011).
4.2. Food intake
Playing the violent game for 1 h was accompanied by a higher
energy intake of 208.3 kcal relative to the non-violent TV group
(p < 0.03), however no significant difference from the TV group was
seen in those playing the non-violent game. Combining the two
groups, energy intake was 172.6 kcal (95%CI 23.3, 321.9, p < 0.04)
greater than in TV controls, without any apparent increase in
feelings of hunger as measured by VAS. Energy expenditure was not
measured directly, however heart rate declined significantly less in
the Video Games groups than controls. Chaput and co-workers
(Chaput et al., 2011) reported that playing FIFA e one of the ex-
posures used in this study - resulted in a 21.3 kcal/h increase in
energy expenditure during the 1-h intervention. Assuming a
similar increase in energy expenditure in our study, the Video
Games group would have demonstrated a net energy gain of
151.3 kcal.
Overall, our findings show consistency with those of Chaput and
colleagues (Chaput et al., 2011) who demonstrated an increased
caloric intake of 80.1 kcal without any increase in sensations of
hunger in response to 1 h of non-violent video gaming. The overall
effect of video gaming was greater in our own study (172.6 kcal),
which might be due to any of several differences between the
studies. First, ad libitum intake was tested using spaghetti bolo-
gnese by Chaput et al. (Chaput et al., 2011), whereas we offered a
selection of energy-dense sweet and savoury snacks. Second, the
average BMI of participants in our study was much greater (27.0 kg/
m2 vs 21.5 kg/m2), which could affect food consumption in the
immediate period after the intervention (though high BMI might
also affect energy balance through reducing physical activity level
later in the day). Third, our controls watched non-violent TV,
whereas those of Chaput et al. were at rest. Fourth, we investigated
both non-violent and violent video games, whereas Chaput ana-
lysed only a non-violent video game. Unlike Chaput's study, we did
not find that the FIFA was associated with a significantly greater
energy intake than controls, however the study of Chaput et al. had
greater statistical power, due to the within-person cross-over
design on 22 participants. Nevertheless, both studies provide evi-
dence in support of the hypothesis that, if not compensated by
reduced energy intake later in the day, regular appetite perturba-
tions induced by video gaming could play a role in chronic weight
gain.
The key novel finding in our study was that the presence of
violence in the video game appeared to elevate the increase in food
intake by video game players, relative to watching TV. Although the
two video game groups did not statistically significantly differ from
each other in relation to energy intake, or specific macronutrient
intakes, only the violent game group was significantly different to
the TV group for these outcomes, consuming significantly more
energy (37.4%), sugar (70.2%), added sugar (79.6%) and saturated fat
(61.6%) as a percentage of the intake of the TV-watching controls.
These outcomes were observed despite a lack of differences in the
desire to eat any specific food type indicated by VAS. Moreover,
though not quite significant (p ¼ 0.072), the violent video game
group consumed on average 16.0 g (SE 8.7 g) more sugar compared
to the non-violent game group. Our findings support hypothesis 2A
more strongly than 2B, but the study merits replication with a
larger sample size, to confirm whether violent video games do
indeed elevate energy consumption above the level induced by
non-violent games.
These findings support the notion that central metabolic path-
ways, elevated by the stress response, may drive greater energy
intake following stress exposure. Previous work showed that an
increase in cerebral glucose metabolism persisted for 40 min after
cessation of a psychosocial stressor (Lund Madsen et al., 1995). Both
fatty and sweet food types can enhance mood and mitigate the
effects of stress through neurotransmission of dopamine and opi-
oids (Davis, Strachan, & Berkson, 2004; Leigh Gibson, 2006). This is
consistent with the observed increase in intake (due to both sweet
and savoury foods) shown by the combined video games groups
during the 25 min rest period. The elevated consumption of sweet
foods in the violent game group may represent an attempt to rectify
higher levels of brain glucose depletion. Chronic exposure to video
gaming might thus lead to overeating of unhealthy foods to alle-
viate stress via the reward system, but further work is required to
test whether violent and non-violent video games activate the
stress response differently.
4.3. Strengths, limitations and future studies
The strengths of this study its experimental design, the rela-
tively large sample size, and the high level of protocol compliance.
Several markers of the stress response were obtained, and we
directly measured actual food intakes, rather than expressions of
hunger alone.
However, the study also had several limitations. First, a minority
of members of each group had BMI <25 kg/m2, and so were not
overweight according to the standard definition. However, the
differences were relatively small and applied to each of the three
groups, hence this issue is unlikely to have affected our tests of
differences between groups. Conversely, the results may not be
generalizable to the whole population, as this study was only car-
ried out on overweight/obese males. Although the randomized
design of our study aimed to avoid confounding by potential dif-
ferences in factors such as habitual/recent energy/macronutrient
intake, intake of caffeine or alcohol consumption and physical ac-
tivity/sleep patterns that might influence appetite responses to
stress events or activities, further studies could address such factors
in more detail. We did not strictly control fasting, and accepted the
participants’ word that they had not consumed food since the prior
evening. However, the randomized study design should minimise
the introduction of artefacts from such variability.
Third, we did not take into account differences in the ‘scores’ of
the video game players, and do not know whether some became
frustrated and stressed because of their own limitations. Fourth,
our intervention was in the morning and lasted 1 h, whereas many
gamers play for much longer, and often at night-time (Bavelier
et al., 2011; Cummings & Vandewater, 2007). It would be ideal to
measure energy intake and expenditure over a 24-h period to
calculate net daily energy consumption. Fifth, the majority of the
selections of foods available were unhealthy (though fruit was
offered), therefore selecting greater quantities of sugar and fat in
 M. Siervo et al. / Appetite 120 (2018) 100e108
the video game groups did not reflect free choice. Sixth, the dif-
ferences observed in the objective stress markers between control
and video game groups may reflect a relaxing effect in controls,
rather than increased stress in the video game groups. Lastly, it was
not possible to conduct this study blind due to logistical reasons;
therefore the results are potentially subject to bias, whereby sub-
conscious actions by the investigator could influence the results. To
minimise this possibility, all interactions with participants were
standardized in the protocol.
Future studies should include larger sample sizes to increase
statistical power, and should assess central metabolic pathways to
provide stronger evidence of effects on appetite regulation.
Furthermore, it would be valuable to test for training effects of
playing video games, as this would provide better evidence of how
regular game-playing might affect BMI. Finally, such studies should
be conducted on adolescents, who constitute a large part of the
video-game playing population.
5. Conclusions
The conventional approach to the association between seden-
tary or near-sedentary activities and obesity has been to assume
that they increase risk by reducing energy expenditure, and
therefore promote positive energy balance. This approach cannot
discriminate specific behaviours that have particular relevance for
obesity risk, with the risk that public health policies based on this
approach may be weak and ineffective. This is particularly relevant
to adolescents and young adults, who may rapidly develop strong
behavioural patterns during this formative period (Falbe et al.,
2014). Recently, alternative models of obesity causation have
been developed, suggesting that specific activities may perturb
cellular metabolic regulation, and hence perturb appetite and
eating behaviour (Davis et al., 2004; Lustig, 2008; Spiegel, Tasali,
Penev, & Van Cauter, 2004; Wells & Siervo, 2011). Consistent with
others (Chaput et al., 2011), our study supports this newer
approach, showing that compared to watching non-violent televi-
sion, playing video games generates a stress response, and induces
an increased consumption of calories. A novel finding, supporting
our primary hypothesis, was that playing a violent game was
associated with a significantly greater consumption of sweet foods/
drinks than watching non-violent TV, whereas playing a non-
violent game did not generate such a difference. However, unlike
in a previous study (Siervo et al., 2013), we did not confirm our
primary hypothesis in relation to stress markers, since the violent
video game group did not show a greater stress response than the
other groups. Our study suggests that whilst video games per se
may perturb appetite, violent video games may exacerbate this
effect. Our work therefore identifies violent video games as a topic
meriting further research in relation to obesity prevention and
management.
Author contributions
Study concept and design: Siervo, Fewtrell, Wells. Acquisition of
data: Gan. Analysis and interpretation of data: Siervo, Wells, Gan.
Drafting of the manuscript: Siervo, Gan and Wells. Critical revision
of the manuscript for important intellectual content: Siervo, Gan,
Cortina-Borja, Fewtrell, Wells. Statistical analysis: Cortina-Borja.
Obtained funding: Wells. Study supervision: Siervo, Wells.
Financial disclosure
None reported.
107
Funding/Support
Core budget, Childhood Nutrition Research Centre, UCL Great
Ormond Street Institute of Child Health. Research at the UCL
Institute of Child Health and Great Ormond Street Hospital for
Children receives a proportion of the funding from the Department
of Health's National Institute for Health Research Biomedical
Research Centres funding scheme.
Clinical trial registration number
Clinical-Trials.gov NCT01809470.
Conflict of interest statement
The authors have no conflict of interest to declare.
Appendix A. Supplementary data
Supplementary data related to this article can be found at http://
dx.doi.org/10.1016/j.appet.2017.08.018.
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