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Abstract

Background

Video games provide extensive player involvement for large numbers of children and adults, and thereby provide a channel for delivering health behavior change experiences and messages in an engaging and entertaining format.

Method

Twenty-seven articles were identified on 25 video games that promoted health-related behavior change through December 2006.

Results

Most of the articles demonstrated positive health-related changes from playing the video games. Variability in what was reported about the games and measures employed precluded systematically relating characteristics of the games to outcomes. Many of these games merged the immersive, attention-maintaining properties of stories and fantasy, the engaging properties of interactivity, and behavior-change technology (e.g., tailored messages, goal setting). Stories in video games allow for modeling, vicarious identifying experiences, and learning a story’s “moral,” among other change possibilities.

Conclusions

Research is needed on the optimal use of game-based stories, fantasy, interactivity, and behavior change technology in promoting health-related behavior change.

Background

Usual school health curricular and other behavior-change interventions targeted at children have had limited effectiveness.^1,2 New channels are needed to reach children that offer promise of promoting substantial health-related behavior changes. One such new channel is the video game, since many children spend numerous hours playing them.³ Using video games to promote behavior change could capitalize on the children’s pre-existing attention to and enjoyment of them. No review has appeared of health-related behavior-change video games. A common component of games is “story.”⁴ For those not familiar with games and stories, a simple glossary of terms appears in Table 1. This paper emphasizes the use of theory to enhance the possibilities for behavior change in the design and creation of stories and video games. The focus is on behavior change, because creating knowledge structures, while laudable in educational venues, is not sufficient to induce behavior change.⁵

Table 1

What is a game? Children and adults have played games since prior to written history,⁶ suggesting that playing games meets enduring psychological needs.⁷ A game is a physical or mental contest with a goal or objective, played according to a framework, or rules, that determines what a player can and cannot do inside a game world.⁸ A video game is any game played on a digital device and encompasses a wide range of games played at arcades, over the Internet on personal computers, or on dedicated game consoles (e.g., Nintendo GameCube, Sony PlayStation, or Microsoft Xbox) or handheld units (e.g., Nintendo Game Boy, Sony PSP).

Games are played primarily for entertainment or “fun,”⁹ but what constitutes “fun” is not well understood. Typical measures of enjoyment (or fun) have used synonyms of fun (e.g., enjoy, like, interested, pleasurable, energizing),¹⁰ which do not elucidate the concept. In one study, statements of what constituted fun while being physically active (e.g., playing with friends, talking with friends, doing something daring, being really good at something) did not lead to separate factors in a principal components analysis (R. Jago, personal communication). In another study, six factors of fun in action video games included: novelty and powerfulness, appealing presentation, interactivity, challenging, sense of control, and rewarding.¹¹ Other aspects of a game that children likely find enjoyable are fantasy (e.g., imaginary characters, virtual worlds)¹² and interactivity.¹³ Games satisfy the player’s needs for autonomy, connectedness, and control.⁷ To win the game, video games challenge players to use the information they obtain as they navigate the game world,^14,15 thereby providing an important education and training modality.¹⁶ This has given rise to the emerging genre of “serious video games” that employ the medium’s rich, role-playing, story-based environments to teach, train, and change knowledge, attitudes, and behavior.¹⁷

Prevalence of Video Game Use

Today’s children and young adults are extensive users of digital devices,³ and video games are a big part of their digital experience. In 2004, the average video game player was aged 30 years and had played computer games for almost 10 years.¹⁸ The average child aged 8–10 years spent 65 minutes per day playing video games; 52 minutes/day among youth aged 10–14 years and 33 minutes/day among teenagers aged 15–18 years.³ Thus, video games reach a large and diverse audience who expect extended contact, suggesting games can attract and maintain attention, a key component for effective behavior change.¹⁹

Games and Behavior Change

Theory provides the foundation for promoting behavior change.⁷ A comprehensive model of learning for behavior change in video games is based on social cognitive theory (SCT) and the elaboration likelihood model,^20,21 and includes the following steps: attention, retention, production, and motivation. The elaboration likelihood model proposes that gaining and maintaining a person’s attention is the first step in getting a person to process the information in a message to promote behavior change.²¹ SCT proposes that behavior change is a function of enhanced skills and confidence (self-efficacy) in doing the new behavior,¹⁹ while modeling¹⁹ and feedback²² are keystones for learning skills. Self-control procedures such as goal setting mobilize a person’s personal resources and focus attention on making specific changes.²³ Games add an element of fun, an aspect of intrinsic motivation, thereby enhancing behavior change through enhanced motivation.⁷ Use of electronic or video games for health-related behavior change is in the earliest stages of development, but incorporating theory-based change procedures provides reason to believe that they can be effective.

Methods

A search was conducted for publications on video games for health-related behavior change by searching the authors’ personal files, contacting colleagues at professional meetings, and searching the following terms in PubMed: games, video games, and interactive multimedia, as well as combinations of these terms. Inclusionary criteria included using the word game to describe their software, with the goal of attempting to modify lifestyle behavior change. Exclusionary criteria were interactive multimedia programs that were not games, or that were games but did not target lifestyle behavior change. Games that were not video games²⁴ were excluded. Twenty-seven articles about 25 different such video games were found and met inclusionary criteria through December 2006. These games addressed diet alone, physical activity alone, physical activity alone among the physically challenged, diet and physical activity combined, or other health-related behavior changes, as shown in Tables 2–6, respectively. Two authors abstracted all articles, and information in tables reflects consensus.

Table 2

Table 6

Results

There was substantial variability across studies in their design, the targets for change, and the characteristics (and reporting of characteristics) of the games. The two-group (treatment versus control) randomized clinical trial (RCT) was the most common outcome evaluation design, but several were single-group-only. Four of the physical-activity video game studies tested primarily whether the game offered the possibility of enhancing fitness,^24–29 with only two assessing whether the game changed behavior.^30,31 Several had ample samples for the evaluation,^32,34,35 while others were small pilot studies.³³ The primary outcome measure varied from knowledge^32,36; to psychosocial variables³⁶; to behaviors³³; to anthropometric,³⁰ physiologic,³⁷ or health-outcome³⁸ variables. Many of the reports provided little data on the game’s characteristics. Lack of comparability across game descriptions and outcomes precluded a meta-analysis or any systematic comparison relating games to outcomes. Most reported some positive outcomes, with only one reporting no evidence of change.³⁷

All of the diet-alone change games employed (n=3) a story of some kind, but it was difficult to discern characteristics of the story in one report.³² While one game was predicated on an operant form of learning theory,³² two were predicated on social cognitive theories.^20,34 All the diet-alone change games resulted in some type of dietary change.

Few of the physical-activity-alone promoting games employed story, emphasizing, instead, simply being physically active.^25,26,29,30 The decline in their use over time and the perception of their being boring within just 4 weeks of use³⁰ might be attributed to their lack of story. The two physical-activity-alone games that used story^39,40 used it in different ways, and targeted very different age groups. Three of the studies of the physical-activity-alone games assessed only the extent to which a single session attained a fitness-enhancing level of physical activity^25,26,29 with all raising concerns about the modest intensity of physical activity that was elicited. The fourth study³⁰ suggested that the duration of participation further limited what body composition outcomes could be expected from these games. One of the physical-activity-alone games obtained a decline in BMI among girls, but not boys,³⁹ while the other conducted with boys alone attained no BMI change.⁴⁰ The game that changed BMI paradoxically attained a small decline in moderate-intensity activity in boys and girls,³⁹ while the other attained a moderate increase in light physical activity, but no change in BMI,⁴¹ and all objectively measured physical activity by accelerometry.

Four studies by one group provided innovative user interfaces (wheels or arm ergometry) to enable wheelchair users to be physically active and in doing that control action in a video game (see Table 4).^27,28,31,40 In each case, the interface enabled the participant to be active at a fitness-enhancing level in a one-time trial with the expectation that being able to play the video game would motivate physical activity at an acceptable level of intensity outside the laboratory. One study demonstrated that seven of eight spina bifida patients were sufficiently motivated to attain a fitness effect after 16 weeks of use of the armergometer interface.³¹

Table 4

Physical activity change games for people with disability

Four games proposed to change diet and physical activity (see Table 5). Three were developed by one group^1,20,41–43 and used story as an organizing framework with minigames inserted to deliver behavior change and self-regulation-related activities. The behavioral theory underpinning the first game, “Fun, Food and Fitness,” has been presented,²⁰ and pilot study results have demonstrated some diet and physical activity change.³³ A second pilot study tested as a stand-alone electronic-health program resulted in both diet and physical activity change.⁴³ Preliminary 1-week outcomes of MetaKenkoh³³ demonstrated some diet and physical activity change. Two games benefited from alpha testing,⁴² which enhanced several aspects of their functioning, but outcomes have not been published.

Table 5

Three of the other health-related behavior-change games addressed behavioral issues in asthma. One demonstrated substantial changes resulting in fewer hospitalizations³⁸; another demonstrated increased knowledge and more internal control, but no lung function improvements⁴⁴; the third reported no demonstrable changes.³⁷ It is not clear from the publications what differences across the games, or the samples, might have accounted for the different outcomes. Five other games addressed diabetes-related behavior.^36,45 One of these games demonstrated substantial changes resulting in lower emergency room and urgent medical care use.⁴⁵ The other games were very limited in focus (e.g., trying to enable children to understand the need and value to balance food intake with insulin administration to control circulating glucose levels),³⁶ and demonstrated psychosocial changes at 3-months followup.³⁶ An action–adventure game with the child shooting cancer-causing agents in the bloodstream targeted medication adherence among pediatric cancer patients⁴⁶ and reported substantial psychosocial and regimen compliance change at 3 months after playing the game.⁴⁶

Discussion

Playing most of these behavior-change video games led to a broad spectrum of desirable outcomes from knowledge increases,³² to attitude changes,³⁶ behavior changes,³⁴ and other health-related³⁸ changes. This bodes well for the future use of video games to promote health-related behavior changes and warrants an intensive analysis of aspects of video games that offer the most promise of promoting behavior change. There appear to be two primary methods by which video games can influence behavior. The first involves the insertion of behavior-change procedures (e.g., goal setting) into the process of playing the game. The second involves the use of story and inserting behavior-change concepts in the story.

Theory-Based Procedures in Behavior-Change Games

Computers have been used to promote behavior change for some time⁴⁷; however, most computerized behavior-change programs are not video games. SCT was the most commonly cited theory providing a foundation for behavior change.¹⁹ Some reported using a full range of behavior-change procedures,²⁰ while others enhanced only knowledge.³⁶ As an example, the SQ! game integrated SCT-specified behavior technology procedures (i.e., goal setting, decision making, goal review, social reward) into game play.³⁴ SQ! goals included changing known environmental, personal, and behavioral factors regarding why children were not eating particular fruits and vegetables. The goals were tailored to whether these factors pertained to each child specifically: SQ! attempted to increase preferences for targeted fruits and vegetables and used self-regulation procedures, e.g., goal review and problem solving, when goals were not attained. Setting and attaining goals enhanced the fruit and vegetable intake among various student subgroups⁴⁸ and overall the video game achieved a 0.9 serving per day increase in fourth-grade children’s fruit and vegetable consumption.³⁴ How diverse behavior-change procedures can be inserted in video games has been addressed elsewhere.²⁰

Importance of a Story

A story is a narrative of a series of events.⁴ Stories take place at a particular time (e.g., the winter of 1776, the week after college graduation); at a particular place (in a boat crossing the Delaware, on the bridge of a starship); and have characters. Ordinarily, one character, called the protagonist, takes the lead in the story. Protagonists can have external or internal conflicts. When protagonists oppose someone else, that character is the antagonist. The struggle between these two is the conflict, which is the motivating factor behind the story’s action and plot.⁴ Stories usually engage individuals by means of their empathy with the protagonist⁴ and are effective when the protagonist shows change in values in the story (e.g., cowardice to courage, betrayal to loyalty), exemplifying a lesson that can be learned (also called the story’s controlling idea⁴ or moral, e.g., eating fruits and vegetables and being physically active to provide strength and stamina to escape from oppressive situations). These changes in values are engineered by the writer in terms of events that pose conflict for the protagonist. The conflicts can be the commonly reported barriers to making behavior change, and the protagonist’s ways of overcoming the barriers can be the modeling of effective problem solving.

This very abbreviated exposition suggests that behavior change can be enhanced when stories address behavior-change issues, and the lesson to be taken from the story promotes health behavior changes. While stories have been used for health-related behavior changes (soap operas),⁴⁹ the exposition of how this has been done, especially using story structure to promote behavior change, has not been addressed. An example of such a story was Squire’s Quest! (SQ!) a 10-session video game.³⁴ The story’s controlling idea was that eating more fruits and vegetables gives strength to resist dangerous characters. SQ! used a variation of a common medieval story involving a king, queen, knights, invaders, and a struggle. Invaders were destroying a kingdom by destroying its fruits and vegetables, the source of energy. The king didn’t have enough knights to fight off the invaders, so each player was asked to become a squire, a person in training to become a knight. As per medieval lore, squires must face and overcome challenges to become knights. The challenges in this game just happened to require that the squires eat more fruits and vegetables, resulting in an increase of 0.9 serving/day in fruit and vegetable intake. Thus, SQ! used a story to engage the students, maintain their interest and model the desired behaviors by key characters.

Stories have been told by every culture throughout human history,⁵⁰ thereby also suggesting that they meet some enduring psychological need. Different cultures have evolved somewhat different ways of conveying stories, although many elements are common to all.⁵¹ The dominant format used in most Western society books, films, and video games is a three-act structure, a pattern Western audiences have come to expect: Act 1—exposition and the beginning of the conflict; Act 2—complications and climax; and Act 3—resolution and conclusion (denouement). Stories that do not adhere to these conventional storytelling rules risk alienating Western audiences. Why certain stories appeal to certain audiences is not clearly known.⁴¹

Story Genre

Patterns of story telling have evolved into story genre,⁵² e.g., western, murder-mystery, and comedy. Melodrama was originally developed for the stage to focus on plot and action and reduce story complexity.⁵² Most melodrama issues are reduced to struggles between good and evil, which appeal more to viewers’ emotions than cognitions,⁵² thereby presenting a potentially promising tool for behavioral intervention in serious games. Behavioral theory on the role of emotions in health-behavior change⁵³ will need to advance rapidly to capitalize on these possibilities.

Serials are a single narrative developed through a number of individual, linear episodes. Each serial episode forms a separate unit of a larger story. Serial melodramas often end with a cliffhanger, unresolved tensions in a storyline designed to motivate viewers’ return to the next episode. Research on the Zeigarnik effect⁵⁴ presages an understanding of the role of cliffhangers in story and game design, but more research on this point is necessary in advancing their use and effectiveness in behavior change video games.

Episodic stories are also short, complete narratives. Instead of linearly building to a conclusion, they loosely arc and intertwine substories, related by the same characters and settings. Soap operas are episodic, melodramatic stories involving a group of individuals. Each character has his or her own story, which link in unpredictable ways from episode to episode. Episodic stories may function primarily to maintain attention. In serious video games, interrelated components among the differing stories could be used to reinforce behavioral-change messages in diverse situations. For example, each component story could deal with different barriers to eating more fruits and vegetables (e.g., distaste, home availability, skills to prepare more, and tastier dishes).

Game Immersion

Video games can encompass and capture a player’s full attention, as if the player were actually part of the game environment. This has been called immersion, or presence.⁷ Video game environments were confined initially to flight simulators and research laboratories⁵⁵; realistic or otherwise complex virtual three-dimensional environments are now common in many video games. Game players become involved literally and emotionally in the story. While skilled game developers effectively create such immersive experiences regularly, the behavioral science of how this is achieved, or optimized, is not known. Immersion is believed to be a component of intrinsic motivation.⁷

Interactivity

Nine dimensions of interactivity in a website (i.e., accessibility, navigation, time, personalized content, delivery of message, data entry and use, entertainment, promotions, relationship) and 52 underlying variables have been delineated.⁵⁶ Subsets of these appear relevant to interactivity in a video game. Directly participating in story situations and taking first-person control of events are key aspects of interactivity in video games.¹³ Just as in real life, players learn through planning, decision making, and personally witnessing cause-and-effect relationships. Role playing likely increases a player’s personal stake in a video game’s outcome. In part, role-playing performances combine the emotion of storytelling with the power of character immersion. The video game designer can structure the interactive options to provide meaningful feedback for player-made choices. The feedback can be in the form of reinforcement (e.g., statements of positive regard), information to make next choices, or experiential learning sequences (e.g., interactions with animated characters that provide theoretically specified experiences).

Fantasy

Fantasy, defined as the active use of imagination,⁵⁷ has facilitated active engagement among youth,⁵⁸ and is a primary source of intrinsic motivation.^{34, 57–59} Both youth and adults engage in fantasy, although the content of the fantasies vary in that they tend to reflect personal interests and concerns.⁵⁷ For example, adolescent fantasies tend to include themes such as appeal to opposite gender, future vocation, sports, and achievement.⁵⁷ Fantasy has been reported to peak between late adolescence and early adulthood.⁵⁷ A review of text-based nutrition education materials found that fantasy was included in 16 of 30 of the materials reviewed.⁶⁰ The materials that included fantasy were described as more creative and fun than those not including fantasy, and they were more likely to use characters and scenarios to foster engagement.⁶⁰

Fantasy contexts have also been used in video games.^58,59 Video games excel at “what if” scenarios, i.e., the ability to personally inhabit an improbable world, wander around on one’s own, and interact with fantastic characters or events. Fiction and action–adventure stories may be better suited to video games’ rich, immersive, fantasy role-playing environments than nonfiction genres. In a study of 7th- and 8th-grade children, focus groups to select video game storylines revealed that child participants preferred action–adventure over other genres (V. Thompson, personal communication). In another study with 3rd- and 4th-grade students, embedding educational information in fantasy contexts was found to result in significantly more learning and knowledge transfer than nonfantasy contexts.⁵⁸ The effect was not mediated by choice, i.e., choosing the fantasy context was no more effective than having the fantasy context assigned. The fantasy context used in the study was created by embedding educational information in simple stories that required a child to solve problems.⁵⁸ A video game program promoting asthma self-management to children aged 9–13 years⁵⁹ included elements of fantasy. The video game had motivational appeal, and children who used the game had gains in knowledge, self efficacy, and attributions leading to self-management. SQ! also used a fantasy-based game format to effectively promote fruit and vegetable consumption to 4th graders.³⁴

Video Game Design and Structure

Video game cinematics (sometimes called cut scenes) advance a game’s storyline, but are relatively short movie clips that are watched passively by players intermittently throughout the game. Unlike traditional passive-only media, video games depend on the player’s action to move the story forward (via branching logic based on player selections). There is more than one ending in a video game (at a minimum, there are two: winning and losing), and sometimes multiple ways of getting to an ending. Players’ actions, often called game mechanics, are the way that players navigate story environments, interact with story events, and chose story paths. The mechanics of game play need to be inventoried and their role in involvement and individualizing messages more clearly understood to be able to create successful behavior-change video games.

Age and Game Play

The kinds of games appealing to young children should be quite different from those appealing to adolescents or young adults, because of substantial differences in cognitive or emotional development throughout this age range. Research, however, has not as yet led to development of a theory of developmentally appropriate games. Thus, development of an age-appropriate intervention requires substantial formative research (e.g., focus group discussions, intensive interviews, observations) with the targeted demographic group on story and character concept, story arc, personality and visual representation, and alpha testing on fun and functionality of the interactive components. No health-related behavior-change games were found with stories for adults. While in theory, games with stories should be able to be designed for this demographic, little guidance was found in the published literature.

Health Behavior Change Game Development

To capitalize on the possibilities of video games for promoting health behavior changes, behavioral scientists need to collaborate with professionals who can write an engaging story and have knowledge and skills in game design, formative research, story boarding, producing, directing, music composition (for games with music scores), computer art, animation, and programming. In larger projects, each of these skills is offered by different professionals, whereas in smaller projects, one person may play several or even all roles. For a health behavior-change video game, additional expertise is required in regard to content expertise about the health problem and/or the health behavior(s) of concern, and behavior-change intervention design (theory and procedures). Initially there would be a vast divide in the understanding and even the languages used by these differing sets of professionals. Over time, they must learn to effectively communicate and respect each others’ contributions.⁶¹

There is no consensus model for serious video game development strategy or process. The process used in part will reflect the amount of funding available. Greater funding will have larger teams and larger incubation periods producing more fully developed products. Lesser funding likely imposes an incremental developmental period where smaller products are added to earlier products. The Spiral Technology Action Research (STAR) Model was propounded to capture the latter⁶² and capitalizes on action research methods.⁶³

Time and Cost

Developing a video game is a time-consuming process. Some commercial video games take 3 or more years to develop. (The authors spent 3.5 years developing a health-related behavior-change game.) The costs of developing a commercially viable video game have been estimated in the millions of dollars. Major components of such costs are the high-end graphics, animation, and interactivity needed to attract and maintain attention for a sophisticated audience. As the qualities of commercial video games increase in sophistication, similarly high expectations will be created for health-related behavior-change and other serious video games.

Perhaps economies can be achieved by reusing and adapting computer program code (sometimes called game engines) to create new video games. Perhaps certain characters will achieve a level of notoriety that their original art work transferred to new video games will assure attention in the market place. It is not clear the extent to which the market exists that will buy health-related behavior-change video games (e.g., parents of children suffering from certain health issues, schools for health education curriculum, or just concerned parents). The ideal purchasers of serious video games would be the children themselves, attracted by the prospect of a fun experience. Proof of markets would enable software publishers and investors to invest capital in the development of behavior-change video games. Until then, or absent such markets, governmental or charitable organizations will need to invest in this development.

An Agenda for Research on Health Behavior-Change Video games for Children

To enable the field to advance, the outcome evaluations of health-related behavior-change video games need to employ state-of-the-art designs, adequately powered samples, valid and reliable measures of outcomes and mediators,⁶⁴ and be reported in a way consistent with other randomized clinical trials (e.g., see the CONSORT statement)⁶⁵ to ensure that data required for meta-analyses are available. Using the earlier framework for understanding behavior change (i.e., attention, retention, production, motivation), this section identifies priority research issues to better understand how change occurs in video games, and thereby how to better design them in the future.

Attention

The capabilities and limitations of diverse video game platforms deserve careful investigation. For example, the depth and breadth of the visual and audio experience on a full computer screen is quite different from that on a small handheld game unit. Whether the depth and breadth of this experience influences the player’s immersion in the story is not known. The handheld unit may hold the same appeal for younger players (who are likely more prone to fantasy) as the larger units have for adults. Characteristics of the game that lead to intense involvement, and the effect of immersion on behavior change, need to be better understood. For example, players might come to a game expecting to be immersed in the story, thereby not requiring much effort on the part of the game (e.g., before children started a game, they expected it to be fun).⁶⁶ There may be elements of story, visual effects, or ability to participate in what happens (the interactivity) that trigger or facilitate immersion. Players may have certain expectations for health behavior-change video games. These may vary from other video games. Health behavior-change video games may minimize possible difficulties caused by some expectations (e.g., “they can’t be much fun because they are not first-person shooter games”).⁸

Novelists and screenwriters may intuitively know how to tailor a story to maximize the involvement of an audience, but behavioral scientists likely do not. Research on how best to use the three-act structure to design games offers the possibility of enhancing effective behavior-change programming. Research on why audiences expect these story conventions offers the possibility of innovative approaches to the use of stories with new structures in behavior change gaming.

Retention

Emotion has been strongly linked to memory,⁶⁷ or retention. Stories are designed in part to evoke emotion.⁴ Recent models predicting behavior have incorporated emotional variables.⁵³ Reinforcement mechanisms in video games influence positive and negative emotions.68 How emotions influence health-related behaviors and its changes are not well known. An empiric literature needs to be generated on how aspects of story, components of games and stories within games, evoke emotional responses, which in turn enhance attention to and retention of messages and otherwise enhance (or inhibit) behavior change.

Production

Games promoting physical activity alone, whether for the fully abled or for those physically challenged, have emphasized primarily just being physically active (i.e., just producing the behavior), apparently assuming that the aspects of being active will be rewarding, or using commercially available nonactivity-promoting games as incentives for doing the activity.

Research is needed on the extent to which different categories of children (e.g., the usually inactive, the obese, different ages, both genders) are willing to initiate activity in response to these video games, how much activity is elicited, and for how long the behavior will be maintained. Mechanisms whereby such behaviors are elicited and maintained need to be elucidated. Activity-promoting video games with and without story need to be compared.

A number of video games are single-entity games,³² while others use a series of smaller minigames that encapsulate and present behavior-change procedures.⁶⁹ These represent different uses of games; understanding when each is most appropriate and effective need to be delineated.

Industry and the military have used simulation experiences to train employees in how to better perform work-related behaviors, especially in virtual high-risk settings, where making a mistake in real life could have substantial personal and social costs (e.g., how to search for a missing soldier in a war zone). Similar kinds of simulated virtual experiences could be used to train parents to provide better food parenting,⁷⁰ or to train children how to “ask” for fruit and vegetables.⁷¹

Motivation

The theory of self determination (TSD)⁷² has posited that intrinsic motivation, i.e., doing something because you want to do it, is a predictor of initial and continuing performance of a behavior.⁷ “Fun” is an aspect of intrinsic motivation. Research needs to explicitly determine what aspects of playing a video game and of story are fun. This might be done experimentally by systematically varying aspects of games and testing their perceived fun,⁶⁶ by doing surveys including items usually considered fun, or by comparing games that vary in their enjoyment ratings.

Mastery is another aspect of intrinsic motivation. A nine-factor solution with three higher-order factors captured adult’s motivations to play massively multiplayer role playing games.⁷³ Consistent with TSD, “achievement” (an aspect of mastery) was one of the higher order factors. Boys were more motivated by achievement, while girls were more motivated by affiliative or social factors.⁷³ Similar measures need to be developed for health-related behavior-change video games.

Conclusion

Serious video game–based behavior change is an exciting form of media-based intervention. A peer-reviewed literature is emerging on this topic. The many desirable outcomes warrant moving forward in this area. A second generation of research requires models of pathways of effects, and testing theory-based propositions. This should include how to use story to affect variables on the pathways to change. Understanding how to harness the power of media-based video game interventions offers great promise to promote health-behavior change, but requires extensive research.

Table 3

Acknowledgments

This research was primarily funded by a grant from the National Institute of Diabetes & Digestive and Kidney Diseases (5 U44 DK66724-01). This work is also a publication of the United States Department of Agriculture (USDA/ARS) Children’s Nutrition Research Center, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, and had been funded in part with federal funds from the USDA/ARS under Cooperative Agreement No. 58-6250-6001. The contents of this publication do not necessarily reflect the views or policies of the USDA, nor does mention of trade names, commercial products, or organizations imply endorsement from the U.S. government.

No financial disclosures were reported by the authors of this paper.

Footnotes

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References

This week, we’re running a big list of what we — and a group of trusted friends — recently voted as the 500 best video games of all time. For the backstory, criteria, explanation of why Breath of the Wild isn’t on the list, etc., head to the beginning here: The 500 best games of all time.

For numbers 200-101, scroll down.

500-401 • 400-301 • 300-201 • 200-101 • 100-1

200. 30 Flights of Loving

(2012, Mac, PC)

Sometimes the most striking parts of a story only exist in the viewer's mind. 30 Flights of Loving leaves it up to the player to imagine the events of a heist gone wrong, subverting the video game trope of over-explaining everything to the player through hours of exposition, and telling a short, out-of-order story.

199. Halo 3

(2007, Xbox 360, others)

When you buy a new Halogame, you can generally expect it to be more of the same, but bigger. And Halo 3 was pretty much that. That's not to undersell some of its key features, though. Its Forge map editor allowed players to create and play their own multiplayer maps — an awesome addition to one of the series' hallmark modes.

198. Overwatch

(2016, PC, PlayStation 4, Xbox One)

Overwatch left a crater in its wake when it landed in the gaming scene. Full of heart, full of character and one of the best-playing first-person shooters in recent years thanks to a bevy of vastly different, finely-adjusted characters, Overwatch wasted no time changing the game industry at large.

197. Mario Kart 64

(1997, Nintendo 64, others)

This is where all business is settled. One of the industry's best examples of local multiplayer, Mario Kart 64 brought the series into 3D for the first time and it is still a staple of get togethers for those who remember fondly playing it as kids.

196. XCOM: Enemy Unknown

(2012, PC, PlayStation 3, Xbox 360, others)

A remake of the original X-COM, Enemy Unknown reinvents the wheel. Retooling and modernizing the series' trademark turn-based strategy, Enemy Unknown quickly earned praise as an 'instant classic' and a 'singular achievement that every gamer deserves to experience.'

195. Final Fantasy 9

(2007, PlayStation, others)

Thanks to a combination of old and new elements, Final Fantasy 9 resonated immensely with fans and critics. Today, it still retains the series' highest Metacritic score.

194. Dragon's Dogma

(2012, PlayStation 3, Xbox 360, others)

Dragon's Dogma struck a beautiful balance between deep role-playing mechanics and fast, fluid combat. The way Dragon's Dogma combines these two disparate parts makes for one of the most interesting role-playing experiences in recent years.

193. Star Wars: X-Wing vs. TIE Fighter

(1997, PC)

Completely lacking a storyline, X-Wing vs. TIE Fighter allowed players to jump right into the action and play against others or practice on their own. While this approach has been controversial for many other games, here it paid off with strong enough mechanics to make a fulfilling product.

192. Pokemon Gold and Silver

(2000, Game Boy Color)

Pokemon Gold and Silver marked the transformation of the Pokemon brand from a major success to a multi-billion series. While this wasn't the most innovative pair of releases, it was responsible for pushing the franchise over the edge to becoming the juggernaut it is today.

191. Sonic The Hedgehog

(1991, Genesis, others)

Sonic wasn't always a punchline. When the original Sonic The Hedgehog hit the market, it was like nothing players had seen before. It was fast. It was cool.It had attitude. Sega's answer to Mario quickly became a massive brand.

190. Command and Conquer

(1995, Mac, PC, others)

Inspired by real-world events like the Gulf War, Command Conquer was partly responsible for the popularization of the strategy game genre. Taking a more realistic approach than most other strategy games, Command and Conquer focused primarily on action, making it more exciting than many of its competitors.

189. Myst

(1993, Mac, others)

Myst trimmed the fat from the adventure game template. Abandoning the obtuse puzzle designs and seemingly random punishments many were accustomed to, it appealed to enough players to spawn several sequels and spinoffs. Ultimately, it was so popular that it's sometimes credited for killing the traditional adventure game.

188. P.T.

(2014, PlayStation 4)

These days, P.T. is a window into an alternate universe — one where Hideo Kojima, Guillermo Del Toro and Junji Ito could have made the scariest game of all time. Released as a 'playable teaser' for Silent Hills, a now-cancelled Silent Hill game, P.T. created something of a water cooler moment where players gathered in droves to compare and contrast their individual experiences and try and figure out what it all meant.

187. Left 4 Dead

(2008, PC, Xbox 360, others)

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Released during the rise of competitive online console shooters, Left 4 Dead brought back co-op. The ever-changing gameplay — dictated on the fly by the game's A.I. 'Director' — kept each playthrough interesting for groups of players, and led IGN to call it 'quite possibly the perfect co-op shooter.'

186. Fallout 3

(2008, PC, PlayStation 3, Xbox 360)

Fallout 3 set a precedent for the Bethesda Game Studios' future games. Incredibly ambitious, the sheer amount of content and meticulous world design made for a game still considered one of the best in the genre — even compared to more recent contemporaries.

185. City of Heroes

(2004, Mac, PC)

When it released, City of Heroes felt like a breath of fresh air. Colorful, goofy and, most of all, fun, it was a far cry from the overly serious style of most MMORPGs. Allowing characters to build their own superheroes and power sets — and later missions — City of Heroes let players become who they wanted.

184. Rez/Rez Infinite

(2002, PlayStation 2, others)

Rez is a game you can feel — sometimes literally. Not so much a simple rhythm game as it is a journey through sound, the melodies players create happen in the background of a lock-on shooter. Rez's abstract, art house-like subversion of the rhythm genre is something you need to see to fully appreciate — and it's even better in VR.

183. StarCraft 2: Wings of Liberty

(2010, Mac, PC)

StarCraft 2: Wings of Liberty's multiplayer alone is enough to secure a spot on this list. Satisfying, challenging and full of content, Wing's of Liberty's multiplayer made for one the most successful games in esports competitions — especially in South Korea. Since release, the game's consistently been a star attraction for tournaments paying out well over $100,000.

182. Warcraft 3: Reign of Chaos

(2002, Mac, PC)

Warcraft 3: Reign of Chaos is a game that just won't quit. Still supported and updated by Blizzard 15 years later, Reign of Chaos is still loved not for reinventing the real-time strategy genre, but for nearly perfecting it — all the while fleshing out the Warcraft storyline and introducing two new races to the series.

181. Vagrant Story

(2000, PlayStation)

Vagrant Story stripped away many of the typical Japanese action role-playing conventions. Featuring no shops or even interactions with other players, the game instead tasked players with creating and upgrading their weapons as they journeyed alone through catacombs. And the game's deep story and trope-breaking found success around the world.

180. Ultima Underworld: The Stygian Abyss

(1992, PC, others)

The Stygian Abyss made it possible for series like The Elder Scrolls to exist. The first role-playing game to be set in first-person in a 3D environment, as well as the first to let players look up and down, The Stygian Abyss was massively innovative, changing the way role-playing games were played and how games in general approached navigation.

179. Star Wars: TIE Fighter

(1994, Mac, PC)

Called 'the best space combat game ever made' by GameSpot upon its release, Star Wars: TIE Fighter refined the feel and combat of games like X-Wing. But its visuals made the biggest waves. Making use of Gouraud shading, Tie Fighter was more realistic looking than most games at the time.

178. The Secret of Monkey Island

(1990, PC, others)

The Secret of Monkey Island played with the idea that point-and-click adventure games didn't have to harshly punish mistakes. Also, that they could make you laugh. Full of inventive, weird puzzles and a genuinely funny script about the misadventures of pirates, Monkey Island helped cement Lucasfilm Games as the premier adventure game developer.

177. The Last of Us

(2013, PlayStation 3, others)

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The Last of Us is about being alive — even when it seems impossible. Telling a brutal, yet intimate post-apocalyptic story with some of the finest examples of character development in games, The Last of Us' tale of love, lies and the human condition set a new bar for storytelling in games — one that'll be hard to top.

176. System Shock 2

(1999, PC, others)

System Shock 2's thinking-man's approach to the first-person genre became a blueprint for the genre going forward. Terrifying, tense and open-ended, System Shock 2 earns special praise for its story of AI sentience.

175. Superhot VR

(2016, PC, others)

Superhot VR lets you watch death come for you in slow motion. Maintaining the gameplay of Superhot —time only moves when you do — in VR, an already tough game becomes a ballet of sorts as you physically avoid slow-moving, then fast-moving bullets while strategically placing your own shots.

174. Streets of Rage 2

(1992, Genesis, others)

Streets of Rage 2 is one of the best side-scrolling beat-'em-ups of all time, and a hell of a time if played with another person. The game's expanded roster, unique special moves and, of course, the combat make for something special. And the music's pretty good too.

173. Star Wars: The Arcade Game

(1983, Arcade, others)

Star Wars: The Arcade Game faithfully recreated one of Star Wars' best moments: the destruction of the Death Star. Playing as Luke Skywalker, players flew through 3D vector dogfights before ultimately destroying the superweapon. This was one of the best licensed games of its time due to its ability to make you feel like you were in the action.

172. Spacewar!

(1962, PDP-1)

First developed in 1962, Spacewar! simply tasked two players with destroying each other while flying around and dodging incoming attacks. Its early innovations helped influence the creation of groundbreaking games like Asteroids.

171. Red Faction: Guerilla

(2009, PC, PlayStation 3, Xbox 360)

Though the game's plot and gameplay were weak points, the degree to which the game's buildings and structures could be torn apart changed how scenarios could be approached and found critical praise. Guerilla's approach to destruction forced players to be more active and experimental.

170. Planescape Torment

(1999, PC, others)

Planescape Torment was a small fish in a big pond — at least commercially. A cult classic, Torment's rich story gets points for being smarter than its peers, casting players as a selfish protagonist with surprising depth.

169. Phantasy Star 4: The End of the Millennium

(1995, Genesis)

The End of the Millennium has aged great. Considered years behind in presentation upon release, retrospective reviews have since praised the game for its striking visuals, great gameplay and wonderful soundtrack. Perhaps ahead of its time, Phantasy Star 4's ambition made it a role-playing game still worth going back to almost 15 years later.

168. Monster Hunter 4 Ultimate

(2015, Nintendo 3DS)

Everything done right in Monster Hunter 4 is done better in Monster Hunter Ultimate 4 —an expanded version of the former. Ultimate 4 offers more player movements and actions, giving the game added depth. If you want to play Monster Hunter 4 now, get this version.

167. Homeworld 2

(2003, PC, others)

Homeworld 2 opened up the playing field for the real-time strategy genre — literally. Allowing complete three-dimensional movement for players, Homeworld 2 abandoned the archaic point-and-click design of previous similar games, making battles more dynamic and interesting.

166. Giants: Citizen Kabuto

(2000, PC, others)

Giants: Citizen Kabuto's greatest strength was being two games at once. One part real-time strategy game, one part third-person shooter, Citizen Kabuto seamlessly melded the two into a game that's as action-packed as it is strategic. Praised for its revolutionary graphics and funny story, the game maintains a cult status to this day.

165. Galaga

(1981, Arcade, others)

Galaga was the apex of vertical shooters. Expanding on games like Galaxian and Space Invaders by adding more than one gun, challenge levels and the danger of being captured, Galaga was one of the most popular games from the early arcade era.

164. FS1 Flight Simulator

(1979, Apple II)

One of the early examples of a simulation game, FS1 Flight Simulator was one of the most technically impressive games when it released in 1979. Paving the way for both other flight sims like Microsoft Flight Simulator and the simulation genre in general, FS1 and its early approach set a new standard for the way games presented real-life activities.

163. Dragon Quest 8: Journey of the Cursed King

(2005, PlayStation 2, others)

Dragon Quest 8: Journey of the Cursed King brought the series into 3D, allowing for a more fully realized Dragon Quest world for players to explore, as well as making battles more visually impressive. These changes were popular enough that many fans cite the game as the best in the series.

162. Defender

(1981, Arcade, others)

Considered one of Eugene Jarvis' best games, and his most difficult, Defender was one of the all-time greats from the heyday of arcade gaming. Defender helped create the horizontal shoot-'em-up genre, as well as establishing games as challenges to overcome through skill and reflex.

161. DEFCON

(2007, Mac, PC, others)

DEFCON pioneered the idea that just because a game was cheap, that didn't mean it was bad. In fact, most critics were surprised that such a low budget game shipped with the quality it did. DEFCON was an early example of a game challenging the conventional models of the industry.

160. Crusader Kings 2

(2012, Mac, PC, others)

Tasking players with running a successful dynasty and appointing an heir, Crusader Kings 2 stood out in a genre largely populated by simulations of mundane tasks. It gave players power while expecting them to work with the rules of the simulation.

159. Civilization 4

(2005, PC, others)

The best game in the turn-based strategy series, Civilization 4 introduced refined AI systems, presenting harder challenges for players. It was also just a better package. With completely new visuals and enhancements to single-player and multiplayer, Civilization 4 further cemented Civilization as the premier series of its kind. Its title song was also the first game track to win a Grammy, so that's cool.

158. Castlevania: Aria of Sorrow

(2003, Game Boy Advance, others)

Castlevania: Aria of Sorrow was one of the only Game Boy Advance Castlevanias that felt just right. Widely compared to that of Symphony of the Night, Aria of Sorrow's gameplay was simple enough to jump into but deep enough to stand among its console brethren.

157. Brothers: A Tale of Two Sons

(2013, PC, PlayStation 3, Xbox 360, others)

Brothers: A Tale of Two Sons conveyed its message through gameplay. Telling the story of two brothers, each controlled with one of the two thumbsticks, the game's unique set-up tested the bonds of family. Lauded for its emotional story driven by this mechanic, A Tale of Two Sons was about learning to work together, all the while growing closer.

156. 80 Days

(2014, Android, iOS, PC)

By 2014, branching narratives were old hat. But the masterfulness in which 80 Days told its story of world travel, and the nuances and complexities in which the story is dissected by player choice, was one of the finer examples storytelling in video games.

155. Assassin's Creed 2

(2009, PlayStation 3, Xbox 360, others)

An impressive follow-up to the well-received but disappointing first Assassin's Creed game, Assassin's Creed 2 improved upon nearly everything the first game did wrong. Mixing intuitive stealth gameplay with a lighthearted, emotional tale of revenge, Assassin's Creed 2 was a great example of how a sequel can be made.

154. Pac-Man: Championship Edition DX

(2010, PlayStation 3, Xbox 360, others)

Pac-Man Championship Edition DX made for a masterclass in how to modernize a classic game. Taking the traditional gameplay of Pac-Man, but adding new mechanics like increased speed, score boosts and new ghost types, Championship Edition became one of the most addictive games ever released, even rivaling, you guessed it, Pac-Man.

153. Geometry Wars

(2005, Xbox 360, others)

Like Pac-Man: Championship Edition DX, Geometry Wars was a masterful retake on an old genre. Disguised as a simple twin-stick shooter, Geometry Wars felt overwhelming due to waves of enemies that exploded into bright, colorful particles. Geometry Wars added a modern sheen to a classic genre.

152. The Walking Dead Season 1

(2012, Mac, PC, PlayStation 3, Xbox 360, others)

The Walking Dead changed everything we knew about game writing. Focusing on the impact of every decision, it presented numerous heart-stopping experiences. The Walking Dead asked a near-impossible question: How far will you go to save someone's life?

151. Metroid Prime

(2002, GameCube, others)

The first Metroid game to be in first-person, Metroid Prime still retained everything that makes the series great. Prime's perspective made it one of the more engulfing games in the series, incentivizing further exploration and leading players around every corner.

150. Soulcalibur 2

(2002, Arcade, others)

Soulcalibur 2's character roster stands out even today. Settling arguments some might have about who would win in a fight, it let players pit Spawn against Astaroth, or Link against Taki. Though not the first game to feature crossover characters, its use of big names stood out from the pack.

149. Animal Crossing: New Leaf

(2013, Nintendo 3DS)

Expanding on Animal Crossing's accessible life-sim gameplay, New Leaf gave players a host of new customization options and ways to interact with the world. With the series already easy to get lost in, these improvements and the game's handheld nature made it one of the most addictive Animal Crossings.

148. Super Mario 3D World

(2013, Wii U)

Super Mario 3D World was a shapeshifter. Best played with four players, it constantly bounced between genres but never suffered an identity crisis because of it. As Polygon's Justin McElroy put it, 'Even at its most unrecognizable, it's one of the most joyous multiplayer experiences we've ever been a part of.'

147. Wolfenstein 3D

(1992, PC, others)

Wolfenstein 3D started it all. Id's groundbreaking first-person shooteroften hides behind the shadow of Doom, but without Wolfenstein 3D there would have been no Doom. Without Doom, well, you know the rest. Every virtual trigger pulled and every bullet shot in games owes a great deal to Wolfenstein's revolutionary take on the first-person genre.

146. Mortal Kombat 2

(1993, Arcade, others)

After Mortal Kombat shocked half the world with its gratuitous displays of violence, Mortal Kombat 2 embraced the controversy like a badge of pride. Continuing the tradition of bloody arcade fighting and pissing people off, Mortal Kombat 2 added more of pretty much everything.

145. Team Fortress 2

(2007, PC, PlayStation 3, Xbox 360, others)

Team Fortress 2 featured a cast of unique, funny characters, a different approach at a moment in time when many games featured voiceless killing apparatuses. Team Fortress 2's lighthearted approach helped pave the way for an influx of hero shooters.

144. The Legend of Zelda: Link's Awakening

(1993, Game Boy, others)

The Legend of Zelda: Link's Awakening felt too big to be a Game Boy game. Its full Zelda adventure, depth and made for an incredible feat when the game launched in 1993. Though now the series is well-established on handhelds, Link's Awakening was the first to make us feel those feelings on the go.

143. Unreal Tournament

(1999, PC, others)

Quickly cementing itself as one of the best online first-person shooters, Unreal Tournament featured some of the best gameplay, visuals and level design seen at the time. Online only, Unreal Tournament was awash with thousands of players trying to prove their skills.

142. The Operative: No One Lives Forever

(2000, PC, others)

A mix between a first-person shooter and a stealth game, No One Lives Forever was more stylish than almost any game released before or after. The game's '60s chic, hilarious script and gadgets would make a Bond blush.

141. Super Smash Bros.

(1999, Nintendo 64)

Super Smash Bros. felt like playing with action figures. Starring a who's-who of classic Nintendo characters, the game distilled down to knocking each other off each map. Super Smash Bros. was the beginning of a titan that went on to shape the competitive gaming scene.

140. EverQuest

(1999, Mac, PC)

EverQuest 'obliterated' the bar for online gaming when it released in 1999, according to GamePro. Credited as the second successful MMORPG ever released, EverQuest gave players three continents to explore, and 14 classes/12 races to choose from when creating a character. Unprecedented its size, the gameset forth conventions and designs that'd define the genre going forward.

139. The Oregon Trail

(1971, Apple II, others)

One of the most widespread games of all time, The Oregon Trail gamified learning. It taught kids about American history while being immensely fun and engaging to interact with over the course of its long journey.

138. Resident Evil

(1996, PlayStation, others)

It wasn't even close to being the first survival horror game, but Resident Evil defined the genre after its 1996 release. Utilizing fixed cameras to give the game a cinematic look, while under-distributing ammo and save spots, Resident Evil created a sense of tension unseen before players walked through its numerous winding halls and traps.

137. Phantasy Star Online

(2001, Dreamcast, others)

Phantasy Star Online didn't bring the MMORPG to consoles; it was a tailor-made experience for the desires and demands of console players — with hack-and-slash gameplay and beautiful visuals. Coming before the success of titans like World of Warcraft, Phantasy Star Online evolved online gaming in its own small way.

136. Kirby's Adventure

(1993, Nintendo Entertainment System, others)

One of the NES' best looking games, Kirby's Adventure let you experiment in your approach, changing your play style to make each attempt a little bit different than the last.

135. Hearthstone

(2014, Android, iOS, Mac, PC)

Hearthstone single-handedly made the digital card genre what it is today. Taking cues from Magic: The Gathering but making something approachable and flashy, Blizzard was able to bring in hoards of fans across the world who otherwise would have never touched a collectible card game.

134. Street Fighter 3: Third Strike

(2000, Dreamcast, others)

The third iteration of the third Street Fighter, Third Strike bolstered the game's lineup of fighters, adding Chun-Li, Q and others. From a competitive perspective, it's the version of SF3 that's stood the test of time, often still appearing in tournaments. And it features some of the smoothest animation ever seen in a fighter.

133. Kirby: Canvas Curse

(2005, Nintendo DS, others)

In a series known for iterating on the traditional platforming of Nintendo games, Kirby: Canvas Curse iterated on the traditional platforming of Kirbygames. Played exclusively with a stylus to draw traversal options for Kirby, this new take made Canvas Curse a fan favorite and a welcome change of pace from other 2D platformers.

132. Vampire the Masquerade - Redemption

(2000, Mac, PC)

One of the best parts of Vampire the Masquerade - Redemption was its multiplayer 'Storyteller' mechanic. Allowing one player to take on a role similar to a Dungeons & Dragons dungeon master, it enabled players to set up scenarios for others to play through, modifying them with monsters, items and characters. This mechanic opened possibilities for Redemption's replayability, and changed the dynamics of the multiplayer game.

131. Her Story

(2015, iOS, PC, others)

Her Story is, as Polygon's Phil Kollar put it, 'as much a game as Google.' Centered around investigating computer files in an effort to find information, Her Story tells its story by dragging players down a rabbit hole of mystery in the pursuit of truth. Wholly unique, Her Story's format was one that could only exist as a game, and it was better for it.

130. Undertale

(2015, Mac, PC, others)

Undertale was never afraid to jerk the wheel, shifting genres and subverting gameplay tropes. One part emotional story, one part role-playing game, one part bullet-hell game and one part pacifism simulator, Undertale earned immense praise for its gameplay and approach to combat, which allowed players to opt out by simply talking to enemies.

129. Rock Band

(2007, PlayStation 3, Xbox 360, others)

Rock Band took what made Guitar Hero excellent and gave it a backing group. With guitar, bass, drums and vocals all accounted for, Rock Band was equally a karaoke machine and a rhythm game. Though the peripheral-based music genre waned significantly as the years went on, Rock Band still stands out for how it brought four players together for something more than competition.

128. Dune 2: The Building of a Dynasty

(1992, PC, others)

Dune 2: The Building of a Dynasty's name is fitting. Establishing the skeleton from which all future real-time strategy games would come from, Dune 2 established resource management, base construction and three factions for players to choose from.

127. Cart Life

(2011, PC)

In Cart Life, you manage the stresses of a running food cart, you make what little money you can and you try your best to care for yourself and your family. The push and pull of the job and the personal life made Cart Life an emotional experience, one emphasizing empathy over economic growth.

126. Uncharted 2: Among Thieves

(2009, PlayStation 3, others)

Few games match the pacing of Uncharted 2: Among Thieves. Seemingly down to the second, Uncharted 2 knew exactly when to put players through amazing set pieces, when to introduce puzzles and when to pull back for quieter, more intimate moments.

125. Mike Tyson's Punch Out!!

(1987, Nintendo Entertainment System, others)

If you could take down Mike Tyson in Mike Tyson's Punch Out!!, you were the undisputed king. The notoriously hard titular final boss offered a true test of skill, making this a game players constantly came back to, thinking, 'I've got it this time.'

124. Rock Band 2

(2008, PlayStation 3, Xbox 360, others)

Rock Band 2 wasn't an Earth-shattering reinvention of the first game. Rather, its small tweaks and quality of life updates served to make an already great experience even better, allowing for 'No Fail' modes for people who just wanted to play around with friends. Rock Band 2 turned the Rock Band experience into a more streamlined, accessible party treat.

123. Diablo

(1996, PC, others)

Diablo was Blizzard's first foray into the action role-playing genre and was quite the premier. Also marking the launch of Battle.net, Diablo's dark world and addictive loot-based gameplay received critical and fan praise, establishing Blizzard as one of the top role-playing game developers. Focused on rewards, Diablo's feedback loop of fight-then-receive-loot influenced countless other games to implement similar structures.

122. Quake

(1996, PC, others)

Quake took the fast-paced gameplay of Doom and made it work in an advanced 3D engine. Its massively-popular online multiplayer made such a thing a staple of the video game industry.

121. Frog Fractions

(2012, Browser)

Disguising itself as a math game, Frog Fractions constantly changes forms as you play. It's undeniably weird. Frog Fractions shattered any preconceived notions of what to expect from a game, proving games can be whatever you want them to be.

120. Device 6

(2013, iOS)

Device 6 managed to evolve the text-adventure format. Whereas usual text-adventures would roll out their stories in long paragraphs, Device 6 presented words as malleable narrative devices — with some that bent around corners as they described the game doing the same. Device 6 was an amazing breakthrough in storytelling and a surprising reinvention of one of the oldest genres.

119. The Legend of Zelda: The Wind Waker

(2003, GameCube, others)

Wind Waker took Zelda's mechanics to a new level. It was deeper, more complex and let players move the camera and counter attack to open up the game's action, making for a richer game. Though its cartoony visuals were divisive at the time of release, Wind Waker's aesthetic made for a more expressive game that has gained fans over time.

118. Mario Kart 8

(2014, Wii U, others)

Introducing new, game changing mechanics such as anti-gravity movement, Mario Kart 8 changed up the game's old — but classic — formula. More impressive looking than other games in the series, too, Mario Kart 8's changes and refinements made it a standout in a series of amazing arcade racers.

117. Gunstar Heroes

(1993, Genesis, others)

Controlling like a dream, full of insane boss fights and featuring some of the best graphics of its time, Gunstar was a relentless game full of inventive mechanics, culminating in one of the finest Sega Genesis games ever released.

116. Call of Duty 2

(2005, PC, Xbox 360, others)

Call of Duty 2 built upon its predecessor's level of bombast and personal stories of wartime soldiers with a with a new level of realism and action never seen before in games. Considered a pinnacle of video game visuals, storytelling and action in 2005, Call of Duty 2 also continued the series' influence on other first-person shooters.

115. BioShock

(2007, PC, Xbox 360, others)

Pc 200 In 1 Game Real Arcade 1 Gameplay

BioShock is still, 10 years later, like nothing seen elsewhere. Its art deco underwater metropolis-gone-wrong instantly invited players in, enticing them to search every corner to learn what went wrong with Andrew Ryan's utopia. Telling a complex story about the nature of man, BioShock offered one of the most unforgettable experiences in games.

114. Herzog Zwei

(1990, Genesis)

Herzog Zwei was one of the first real-time strategy games. Allowing players to pilot a flying mech while simultaneously buying and deploying combat units on the battlefield, Herzog Zwei paved the way for other strategy games like Dune 2 — even though it itself wasn't very successful.

113. Prince of Persia: The Sands of Time

(2003, GameCube, PlayStation 2, Xbox, others)

It's hard to imagine a world where Braid and Arkham Asylum had the impact they did without Prince of Persia: The Sands of Time not coming first. Allowing players to bend time backward and forward while fighting enemies with a fluid combat system, Sands of Time's pacing made it a standout.

112. Sid Meier's Railroad Tycoon

(1990, PC, others)

Railroad Tycoon is just one of dozens of groundbreaking games bearing Meier's name. Allowing players to plan and manage their own railroad company — making them responsible for laying train tracks, building train stations and actually scheduling trains — Railroad Tycoon received numerous perfect scores and spots on greatest games of all time lists in the early '90s.

111. Hitman: Blood Money

(2006, PlayStation 2, Xbox, Xbox 360)

Hitman: Blood Money feels like a simulation rather than just a stealth game. Holding players accountable for performing clean jobs, Blood Money ratcheted up the difficulty of the series by penalizing players for being too violent, loud or otherwise out of character for a professional assassin.

110. Counter-Strike

(2000, PC, others)

Counter-Strike threw out what players expected from first-person shooters; a guns-blazing approach would only result in death. The game focused on teamwork, guns had accurate recoil and shooting someone in the arm did less damage than, say, shooting them in the head. Because of this realistic approach, Counter-Strike and its sequels have become staples of the esports industry.

109. Kentucky Route Zero

(2013, PC, others)

Pc 200 In 1 Game Real Arcade 1 Games

Kentucky Route Zero is one of those games people tell you to go into blind. Somber and contemplative, Kentucky Route Zero explores the life of rural America, both in its simplicity and its bizarreness. Though all its episodes aren't out yet, Kentucky Route Zero has become a highly talked-about game, as players wonder what secrets still hide on the backroads of Kentucky.

108. Super Mario Maker

(2015, Wii U, Nintendo 3DS)

After decades of Nintendo inventing and reinventing the wheel, Super Mario Maker gave players the chance to make their own 2D Mario levels. Super Mario Maker pushed the boundaries of creativity, allowing fans the chance to reimagine some of the most influential levels in games — and make new ones.

107. Papers, Please

(2013, PC, others)

As the fictional country of Arstotzka collapses, Papers, Please puts players in the role of an immigration inspector, allowing or detaining would-be immigrants at a border checkpoint. The game puts the lives of others in your hands — possibly at the cost of your family's safety. Upon its release, Papers, Please was lauded for its intense moral dilemmas.

106. Final Fantasy Tactics

(1998, PlayStation, others)

A different kind of Final Fantasy game, Tactics abandoned the series' traditional role-playing approach, replacing it with an isometric tactical game. This new direction, and the masterful depth with which it was pulled off, gained the game universal acclaim, with many praising its challenging gameplay.

105. Grand Theft Auto: Vice City

(2002, PlayStation 2, others)

Vice City took the drab, gray buildings from Grand Theft Auto 3 and replaced them with sun-soaked beaches and flashy muscle cars. Its wide cast of wild characters, exciting open world and amazing soundtrack made Vice City one of the best entries in a series full of some of the best game of all time.

104. Burnout Paradise

(2008, PC, PlayStation 3, Xbox 360)

Burnout Paradise introduced the series to open-world gameplay. Players were free to progress in the game as they chose, meaning if they wanted to just drive around and engage in the game's ever-absurd crash physics without racing, they could.

103. Elite

(1984, BBC Micro, others)

Elite more or less created the modern space flight simulator genre. Paving the way for persistent world games like Second Life and World of Warcraft, Elite's establishment of space-trading also greatly influenced games like No Man's Sky and Eve Online.

102. Tony Hawk's Pro Skater 2

(2000, PlayStation, others)

Tony Hawk's Pro Skater 2 marked an apex for both the series and action sports games. Building on a proven formula, the game sold better than nearly any other action sports game at the time. While not the most revolutionary in the series, Pro Skater 2 was the product of intense dedication and iteration from developer Neversoft.

101. Metal Gear Solid 2: Sons of Liberty

(2001, PlayStation 2, others)

Sons of Liberty was masterclass in how to write a plot twist, smashing player expectations by introducing series newcomer Raiden as the protagonist after the game's prologue. And that was one of just many surprising elements of the story, which dealt with topics like incest and existentialism.

[Check back Friday for entries 100-1.]

Story text: Blake Hester