Journal of Exercise Physiologyonline

June 2020Volume 23 Number 3

Editor-in-ChiefTommy Boone, PhD, MBAReview BoardTodd Astorino, PhDJulien Baker, PhDSteve Brock, PhDLance Dalleck, PhDEric Goulet, PhDRobert Gotshall, PhDAlexander Hutchison, PhDM. Knight-Maloney, PhDLen Kravitz, PhDJames Laskin, PhDYit Aun Lim, PhDLonnie Lowery, PhDDerek Marks, PhDCristine Mermier, PhDRobert Robergs, PhDChantal Vella, PhDDale Wagner, PhDFrank Wyatt, PhDBen Zhou, PhD

Official Research Journal of the American Society of

Exercise Physiologists

ISSN 1097-9751

Official Research Journal of the American Society of Exercise Physiologists

ISSN 1097-9751

JEPonline

Gamification: A Tool to Increase the Frequency of Physical Activity in Overweight Adolescents

Diego S. Patricio1, Yggo R. Aires1, Carla M. Medeiros1

1Postgraduate program in Public Health at the State of Paraíba (UEPB), City: Campina Grande, Brazil

ABSTRACT

Patricio DS, Aires YR, Medeiros CM. Gamification: A Tool to Increase the Frequency of Physical Activity in Overweight Adolescents. JEPonline 2020;23(3):13-24. The purpose of this study was to construct and test a Gamification protocol to increase the frequency of physical activity, through the active video game, in overweight adolescents in school settings. It is a randomized intervention study with two comparison groups: (a) Control Group; and (b) Experimental Group. The Experimental Group used games from the category video game or exergames + a gamified protocol through an application while the Control Group used an active video game. An integrated review was performed using a systematization in game specialized sites for the selection of games (exergames) applied to the intervention. Two schools were selected with a high prevalence of overweight and obesity in the municipality. A random lottery was made to define the school that would be the Control Group and the Experimental Group. The subjects consisted of 65 adolescents aged 15 to 19 yrs of which 37 were in the Experimental Group and 28 were in the Control Group. The intervention with gamification was associated to a higher frequency of adolescents to physical exercise. Adherence of adolescents to physical exercise is not an association with the initial nutritional status, but was associated with the type of intervention. Gamification proved effective in relation to the increased adherence in adolescent participants in weight loss programs.

Key Words: Active Video Game, Adolescent Obesity, Gamification

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INTRODUCTION

The lack of adherence to treatment has been considered a serious public health problem, especially when it involves chronic diseases and disabilities (2). Therapeutic adherence (or the adherence to treatment) refers to the degree of agreement between a person's behavior and the health team's prescriptions (19).

Nourse and colleagues (22) indicate that overweight and/or obese patients have a lower adherence to treatment, since therapies are often very complex that require dedication and continuous monitoring of the patient. This problem is even greater when considering the period of adolescence, especially since the rate of treatment abandonment is much higher.

The prevention and treatment of obesity in adolescence are two of the main public health challenges. In fact, the World Health Organization (WHO) considers adolescent obesity a worldwide epidemic that is associated with several comorbidities, such as hypertension, type 2 diabetes, atherosclerotic disease, dyslipidemia, respiratory and bone disorders, and even cancer. The WHO reports that one or more of these diseases can cause a decrease in quality of life that often leads to death (32).

The prevalence of overweight and obesity in children and adolescents has increased in recent years (13,27). Currently, there are more than 30 million overweight children, which one of the risk factors for obesity. The overweight children live in developing countries, and 10 million live in developed countries (32). In Brazil, about 6.5% of the children and adolescents are diagnosed with obesity (6).

Several factors are identified as causing childhood and youth obesity. One very important factor is the excessive use of technologies, such as video games and/or computers in addition to the time spent in front of the television. As a result, these children and adolescents were sedentary (15,16,18).

In order to overcome a sedentary lifestyle in a playful and pleasurable way, recent research has incorporated Active Video Games (VGAs) in their treatments to increase the level of physical activity, especially in children and adolescents (3-5,7). The findings indicate an improvement in sedentary living, although it was not enough to increase the participation of the subjects in weight loss programs, even when incorporated into long-term multi-professional programs considered today the most effective in the treatment of overweight children and adolescents (1,8).

In this context, the need arises to test another methodology in order to increase the public's adherence to a physical exercise program with VGAs. Thus, the gamification of the English word Gamification, which corresponds to the use of game mechanisms aimed at solving practical problems or awakening engagement among a specific audience, appears as a tool for this problem (31). Based on this information, the purpose of this study was to compare the gamification methodology associated with VGA with the methodology that uses only VGA regarding the frequency of obese adolescents/overweight to physical activity in the school environment and the impact on the nutritional status of the individuals.

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METHODS

This is a randomized intervention study that involved 65 adolescents between 15 and 19 yrs of age. Twenty-eight of the subjects made up the Control Group and 37 were in the Experimental Group for a 4-wk period. The Experimental Group used, for exercise, the VGA associated with a gamified methodology through an application called Arena de Metis and the Control Group used only the VGA.

The study involved adolescents from two state public schools that had the highest prevalence of overweight and obesity. Adolescents were excluded from participation in this study if they: (a) had motor or mental limitations that prevented the activities contained in the intervention; (b) had diseases and/or were using drugs that altered glucose and/or lipid metabolism; (c) were using video games constantly for at least 2 months; and (d) were pregnant.

Initially, screening was carried out to identify overweight adolescents in the first and second years of high school in selected schools. After identification, the importance and the procedures that would be carried out in the research were explained, and later the invitation to participate in the study was announced. For those who wanted to participate, the inclusion and exclusion criteria were evaluated and those eligible signed the Informed Consent Form (ICF) and the Term of Assent (Figure 1).

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A form was used to survey the sociodemographic information (sex, age, color, and economic class) and then anthropometry (weight, height, and waist circumference) was performed at the beginning (baseline time) and at the end of a 4-wk period. It was also computed, in a specific form, all the participations of individuals in the physical activity sessions, with a weekly frequency calculation, and at the end of the 4th week. Adherence was considered as individuals who obtained 75% or more participation in the exercise program.

Nutritional status was classified using the Body Mass Index (BMI) in accordance with the recommendations of the World Health Organization (WHO) that considers: (a) overweight (BMI ≥ +1 and <Z-score +2); (b) obesity (BMI ≥ Z-score +2 and < Z-score +3); and (c) severe obesity (BMI ≥ Z-score +3), with over 18 yrs of age (in kg∙m -2) considered to be overweight (BMI ≥25 , 0 and <30), obesity (BMI ≥30) (23).

Anthropometric data, weight, height, and waist circumference were obtained from the mean value of the two measurements with the adolescent in light clothing. To measure height, a portable WCS® stadiometer was used with a 0.1 cm precision. To measure body weight, a Tanita® digital scale with 150 kg capacity and 0.1 kg precision was used. Abdominal circumference was determined with a Cardiomed® brand inelastic measuring tape that accurate to 0.1 cm. All the measurement procedures followed the recommendations of the WHO.

Physical Exercise Intervention (PE) with ExergameBefore starting the intervention, the procedure was randomized by schools. In school A, VGA was used with the gamification protocol and in school B only VGA, so the type of intervention in which the adolescent was submitted was dependent on the school in which he was enrolled.

The exergame intervention was supervised and monitored. The modality adopted was the practice of exercises with the aid of an active video game, in which physical movement is part of the mechanism of the game. The intensity was moderate with a weekly frequency of 3 times for 50 min in each session with an additional 10 min for checking vital signs before and after exercise for a period of 4 wks.

The Experimental Group, in addition to performing the physical activity using the exergame intervention, had a challenge at each session, through gamification, to encourage motivation in performing the exercise. The activities were carried out in subgroups of up to 4 participants who were guided and supervised by physical education professionals, physiotherapists, and/or undergraduate and students in the master’s program who were linked to the project. The games were made available in a room of the selected school destined for this purpose. At times, the games were available in morning and the afternoon shifts. The XBOX 360 platform was used with the use of the Kinect accessory (Microsoft®) to enable the user to control and interact only with body movements and Just Dance, the selected game.

Game Choice and Gamification

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For the choice of games, an integrative review was carried out to select games with the characteristics of an active video game – Exergames. The analysis and categorization of the games and their respective Consoles (Microprocessor of electronic games) were carried out using the following criteria: (a) value of the console; and (b) value of the games and possibilities of Multplayer (2 or 4 players in the same game), which would be fundamental for the formation of groups in the intervention. This search was carried out through specialized sites during the period from August 2015 to August 2016. After this analysis, the console selected as the best cost-benefit, was the Microsoft® XBOX 360 and the games selected for this research were those of Just Dance franchise from Ubisoft®, more precisely the versions (Just Dance 2014 and 2016). This type of gamification, aimed at weight loss programs, was not found in the literature, therefore, in this work, a prototype of a gamified methodology for specific weight loss programs was built.

Gamification consisted of the insertion of various motivational factors, such as scoring goals, virtual awards, disputes between groups, and advance of stages among others. This process was built from games already available, but with a focus on attitudes that also encouraged the adoption of a healthy lifestyle outside the game. The gamified intervention, which was called the Arena de Metis is composed of a combination of engagement challenges created specifically for the intervention and dance challenges existing in dance exergames.

The gamified intervention, called “Arena de Metis” represents a serious game in alternate reality, since it has part of the gaming experience practiced in the virtual worlds built on the Xbox + kinect console, on the computer + cell phone and another part played outside the environment virtual, that is, in environments where the participant exercises and where he works in other intervention activities. The gamification of this serious game was composed of 6 smaller sequential gamifications, called exergames gamifications (gmex) that correspond to phases experienced during the intervention period.

Ethical ConsiderationsRegarding ethical requirements, this study was submitted and approved under CAAE: 56118616.1.0000.5187 by the Research Ethics Committee of the State University of Paraíba. It obeyed all the principles pre-established by the National Health Council under Resolution 466/2012.

Statistical Analyses

The analysis of the data was performed using SPSS version 22.0 with descriptive statistics to characterize the population. Sociodemographic characteristics and nutritional status between groups were compared at the beginning and at the end using the Chi-Square test. This test was also used to compare the frequencies to physical activities between the groups, as well as the association between sex, nutritional status and the type of intervention with the frequency of 75% in activities with VGA. A graph of frequency polygons was constructed in order to compare the frequency with activities with gamified VGA and only with VGA. For all analyses, a statistical significance level of 5% was adopted.

RESULTS

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The prevalence of severe obesity and obesity at the beginning of the research was 12.4%. It was higher at a school whose intervention was only in the active video game, as well as many other resources available in the distribution (Table 1). The intervention with VGA associated with gamification was linked to a higher frequency of adolescents to physical exercise (P=0.048) (Table 2).

Table 1: Description of the Sample and Its Variables According to the Type of Intervention (n = 65).

Variables AVG + Gamification AVG RP (IC95%) P

GenderFemale 21 (56.8) 17 (63) 0.62

Male 16 (43.2) 10 (37) 1.29 (0.47-3.58)

Initial CA        Elevated 3 (8.1) 7 (25.9)   0.081Normal 34 (91.9) 20 (74.1) 0.25 (0.58-1.09)  

Initial Nutritional StatusObese / High Obesity 6 (33.3) 12 (66.7) 0.24 (0.08-0.77) 0.013

Overweight 31 (67.4) 15 (32.6)

Table 2: Description of the Sample and Its Variables According to the Type of Intervention (n = 53).

Variables AVG + Gamification AVG RP (IC95%) P

CA FinalElevated 5 (17.2) 6 (25.0) 0.63 (0.16-2.38) 0.488Normal 24 (82.8) 18 (75.0)

Final Nutritional Status        Obese / High Obesity 6 (20.7) 8 (33.3)   0.285

Overweight 21 (72.4) 16 (56.7) 0.25 (0.58-1.09)  Eutrophic 2 (6.9) 0 (0.0)    

Frequency≤25% 3 (8.1) 7 (25.9) 0.048

> 30% < 75% 13 (35.1) 12 (44.4)≥75% 21 (56.8) 8 (29.6)

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Note that there is a difference in adherence during the 4 wks of intervention. The Experimental Group (VGA + Gamification) registered a superior adherence vs. the Control Group (VGA). At the end of the 4 wks of intervention, the Experimental Group showed an adherence of 68% of the participants, while the Control Group ended an intervention with 27% of its participants, totaling a difference of 41% of participation between the Groups analyzed. Of the 65 adolescents, 53 (81%) completed an intervention, but only 44.7% participated in 75% or more of the sessions. When considering the type of intervention or gamified, there was a 56.8% adherence and 43.2% non-gamified. Adherence of adolescents to physical exercise was not associated with the initial nutritional status, but it seemed to be associated with the type of intervention (P=0.031) (Table 3).

  75% Frequency   P RP (IC95%)

Variables Yes No    Gender        Female 23 (60.5) 15 (39.5) 0.257 0.56 (0.20-1.53)

Male 14 (53.8) 12 (46.2)    

Initial CA        

Changed 4 (40.0) 6 (60.0) 1.00 1.29 (0.33-5.1)Normal 25 (48.3) 29 (53.7)    

Initial Nutritional Status

       

Obese / High Obesity 7 (38.9) 11 (61.1) 0.585 1.44 (0.48-4.4)Overweight 22 (47.8) 24 (52.2)    

Type of InterventionAVG+Gamification 21 (56.8) 16 (43.2) 0.031 0.32 (0.11-0.92)

AVG 8 (29,6) 19 (70.4)Table 3. Factors Associated with Physical Exercise.

DISCUSSION

While the most appropriate approach for the treatment of chronic diseases (such as obesity in particular) is with long-term multiprofessional follow-up, it has not been all that effective for overweight or obese children and adolescents. Research indicates different techniques that require dynamic participation of the individual can promote a greater engagement in weight loss program (11,12). For example, the use of exergames as a tool to increase physical activity among adolescents is helpful, but none have used the gamification technique.

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This experiment is pioneering, since gamification has not yet been used as a tool within an intervention program for weight loss. In addition, other studies that had already used electronic games (e.g., Exergames or Active Videogames) did not directly analyze the participation of the subjects within the programs, but rather verified the increase in physical activity and its metabolic repercussions (1,9,21,29,30).

Studies related to the adherence to behavior change show that 60 to 80% of individuals reached the minimum percentage of recommended sessions (70%), and about half of the patients dropped out in the first 6 months of treatment even before the health benefits were observed. The estimated proportion of individuals who drop out of programs that include exercise and lifestyle changes is approximately 50% (11).

Sub-Heading 1In the present study, although obese adolescents belong mainly to the school whose intervention was only with VGA, the nutritional status did not influence adherence to the exercise program. However, intervention with VGA within a gamified protocol was associated with a significantly greater adherence to physical activity (P=0.031). In addition, the group that used the gamified VGA had a higher number of adolescents by the end of the intervention with a difference of 41% between the groups analyzed (68% group that used VGA + Gamification X 27% group that used only VGA).

Among the factors that can decrease adherence to the weight program are school activities, holidays, and forgetting sessions (22). In this context, gamification can increase adherence since it can avoid forgetting the days of the sessions as well as allowing physical activity outside the school environment through the motivation associated with this tool.

Gamification techniques have been used by companies and entities in different segments as an innovative alternative to traditional learning approaches, especially with regard to encouraging people to adopt certain behaviors, familiarizing themselves with new technologies and streamlining their learning process (26,28.31). However, in the literature it was not found the use of gamification techniques specifically to combat obesity, whether adult or children, which is the target audience of this research.

Sub-Heading 2Among several studies on the use of Exergames for weight loss (18,20,22 ,24,25), one stands out. It was carried out in the United States with a multidisciplinary program to combat childhood obesity. The research, Exergaming as a Health Program, was based on three areas: (a) physical activity with exergames; (b) nutritional and psychological monitoring; and (c) direct participation of family members. This project followed an audience aged 8 to 16 yrs for 10 wks. There was an improvement in the body mass index (BMI) and in some nutritional aspects. The adherence rate was 83% of the participants (10). Those who participated in more than 50% of the sessions may have justified an index of 83% in the results for adherence, which was different from the study proposed with gamification where adherence was considered at 75% of participation in the sessions. Another point that should be considered is the fact that the Exergaming for Health Program is a multiprofessional approach with family, nutritional, and psychological monitoring in addition to exercising with exergames. In the research with gamification, only the exercise factor was proposed as an

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intervention and the gamified methodology was concerned with the frequency of participants in physical activity sessions with VGA’s.

The data demonstrate that adolescents are increasingly sedentary with only 27% reaching a level of 60 min of moderate to vigorous physical activity per day (30). The dazzle of electronic games should be considered as a viable approach to increasing the percent, since more than 60% of teenagers regularly play electronic games (30). Hence, the use of exergames should be considered an important strategy to attract this group of teenagers. But, how can gamification contribute to such a complex intervention? Gamification has attributes inherent to its methodology that help in emotional, cognitive, and social aspects (17), mainly by promoting a feeling of integration between the users and the proposed tasks (26).

According to McGonigal (17), "Video game players are tired of reality". It clarifies that, as games become popular in different regions of the planet, there is an increase in the involvement of players that can be used in a much broader spectrum of objectives (14). Given this perspective, Gamification uses the power and fascination that the game exerts on children and adolescents to change their behavior in order to combat real problems and, in this research study, it proved to be efficient in increasing the adhesion of the participants.

Sub-Heading 3Although gamification in this study was shown to be effective in increasing the time of adherence to the exercise program, the evaluation period was short. It is necessary that other studies are carried with a longer intervention time that includes not only evaluation and other indicator adherence (such as the motivation of the groups and the testimonies and reports of the participants), but also the assessment of the impact on the cardiometabolic profile. Despite some limitations, this study is important for public health since it is a pioneer in evaluating a technology that can increase the adherence of overweight adolescents to physical activity in a school environment. Studies like this one can also help provide more interaction between teachers, students, and health professionals, which is one of the pillars of the School Health Program.

CONCLUSIONS

Although gamification proved effective in relation to the increased adherence in adolescent participants in weight loss programs, there is the need for further research with a longer duration to demonstrate that the increase in adherence can be associated with improvements in the lipid profile and nutritional status of adolescents. There is also the need to associate a gamified methodology with the long-term multiprofessional treatment model and, therefore, analyze whether the methodology increases the participants’ response to treatment adherence along with an assessment of the clinical benefits.

ACKNOWLEDGMENTSWe thank Professor Marcelo Barros for his help in the construction of the gamified methodology and all composition of the serious game: Arena de Metis

Address for correspondence: Diego Silva Patrício, Street President Arthur Barnardes, 389, ap 202, Bessa, City: João-Pessoa-PB. CEP: 58.035-300, diego.patricio@adventista.edu.br

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