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Improved Executive Functioning from Wii Active Exergame Play

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Presentation by Amanda E. Staiano, Anisha Abraham, and Sandra L. Calvert given May 27, 2010, at the annual Games for Health conference in Boston, MA.

Presentation by Amanda E. Staiano, Anisha Abraham, and Sandra L. Calvert given May 27, 2010, at the annual Games for Health conference in Boston, MA.

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  • There's too much wasted effort into researching marginal results by restricting studies to just Wii. The first question that should be asked is what exergames are the most effective in terms of engagement (for boys and girls), calories burn and sustainability.. Exergaming should not be marginalised or stereotyped by limited research.
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  • Definitions: Obesity: Having a very high amount of body fat in relation to lean body mass, or Body Mass Index (BMI) of 30 or higher. Body Mass Index (BMI): A measure of an adult’s weight in relation to his or her height, specifically the adult’s weight in kilograms divided by the square of his or her height in meters. Source of the data: The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults. Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used. Particularly high obesity rates for low-income and for African American Obesity leads to cardiovascular disease and hypertension, type 2 diabetes, sleep apnea, discrimination, etc Youth Risk Behavior Surveillance: Only about 1/3 of adolescents meet minimal PA recommendations (60 min or more most days of week), now recs are 60 min daily; worse for females and for AAs Video Games: Lenhart 2008 Pew Internet –99% of boys & 94% of girls play video games
  • Particularly for low-income and for African American Obesity leads to cardiovascular disease and hypertension, type 2 diabetes, sleep apnea, discrimination, etc Youth Risk Behavior Surveillance: Only about 1/3 of adolescents meet minimal PA recommendations (60 min or more most days of week), now recs are 60 min daily; worse for females and for AAs Video Games: Lenhart 2008 Pew Internet –99% of boys & 94% of girls play video games Approximately 13 million U.S. children and adolescents are obese, with a body mass index at or above the 95 th percentile. Obesity is a major risk factor for many serious health conditions, including type 2 diabetes, stroke, heart disease, high blood pressure and certain cancers. During the past 40 years, obesity rates for children age 6 to 11 nearly tripled—from 5% to 14%—and more than tripled for adolescents age 12 to 19—from 5% to 17.1%. Obese adolescents have an 80% chance of becoming obese adults. An estimated 61% of obese young people already have at least one additional health risk factor such as high blood pressure or high cholesterol. Childhood obesity health expenses are estimated at $14 billion annually. Good nutrition and physical activity can help prevent obesity, but opportunities for healthy choices may be limited. Wealthy communities have three times as many supermarkets as poor areas, increasing their access to fruits, vegetables, and a wider selection of healthy foods.  Poorer areas also often have less access to places to be physically active. Almost 30% of U.S. children do not exercise three or more times a week. More than 75% of high school students do not eat the recommended servings of fruits and vegetables each day. Sources: Ogden, et al. JAMA , 295 (13): 1549-1555 and JAMA , 288 (14): 1728-1732. CDC, Morbidity and Mortality Weekly Report 54, no.8: 203. Pediatrics 103, no.6: 1175-1172. CDC, Preventing Obesity and Chronic Diseases through Good Nutrition and Physical Activity. Interagency Forum on Child and Family Statistics America's Children; Key National Indicators of Well-Being, 2007.
  • Lowers self-esteem, hinders academic and social functioning, persists into adulthood Abnormal glucose tolerance; population-based sample, 70% of obese children had at least 1 CVD risk factor while 39% had 2 or more Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between childhood obesity and asthma.41, 42 Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. Weight reduction causes liver enzymes to normalize.39 Sleep apnea is a less common complication of obesity for children and adolescents. Sleep apnea is a sleep-associated breathing disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. Sleep apnea is characterized by loud snoring and labored breathing. During sleep apnea, oxygen levels in the blood can fall dramatically. One study estimated that sleep apnea occurs in about 7% of obese children.43 Type 2 diabetes is increasingly being reported among children and adolescents who are obese.44 While diabetes and glucose intolerance, a precursor of diabetes, are common health effects of adult obesity, only in recent years has Type 2 diabetes begun to emerge as a health-related problem among children and adolescents.45 Onset of diabetes in children and adolescents can result in advanced complications such as CVD and kidney failure.45
  • Youth Risk Behavioral Surveillance 2005 67% don’t attend P.E. daily; only 54.2% attended P.E. 1 or more days in an average week Lowers self-esteem, hinders academic and social functioning, persists into adulthood Abnormal glucose tolerance; population-based sample, 70% of obese children had at least 1 CVD risk factor while 39% had 2 or more Asthma is a disease of the lungs in which the airways become blocked or narrowed causing breathing difficulty. Studies have identified an association between childhood obesity and asthma.41, 42 Hepatic steatosis is the fatty degeneration of the liver caused by a high concentration of liver enzymes. Weight reduction causes liver enzymes to normalize.39 Sleep apnea is a less common complication of obesity for children and adolescents. Sleep apnea is a sleep-associated breathing disorder defined as the cessation of breathing during sleep that lasts for at least 10 seconds. Sleep apnea is characterized by loud snoring and labored breathing. During sleep apnea, oxygen levels in the blood can fall dramatically. One study estimated that sleep apnea occurs in about 7% of obese children.43 Type 2 diabetes is increasingly being reported among children and adolescents who are obese.44 While diabetes and glucose intolerance, a precursor of diabetes, are common health effects of adult obesity, only in recent years has Type 2 diabetes begun to emerge as a health-related problem among children and adolescents.45 Onset of diabetes in children and adolescents can result in advanced complications such as CVD and kidney failure.45
  • Youth spend 49 minutes daily playing videogames
  • Maddison: increase EE between 129-400% from baseline Graves: boxing, tennis, bowling > sedentary; boys > girls
  • The D-KEFS assesses the performance of the frontal system of the brain which control executive control skills. The test employs a game-like structure that encourages optimal performance without providing right/wrong feedback that may frustrate adolescent test-takers. In particular, the Design Fluency sub-test measures response inhibition and cognitive flexibility by having the participant connect dots to design as many novel shapes as quickly as possible. The Trail-Making sub-test assesses temporal sequencing and mental flexibility including visual scanning, number and letter sequencing, and motor speed.  D-KEFS has shown adequate reliability and validity. Test-retest reliabilities range from .62 to .80 depending on age groups and particular sub-test. Validity has been shown through adequate intercorrelations of measures within individual D-KEFS tests and correlations with D-KEFS tests and other cognitive tests including the Wisconsin Card Sorting Test. Homack, S., Lee, D., & Riccio, C.A. (2005). Test review: Delis-Kaplan executive function system. J Clin Exp Neuropsychol, 27(5): 599-609. Design Fluency = This test measures ability to generate novel designs as quickly as possible, response inhibition, and cognitive flexibility. The test is composed of three conditions. In each, the child is presented rows of boxes each containing dots that the examinee must connect, with four lines only, to make different designs. Conditions are 1. Draw as many designs as possible; 2. Connect only unfilled dots, leaving filled dots blank; and 3. Alternate connections between filled and unfilled dots. Trail Making = An adaptation of the traditional Trail Making Test used to measure temporal sequencing and mental flexibility, this test consists of 5 conditions instead of 2 including a number-letter switching condition. The test allows the examiner to tease out more fundamental processes including visual scanning, number and letter sequencing, and motor speed Bender Gestalt is a test of visual spatial skills and fine motor skills. The Bender Gestalt Test is used to evaluate visual maturity, visual motor integration skills, style of responding, reaction to frustration, ability to correct mistakes, planning and organizational skills, and motivation. Copying figures requires fine motor skills, the ability to discriminate between visual stimuli, the capacity to integrate visual skills with motor skills, and the ability to shift attention from the original design to what is being drawn. BG scale (reliability = 0.91; White, 2004). White, R.F., Campbell, R., Echeverria, D., Knox, S.S., & Janulewicz, P. (2004). Assessment of neuropsychological trajectories in longitudinal population-based studies of chidren. J Epidemiol Community Health, 63(Suppl): i15-i26.
  • Transcript

    • 1. Improved Executive Functioning from Wii Active Exergame Play Amanda E. Staiano, Anisha Abraham, & Sandra L. Calvert Games for Health 2010 May 27, 2010 Children’s Digital Media Center Department of Psychology, Georgetown University Funded by Robert Wood Johnson Foundation Health Games Research
    • 2.
    • 3. Outline
      • Study 1: Social Exergame Play for Caloric Expenditure among Adolescents
      • Study 2: Improved Executive Functioning from Wii Active Exergame Play
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 4. 1998 Rise of Adult Obesity (Obesity = *BMI  30, or about 30 lbs. overweight for 5’4” person) 2007 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% BRFSS, Behavioral Risk Factor Surveillance System, http: //www.cdc.gov/brfss/ Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 5. Rise of Pediatric Obesity Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Examination Surveys II (ages 6–11) and III (ages 12–17), and National Health and Nutrition Examination Surveys I, II and III, and 1999–2006. Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 6. Rise of Pediatric Obesity The National Survey of Children's Health. Childhood Obesity Action Network. State Obesity Profiles, 2008. National Initiative for Children's Healthcare Quality, Child Policy Research Center, and Child and Adolescent Health Measurement Initiative. Retrieved 5/9/09 from http://www.nschdata.org:80/Content/ObesityReportCards.aspx. Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 7. Consequences of Pediatric Obesity
      • Physiological
        • Cardiovascular risk factors, type 2 diabetes, asthma, sleep apnea (McGinnis, Gootman, & Kraak, 2006)
      • Psychosocial
        • Social discrimination, low self-esteem (Eisenberg, Neumarck-Sztainer, & Story, 2003)
      • Cognitive
        • Missed school days, poorer academic achievement (Staiano, 2010)
        • Division of Nutrition, Physical Activity and Obesity, CDC, 2009
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 8. Low Physical Activity Rates
      • Youth are not meeting
      • physical activity recommendations
      • Eaton, Kann, & Kinchen, et al., 2006
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 9. High Gaming Rates
      • Youth spend 36 minutes daily
      • playing on video game consoles
      Rideout, Foehr, & Roberts, 2010 Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 10.
      • Exergames burn calories
        • Similar to walking at 3 miles per hour, skipping, or jumping (Staiano & Calvert, 2010; Maddison et al., 2007)
      • Exergames meet requirements for aerobic fitness
      • (Unnithan, Houser, & Fernhall, 2006; Tan et al., 2002)
      • Exergames are engaging (Warburton et al., 2007)
      • Wii Sports: Youth expend more energy when playing boxing, tennis, and bowling than when playing sedentary video game (Graves et al., 2007)
        • Males expend more energy than females, particularly in Wii tennis
      Exergames for Caloric Loss Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 11. Limitations in Current Research
      • Small sample sizes
      • Only target athletic youth
      • Short-term exposure
      • Little comparison to sports activities
      • Only solitary game play
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 12. Study 1 Social Exergame Play for Caloric Expenditure among Adolescents Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 13. Research Questions
      • How does playing a videogame alone (solitary) versus playing a videogame with a partner (social) affect energy expenditure?
      • How does energy expenditure during exergame play compare to actual sport play?
      • How does enjoyment of playing the Wii game differ by gender?
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 14. Hypotheses
      • H1: Exergame play will burn more calories than a sedentary activity
      • H2: Social group will burn more calories than solitary group
      • H3: Tennis court play will burn more calories than exergame play
      • H4: Boys will enjoy exergame more than girls
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 15. Methodology
      • 74 low-income African American 12- to 18-year-old adolescents
        • Mean BMI percentile = 69.28 (SD = 28.06)
        • Proportion overweight/obese = 41.89%
        • Mean Age = 14.45 years (SD = 1.67)
      • Setting: Campus of Georgetown University
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 16. Stimulus: Nintendo Wii Sports Tennis Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 17. Solitary Condition Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 18. Social Condition Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 19. Control Condition Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 20. Treatment
      • 10 min of tennis skills test on tennis court
      • 30 min of solitary or social exergame play
      • or 30 min of sedentary computer activity
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 21. Measures
      • Weight, BMI percentile, waist-to-hip ratio
      • Actical physical activity monitor
      • Self-reported enjoyment of exergame play
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 22. Results Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 23. Caloric Expenditure: By Condition Linear regression predicting caloric expenditure by condition. Variable B SE B β ________ Gender -6.59 2.15 -0.19** Age -1.45 0.64 -0.15* Solitary Condition -6.72 2.49 -0.19** Control Condition -20.12 2.58 -0.58*** Weight 0.64 0.09 0.65*** BMI Percentile -0.09 0.06 -0.14 Waist-to-Hip Ratio 3.75 18.36 0.01 R 2 0.76 _____________________________________________________________________ Values are expressed as coefficient. *** = p < .001, ** = p < .01, * = p < .05. For Gender, 0 = Male, 1 = Female. F (7,66) = 30.373, p = .000, r 2 = .763 (adjusted r 2 = .738). Condition was dummy-coded so that Solitary = 1, Control = 1, and Social = 0. Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 24. Caloric Expenditure & METs (by condition) Staiano, Abraham, & Calvert, 2010 Georgetown University Social Solitary Control Condition (kCal) 62.93 54.83 37.69 Condition (METs) 2.017 1.788 1.262
    • 25. Caloric Expenditure: Tennis Court Play vs. Exergame Play = tennis court play is significantly different than treatment, p < .05. Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 26. Enjoyment of exergame play Note .  2 (1, N = 47) = 4.968, p = .026 Staiano, Abraham, & Calvert, 2010 Georgetown University Enjoy Do Not Enjoy Males 18 4 Females 25 0
    • 27. Summary of Results
      • As expected:
      • Social expended more calories than solitary.
      • Both expended more calories than control.
      • Also, males, younger, and heavier weight individuals burned more calories.
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 28. Summary of Results
      • Social exergame play was comparable to tennis court play
      • Solitary play and control condition burned significantly fewer calories than during tennis court play.
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 29. Summary of Results
      • 100% of girls and 82% of boys enjoyed playing the exergame
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 30. Implications of Findings
      • Social exergame play is a more physically active option than solitary gameplay
      • Exergames may be a viable supplemental physical activity, particularly for low-income adolescents
      • Incorporating enjoyable physical activities in schools and homes may encourage energy expenditure and potentially improve health for at-risk youth
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 31. Study 2 Social Exergame Play for Improved Executive Functioning among Adolescents Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 32. Research Question
      • Exergames produce caloric expenditure that
      • may promote physical health,
      • but can they also promote cognitive health?
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 33. Activity  Improved Cognition
      • Executive function hypothesis (Davis et al., 2007)
      • Aerobic Activity
        • Enhanced executive control skills (Etnier et al., 2006; Hertzog et al., 2008; Hillman et al., 2009)
        • Enhanced attention and concentration (Budde et al., 2008)
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 34. Video Games  Improved Cognition
      • Attention (Green & Bavelier, 2003)
        • Capacities: Task-switching
        • Visual Spatial Skills: Useful field of view, spatial and temporal resolution, attentional blink paradigm, alerting and orienting
      • Retention (Pivec, 2008)
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 35. Hypothesis
      • Participants who play an exergame will improve more in executive functioning and visual spatial skills than those in a sedentary control group.
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 36. Methodology
      • 50 (34 female) low-income African American 14- to 19-year-old overweight and obese adolescents
        • Mean BMI = 33.27 (SD = 6.38)
        • Mean BMI percentile = 94.76 (SD = 5.51)
        • Mean Age = 16.8 years (SD = 1.14)
      • Setting: Inner-city public high school
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 37. Stimulus: EA Active for Nintendo Wii Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 38. Game Play Exposure
      • Baseline cognitive assessment
      • Two 15 minute sessions of Wii Active play
        • Immediate cognitive assessment following each 15 minute session of game play
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 39. Cognitive Measures
      • Delis-Kaplan Executive Function Scale (DKEFS)
        • Design Fluency
        • Trail-Making Test
      • Bender Gestalt visual spatial skills test
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 40. Results Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 41. Executive Functioning (DKEFS) Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 42. Executive Functioning (DKEFS)
      • Repeated measures ANOVA at baseline and week 6
      • All participants improved over time
        • F (1, 45) = 11.073, p = .002
      • Wii players improved more than control
        • F (1, 45) = 4.502, p = .039
      • Wii players increased on average 11.26%
      • vs. 3.34% for control group
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 43. Visual Spatial Skills (Bender Gestalt) Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 44. Visual Spatial Skills (Bender Gestalt)
      • Repeated measures ANOVA at baseline and week 6
      • Wii players improved more than control
          • F (1, 48) = 5.014, p = .030
      • Wii players increased average of 9.45%
      • vs. 5.44% for the control group
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 45. Summary of Results
      • Wii Active players significantly improved scores on executive functioning and visual spatial skills more than the sedentary control group did
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 46. Implications of Findings
      • Only 15 minutes of exergame play produces short-term improved cognitive outcomes
      • The physical activity component and video game component may enhance cognitive outcomes from exergames
      • Exergames could be integrated within the school day (PE; Recess) to produce short-term gains in cognitive performance
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 47. Future Work
      • Analysis of the full 8 month Wii Active exergame intervention
        • Game enjoyment
        • Physical health change (BMI, caloric expenditure)
        • Cognitive change (memory, attention, concentration)
        • Socio-emotional change (self-efficacy, motivation, self-esteem, attitude towards physical activity)
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 48. Conclusion
      • Exergames produce physiological and cognitive benefits for at-risk adolescents
        • Social exergame play produces caloric expenditure similar to low to moderate intensity physical activity and matches actual sport play
        • Social exergame play produces short-term cognitive gains in executive function skills and visual spatial skills
      • Exergames may be a tool
      • to promote physical and cognitive health
      Staiano, Abraham, & Calvert, 2010 Georgetown University
    • 49. Acknowledgements Staiano, Abraham, & Calvert, 2010 Georgetown University