- Email: [email protected]
Feasibility of activity-promoting video games among obese adolescents and young adults in a clinical setting
Available online at www.sciencedirect.com
Journal of Science and Medicine in Sport 14 (2011) 42–45
Original Research
Feasibility of activity-promoting video games among obese adolescents and young adults in a clinical setting Katja Radon a,∗ , Barbara Fürbeck a , Silke Thomas a , Wolfgang Siegfried b , Dennis Nowak a , Rüdiger von Kries c a
Unit for Occupational and Environmental Epidemiology, Institute for Occupational, Social and Environmental Medicine, Clinical Centre of the University of Munich, Germany b Obesity Rehabilitation Centre INSULA, Germany c Division of Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-University of Munich, Germany Received 13 February 2009; received in revised form 30 June 2010; accepted 25 July 2010
Abstract One component of the recent obesity epidemic is the sedentary behaviour of children and adolescents e.g., use of video games consoles. The new generation of video games requires body movements and might thus increase activity. The aim of this study was to evaluate whether such games could have an effect on physical activity in obese adolescents in a clinical setting. Between March and May 2007 activitypromoting video games (“apvg”) were offered to all 84 inpatients (aged 13–28 years) registered in a long-term rehabilitation programme on a voluntary base. Reasons for (non-)attendance were assessed. Frequency and duration of use of the activity-promoting video game sessions were documented. Furthermore, heart rate and activity counts during use of “apvg”, endurance training, and strength training were measured. Of 84 inpatients, 51 used the “apvg” at least once (69%) over the study period. The median weekly use of the intervention was 27 min during the first week (range 0–182 min), declining to zero (range 0–74 min) in week four. Mean heart rate during the sessions (mean 115 bpm; 95% confidence interval 108–122 bpm) was similar to the heart rate during strength training (106 bpm; 101–112 bpm). The results indicate that the video games could have an impact on the activity of obese adolescents and young adults. However, as the interest in the devices seems to be too low the suitability of them for weight reduction programmes in young people cannot be ensured. © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. Keywords: Exercise; Heart rate; Intervention studies; Obesity; Physical fitness; Video games
1. Introduction Obesity might start as early on as during infancy. During the life course more than half of obese children become obese adults.1 Obesity results from an interplay of genetics, dietary energy intake and energy output via physical activity.2 Today adolescents often spent their leisure time with sedentary activities like watching TV, use of computer or video game consoles.3 If the level of enjoyment is equal, children and adolescents usually select a sedentary pursuit over an active one.4
∗
Corresponding author. E-mail address: [email protected] (K. Radon).
The new generation of video game consoles include activity-promoting video games (“apvg”), which require body movements and it was shown that they increase energy expenditure in young people in the experimental setting.5 Web pages and weblogs even promote that these devices improve e.g., players’ weight management and fitness. To test this hypothesis, Madsen et al.6 implemented an interactive music video game series in obesity treatment in the non-clinical setting. Interest declined over the study period. Based on participants’ comments the authors concluded that interventions with activity-promoting video game consoles should include group participation, competitions, and peer or family support. The aim of our pilot study was to test if “apvg” might be a suitable treatment in a clinical setting to enhance physical
1440-2440/$ – see front matter © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jsams.2010.07.009
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45
activity in adolescents and young adults with severe obesity. Furthermore we aimed to assess the acceptance of such devices in the clinical setting.
2. Methods The intervention was carried out at the Rehabilitation Clinic INSULA in Strub/Bischofswiesen (South of Germany). Between March and May 2007 all inpatients were invited to take part in the “apvg” sessions (intervention sessions). Informed consent was sought directly from the patients and in case of less than 18 years of age from the guardian. The study was approved by the Ethics Committee of the Medical Faculty of the Ludwig-Maximilians-University Munich. PlayStation® 2 (Sony Computer Entertainment Germany GmbH) with three activity-promoting video games (EyeToy® : Play3, Kinetic, PlaySports) was used. Patients could use the games alone or with multiple players during pre-defined intervention sessions: weekdays from 10 to 12 a.m., 4 to 6 p.m. and 7:30 to 9 p.m.; weekends from 3 to 6 p.m. During these sessions, utilization habits on an individual base were documented by a study assistant. Participation in the intervention sessions was measured by weekly use of the game consoles in minutes among all eligible participants. Subjects staying in the clinic at least 50% of each particular week were considered eligible during this week. Sociodemographic data and data on medical history were extracted from the electronic patient files. All participants were asked to fill-in a 34-item questionnaire regarding knowledge about and use of “apvg” and media consumption7 prior to admission to the rehabilitation clinic. Furthermore, reasons for their (non-)attendance in the intervention sessions were asked. In order to assess whether use of “apvg” might have an impact on increased physical activity, heart rate and activity counts were measured 20 min during rest (after getting up), endurance and strength training (in each case two units on a weekly base (4 units in total)) and during the intervention sessions. Heart rate (in counts per minute) was measured with a heart rate monitor (Polar RS 400Tm, Polar Electro Oy, Professorintie5, FIN 90440 Kempele, Finland). Activity counts per minute (cpm) were registered uni-axially using ActiGraph AM-7146 2.2 (MTI Health Services, Fort Walton Beach, FL, USA).8
3. Results Of 84 inpatients who underwent therapy for obesity at the clinic during the 12-week intervention period, informed consent was obtained for 77 participants (95%). Complete questionnaire data were available for 68 of these patients
43
(84%). Fifty-one of them used the “apvg” at least once over the intervention period (69%). Complete data on heart rate and activity counts were obtained for 25 participants (49%) who used the “apvg” at least three times during the intervention. The median duration of use per participant ranged from 27 min (range 0–182 min) during the first week of the intervention, declined to zero (range 0–74 min) within four weeks and remained zero until week 12. None of the participants played the “apvg” over the whole period of 12 weeks. Most of the participants played the “apvg” in 2 of the 12 weeks; two participants played the games in 8 of the 12 weeks. Patients who participated in the intervention did not differ statistically significant from non-participants with respect to sex or baseline BMI (Table 1). However, 31% of participants were younger than 15 years compared to 12% among nonparticipants. Both groups reported that a larger diversity of different video games would be necessary to enhance longterm interest in the activity-promoting video game console. Heart rate (counts per minute) during the intervention sessions (mean: 115) was significantly higher than during rest (mean: 68), comparable to heart rate during strength training (mean: 106) but statistical significantly lower than heart rate during endurance training (mean: 131). Similar results were seen for the activity counts per minute. Counts were higher in the game sessions (mean: 1272) than during rest (mean: 11), comparable to counts during strength training (mean: 1146) and lower than during endurance training (mean: 3596).
4. Discussion Our results indicate that “apvg” do not increase physical activity relevantly over a longer period of time in obese adolescents in the clinical setting. Three previous studies have shown that “apvg” increase energy expenditure in children.5,9 The studies indicated that on the one hand “apvg” enhance activity but on the other hand that the level of activity is less than playing sports itself. This was confirmed in our study. In contrast to these previous studies, our participants could use the “apvg” over a 12-week period in a clinical setting. A design similar to our study was used in a small study by Madsen et al.6 who implemented a music video game in obesity treatment in the home environment. Although a previous laboratory study by Epstein et al.10 had indicated that children may be motivated to use such an interactive game, interest decreased largely over the course of this survey.6 Based on the participants’ comments the authors recommended the inclusion of group participation, competitions, and peer or family support in future interventions. All these factors were taken into account in our study. While usage was promising during the first week of the intervention (median 27 min) it declined to a median of zero within only four weeks. Even though the variety of different games was larger than in the study by Madsen et al.,6 our participants also considered the diversity
44
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45
Table 1 Descriptive characteristics of the study population. Participation in active video game sessions over the 12-week intervention period NO YES N = 17 N = 51
n (%) Sex: female Age < 15 years Level of educationa,b : Middle school (≤10 years of schooling) High school (13 years of schooling) School-based vocational training programme Baseline BMI (kg/m2 ) at the beginning of treatment Median (range) Multimedia use before treatment at the rehabilitation clinic On weekdays, on average >2 hours per day use of. . . Computer/internetc Television/videod Video game consolesb Had used activity-promoting video games before treatment Owns an active computer game device Participated in other voluntary programmes at the rehabilitation clinica,c Why did you NOT take part in the activity-promoting video game sessions? (More than one may apply) I do not like activity-promoting video games or do not know how to use them I do not know with whom to play Would like to take the active video game device homeb Under which conditions could you imagine using activity-promoting video games to stay active at home after rehabilitation? . . .if there would be more different games . . .if it would not be that expensivea I can under no circumstances imagine using activity-promoting video games to stay active at home* Others a b c d
9 (53) 2 (12)
26 (51) 16 (31)
2 (13) 2 (13) 12 (75) 44 (32–87)
21 (44) 6 (12) 21 (44) 42 (32–73)
8 (47) 8 (50) 2 (11) 9 (53) 3 (18) 13 (77)
24 (49) 23 (47) 8 (17) 35 (69) 14 (27) 37 (76)
6 (35) 2 (12) 7 (20)
n/a n/a 16 (55)
12 (32) 3 (8) 15 (41) 7 (19)
10 (32) 7 (23) 10 (32) 4 (13)
pChi 2 < 0.1. nmissing = 6. nmissing = 2. nmissing = 3.
of the available games too limited to obtain their interest in the long run. One limitation of our study was the non-usage of a randomized control trial design. However, as our aim was to assess the acceptance of “apvg” on a voluntary base under “every day conditions” in the clinical setting we did not consider a randomized clinical trial beneficial.
5. Conclusions The interest of obese adolescents in using “apvg” over a longer period of time is low. Therefore, they might not be suitable for weight reduction programmes in adolescents. Whether the used games might be suitable for younger children has to be investigated in further studies.
Practical implications • The interest of obese adolescents in using activitypromoting video games over a longer period of time is low.
However, in children they might be a possible completion for weight reduction programmes.
Acknowledgements We thank Dr. Anja Schulze, Eva Rosenfeld, all participants and the team of the INSULA clinic. Funded by the Munich Centre for Health Sciences; Sony Computer Entertainment Germany provided the Eye Toy PlayStation2 hard- and software.
References 1. Baird J, Fisher D, Lucas P, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005;331:929. 2. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev 2007;29:1–5. 3. Matthews CE, Chen KY, Freedson PS, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. Am J Epidemiol 2008;167(7):875–81.
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45 4. Saelens BE, Epstein LH. The rate of sedentary activities determines the reinforcing value of physical activity. Health Psychol 1999;18(6):655–9. 5. Graves L, Stratton G, Ridgers ND, et al. Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study. BMJ 2007;335(7633):1282–4. 6. Madsen KA, Yen S, Wlasiuk L, et al. Feasibility of a dance videogame to promote weight loss among overweight children and adolescents. Arch Pediatr Adolesc Med 2007;161(1): 105–7. 7. Lampert T, Sygusch R, Schlack R. Nutzung elektronischer Medien im Jugendalter. Ergebnisse des Kinder- und Jugendgesundheitssurveys
45
(KiGGS). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007;50(5–6):843–52. 8. Toschke JA, von Kries R, Rosenfeld E, et al. Reliability of physical activity measures from accelerometry among preschoolers in freeliving conditions. Clin Nutr 2007;26(4):416–20. 9. Unnithan VB, Houser W, Fernhall B. Evaluation of the energy cost of playing a dance simulation video game in overweight and non-overweight children and adolescents. Int J Sports Med 2006;27(10):804–9. 10. Epstein LH, Beecher MD, Graf JL, et al. Choice of interactive dance and bicycle games in overweight and nonoverweight youth. Ann Behav Med 2007;33(2):124–31.
Journal of Science and Medicine in Sport 14 (2011) 42–45
Original Research
Feasibility of activity-promoting video games among obese adolescents and young adults in a clinical setting Katja Radon a,∗ , Barbara Fürbeck a , Silke Thomas a , Wolfgang Siegfried b , Dennis Nowak a , Rüdiger von Kries c a
Unit for Occupational and Environmental Epidemiology, Institute for Occupational, Social and Environmental Medicine, Clinical Centre of the University of Munich, Germany b Obesity Rehabilitation Centre INSULA, Germany c Division of Epidemiology, Institute of Social Pediatrics and Adolescent Medicine, Ludwig-Maximilians-University of Munich, Germany Received 13 February 2009; received in revised form 30 June 2010; accepted 25 July 2010
Abstract One component of the recent obesity epidemic is the sedentary behaviour of children and adolescents e.g., use of video games consoles. The new generation of video games requires body movements and might thus increase activity. The aim of this study was to evaluate whether such games could have an effect on physical activity in obese adolescents in a clinical setting. Between March and May 2007 activitypromoting video games (“apvg”) were offered to all 84 inpatients (aged 13–28 years) registered in a long-term rehabilitation programme on a voluntary base. Reasons for (non-)attendance were assessed. Frequency and duration of use of the activity-promoting video game sessions were documented. Furthermore, heart rate and activity counts during use of “apvg”, endurance training, and strength training were measured. Of 84 inpatients, 51 used the “apvg” at least once (69%) over the study period. The median weekly use of the intervention was 27 min during the first week (range 0–182 min), declining to zero (range 0–74 min) in week four. Mean heart rate during the sessions (mean 115 bpm; 95% confidence interval 108–122 bpm) was similar to the heart rate during strength training (106 bpm; 101–112 bpm). The results indicate that the video games could have an impact on the activity of obese adolescents and young adults. However, as the interest in the devices seems to be too low the suitability of them for weight reduction programmes in young people cannot be ensured. © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. Keywords: Exercise; Heart rate; Intervention studies; Obesity; Physical fitness; Video games
1. Introduction Obesity might start as early on as during infancy. During the life course more than half of obese children become obese adults.1 Obesity results from an interplay of genetics, dietary energy intake and energy output via physical activity.2 Today adolescents often spent their leisure time with sedentary activities like watching TV, use of computer or video game consoles.3 If the level of enjoyment is equal, children and adolescents usually select a sedentary pursuit over an active one.4
∗
Corresponding author. E-mail address: [email protected] (K. Radon).
The new generation of video game consoles include activity-promoting video games (“apvg”), which require body movements and it was shown that they increase energy expenditure in young people in the experimental setting.5 Web pages and weblogs even promote that these devices improve e.g., players’ weight management and fitness. To test this hypothesis, Madsen et al.6 implemented an interactive music video game series in obesity treatment in the non-clinical setting. Interest declined over the study period. Based on participants’ comments the authors concluded that interventions with activity-promoting video game consoles should include group participation, competitions, and peer or family support. The aim of our pilot study was to test if “apvg” might be a suitable treatment in a clinical setting to enhance physical
1440-2440/$ – see front matter © 2010 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jsams.2010.07.009
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45
activity in adolescents and young adults with severe obesity. Furthermore we aimed to assess the acceptance of such devices in the clinical setting.
2. Methods The intervention was carried out at the Rehabilitation Clinic INSULA in Strub/Bischofswiesen (South of Germany). Between March and May 2007 all inpatients were invited to take part in the “apvg” sessions (intervention sessions). Informed consent was sought directly from the patients and in case of less than 18 years of age from the guardian. The study was approved by the Ethics Committee of the Medical Faculty of the Ludwig-Maximilians-University Munich. PlayStation® 2 (Sony Computer Entertainment Germany GmbH) with three activity-promoting video games (EyeToy® : Play3, Kinetic, PlaySports) was used. Patients could use the games alone or with multiple players during pre-defined intervention sessions: weekdays from 10 to 12 a.m., 4 to 6 p.m. and 7:30 to 9 p.m.; weekends from 3 to 6 p.m. During these sessions, utilization habits on an individual base were documented by a study assistant. Participation in the intervention sessions was measured by weekly use of the game consoles in minutes among all eligible participants. Subjects staying in the clinic at least 50% of each particular week were considered eligible during this week. Sociodemographic data and data on medical history were extracted from the electronic patient files. All participants were asked to fill-in a 34-item questionnaire regarding knowledge about and use of “apvg” and media consumption7 prior to admission to the rehabilitation clinic. Furthermore, reasons for their (non-)attendance in the intervention sessions were asked. In order to assess whether use of “apvg” might have an impact on increased physical activity, heart rate and activity counts were measured 20 min during rest (after getting up), endurance and strength training (in each case two units on a weekly base (4 units in total)) and during the intervention sessions. Heart rate (in counts per minute) was measured with a heart rate monitor (Polar RS 400Tm, Polar Electro Oy, Professorintie5, FIN 90440 Kempele, Finland). Activity counts per minute (cpm) were registered uni-axially using ActiGraph AM-7146 2.2 (MTI Health Services, Fort Walton Beach, FL, USA).8
3. Results Of 84 inpatients who underwent therapy for obesity at the clinic during the 12-week intervention period, informed consent was obtained for 77 participants (95%). Complete questionnaire data were available for 68 of these patients
43
(84%). Fifty-one of them used the “apvg” at least once over the intervention period (69%). Complete data on heart rate and activity counts were obtained for 25 participants (49%) who used the “apvg” at least three times during the intervention. The median duration of use per participant ranged from 27 min (range 0–182 min) during the first week of the intervention, declined to zero (range 0–74 min) within four weeks and remained zero until week 12. None of the participants played the “apvg” over the whole period of 12 weeks. Most of the participants played the “apvg” in 2 of the 12 weeks; two participants played the games in 8 of the 12 weeks. Patients who participated in the intervention did not differ statistically significant from non-participants with respect to sex or baseline BMI (Table 1). However, 31% of participants were younger than 15 years compared to 12% among nonparticipants. Both groups reported that a larger diversity of different video games would be necessary to enhance longterm interest in the activity-promoting video game console. Heart rate (counts per minute) during the intervention sessions (mean: 115) was significantly higher than during rest (mean: 68), comparable to heart rate during strength training (mean: 106) but statistical significantly lower than heart rate during endurance training (mean: 131). Similar results were seen for the activity counts per minute. Counts were higher in the game sessions (mean: 1272) than during rest (mean: 11), comparable to counts during strength training (mean: 1146) and lower than during endurance training (mean: 3596).
4. Discussion Our results indicate that “apvg” do not increase physical activity relevantly over a longer period of time in obese adolescents in the clinical setting. Three previous studies have shown that “apvg” increase energy expenditure in children.5,9 The studies indicated that on the one hand “apvg” enhance activity but on the other hand that the level of activity is less than playing sports itself. This was confirmed in our study. In contrast to these previous studies, our participants could use the “apvg” over a 12-week period in a clinical setting. A design similar to our study was used in a small study by Madsen et al.6 who implemented a music video game in obesity treatment in the home environment. Although a previous laboratory study by Epstein et al.10 had indicated that children may be motivated to use such an interactive game, interest decreased largely over the course of this survey.6 Based on the participants’ comments the authors recommended the inclusion of group participation, competitions, and peer or family support in future interventions. All these factors were taken into account in our study. While usage was promising during the first week of the intervention (median 27 min) it declined to a median of zero within only four weeks. Even though the variety of different games was larger than in the study by Madsen et al.,6 our participants also considered the diversity
44
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45
Table 1 Descriptive characteristics of the study population. Participation in active video game sessions over the 12-week intervention period NO YES N = 17 N = 51
n (%) Sex: female Age < 15 years Level of educationa,b : Middle school (≤10 years of schooling) High school (13 years of schooling) School-based vocational training programme Baseline BMI (kg/m2 ) at the beginning of treatment Median (range) Multimedia use before treatment at the rehabilitation clinic On weekdays, on average >2 hours per day use of. . . Computer/internetc Television/videod Video game consolesb Had used activity-promoting video games before treatment Owns an active computer game device Participated in other voluntary programmes at the rehabilitation clinica,c Why did you NOT take part in the activity-promoting video game sessions? (More than one may apply) I do not like activity-promoting video games or do not know how to use them I do not know with whom to play Would like to take the active video game device homeb Under which conditions could you imagine using activity-promoting video games to stay active at home after rehabilitation? . . .if there would be more different games . . .if it would not be that expensivea I can under no circumstances imagine using activity-promoting video games to stay active at home* Others a b c d
9 (53) 2 (12)
26 (51) 16 (31)
2 (13) 2 (13) 12 (75) 44 (32–87)
21 (44) 6 (12) 21 (44) 42 (32–73)
8 (47) 8 (50) 2 (11) 9 (53) 3 (18) 13 (77)
24 (49) 23 (47) 8 (17) 35 (69) 14 (27) 37 (76)
6 (35) 2 (12) 7 (20)
n/a n/a 16 (55)
12 (32) 3 (8) 15 (41) 7 (19)
10 (32) 7 (23) 10 (32) 4 (13)
pChi 2 < 0.1. nmissing = 6. nmissing = 2. nmissing = 3.
of the available games too limited to obtain their interest in the long run. One limitation of our study was the non-usage of a randomized control trial design. However, as our aim was to assess the acceptance of “apvg” on a voluntary base under “every day conditions” in the clinical setting we did not consider a randomized clinical trial beneficial.
5. Conclusions The interest of obese adolescents in using “apvg” over a longer period of time is low. Therefore, they might not be suitable for weight reduction programmes in adolescents. Whether the used games might be suitable for younger children has to be investigated in further studies.
Practical implications • The interest of obese adolescents in using activitypromoting video games over a longer period of time is low.
However, in children they might be a possible completion for weight reduction programmes.
Acknowledgements We thank Dr. Anja Schulze, Eva Rosenfeld, all participants and the team of the INSULA clinic. Funded by the Munich Centre for Health Sciences; Sony Computer Entertainment Germany provided the Eye Toy PlayStation2 hard- and software.
References 1. Baird J, Fisher D, Lucas P, et al. Being big or growing fast: systematic review of size and growth in infancy and later obesity. BMJ 2005;331:929. 2. Caballero B. The global epidemic of obesity: an overview. Epidemiol Rev 2007;29:1–5. 3. Matthews CE, Chen KY, Freedson PS, et al. Amount of time spent in sedentary behaviors in the United States, 2003–2004. Am J Epidemiol 2008;167(7):875–81.
K. Radon et al. / Journal of Science and Medicine in Sport 14 (2011) 42–45 4. Saelens BE, Epstein LH. The rate of sedentary activities determines the reinforcing value of physical activity. Health Psychol 1999;18(6):655–9. 5. Graves L, Stratton G, Ridgers ND, et al. Comparison of energy expenditure in adolescents when playing new generation and sedentary computer games: cross sectional study. BMJ 2007;335(7633):1282–4. 6. Madsen KA, Yen S, Wlasiuk L, et al. Feasibility of a dance videogame to promote weight loss among overweight children and adolescents. Arch Pediatr Adolesc Med 2007;161(1): 105–7. 7. Lampert T, Sygusch R, Schlack R. Nutzung elektronischer Medien im Jugendalter. Ergebnisse des Kinder- und Jugendgesundheitssurveys
45
(KiGGS). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2007;50(5–6):843–52. 8. Toschke JA, von Kries R, Rosenfeld E, et al. Reliability of physical activity measures from accelerometry among preschoolers in freeliving conditions. Clin Nutr 2007;26(4):416–20. 9. Unnithan VB, Houser W, Fernhall B. Evaluation of the energy cost of playing a dance simulation video game in overweight and non-overweight children and adolescents. Int J Sports Med 2006;27(10):804–9. 10. Epstein LH, Beecher MD, Graf JL, et al. Choice of interactive dance and bicycle games in overweight and nonoverweight youth. Ann Behav Med 2007;33(2):124–31.