CRITICISMS OF EXERGAMING Elizabeth Lyons, MPH Gillings School of Global Public Health Lineberger Comprehensive Cancer Center The University of North Carolina at Chapel Hill [email_address] Funding support provided by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research initiative and by NIH grant CA75526

What I’m playing

What I’m studying Funding support provided by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research initiative and by NIH grant CA75526

Overview Most common criticisms of exergaming General: exergaming as a concept Specific: current exergames, research, and implementation Evidence base of criticisms Recommendations for addressing the criticisms

Most common criticisms of exergaming

General: exergaming as a concept

Specific: current exergames, research, and implementation

Evidence base of criticisms

Recommendations for addressing the criticisms

Common Sources of Criticisms Mainstream media Online media Exercise/fitness professionals Researchers Providers Advocacy groups Parents Weight loss experts Weight loss “experts”

Mainstream media

Online media

Exercise/fitness professionals

Researchers

Providers

Advocacy groups

Parents

Weight loss experts

Weight loss “experts”

Broad Categories of Criticisms Exergames do not produce health benefits that may result from other types of exercise Exergames encourage screen time and displace exercise Exergames do not produce sufficient motivation to encourage sustained exercise over time

Exergames do not produce health benefits that may result from other types of exercise

Exergames encourage screen time and displace exercise

Exergames do not produce sufficient motivation to encourage sustained exercise over time

Outline For each criticism, there are several things to discuss Examples Research evidence Relevance How to investigate the criticism How to use the criticism to improve research, development, and implementation

For each criticism, there are several things to discuss

Examples

Research evidence

Relevance

How to investigate the criticism

How to use the criticism to improve research, development, and implementation

Exergames do not produce health-related benefits of other types of exercise Lower Intensity Don’t Improve Fitness Don’t Produce Weight Loss Major criticism 1

Exergames do not produce health-related benefits of other types of exercise

Lower Intensity

Don’t Improve Fitness

Don’t Produce Weight Loss

Examples “ I’m not saying it isn’t fun or entertaining…but it’s just not enough to get in shape or increase your fitness to any significant degree.” Stephen Cabral, diet/weight loss blogger “ Wii gaming actually turns over more energy than sedentary gaming, but not as much as authentic sports .” Gareth Stratton, researcher

“ I’m not saying it isn’t fun or entertaining…but it’s just not enough to get in shape or increase your fitness to any significant degree.”

Stephen Cabral, diet/weight loss blogger

“ Wii gaming actually turns over more energy than sedentary gaming, but not as much as authentic sports .”

Gareth Stratton, researcher

Exergames produce varying intensity levels 12 published lab studies of console games All showed significant energy expenditure increases Highest intensity: Jackie’s Action Run (Xavix), 9.0 METs (Mellecker & McManus, 2008) Eyetoy and Dance Dance Revolution produced moderate-vigorous exercise Some found increases during sedentary game play over rest or TV watching Stationary cycling plus gaming increases activity intensity (Warburton et al., 2009)

12 published lab studies of console games

All showed significant energy expenditure increases

Highest intensity: Jackie’s Action Run (Xavix), 9.0 METs (Mellecker & McManus, 2008)

Eyetoy and Dance Dance Revolution produced moderate-vigorous exercise

Some found increases during sedentary game play over rest or TV watching

Stationary cycling plus gaming increases activity intensity (Warburton et al., 2009)

Video game activity levels, in METs Vigorous Moderate Light Sedentary Lyons, E.J., Tate, D.F., Erickson, K.E., Vaughn, A., & Ward, D.S. (2008). Energy expenditure during Wii Sports minigames in overweight children: comparing data parameter selection. Presented at the Obesity Society Annual National Meeting, October 3-7, Phoenix, AZ. Includes: Borusiak, 2007; Graves, 2007; Lanningham-Foster, 2006; Maddison, 2007; Sell, 2008; Straker, 2007; Unnithan, 2006; Wang, 2006

Light intensity activity is also beneficial Light activity is independently negatively associated with markers of CVD/diabetes risk (Healy et al., 2007) Even light, short breaks in sedentary behavior have positive health impacts (Healy & Dunstan, 2008) Non-exercise light-intensity activities like fidgeting and standing are associated with weight (Levine et al., 2005)

Light activity is independently negatively associated with markers of CVD/diabetes risk (Healy et al., 2007)

Even light, short breaks in sedentary behavior have positive health impacts (Healy & Dunstan, 2008)

Non-exercise light-intensity activities like fidgeting and standing are associated with weight (Levine et al., 2005)

Is this criticism relevant? Yes Not all exergames produce MVPA Even ones found to produce MVPA may not do so for everyone Playing games while exercising may increase intensity Strong evidence that exergames can produce moderate to vigorous intensity physical activity levels - but will they? Unclear if these results can be replicated outside of the laboratory

Yes

Not all exergames produce MVPA

Even ones found to produce MVPA may not do so for everyone

Playing games while exercising may increase intensity

Strong evidence that exergames can produce moderate to vigorous intensity physical activity levels - but will they?

Unclear if these results can be replicated outside of the laboratory

Intensity: research directions What we know Some games can produce moderate-vigorous intensity activity; others produce light intensity activity Both intensity levels show health benefits Where do we go from here? How are exergames played outside of the lab, in the real world?

What we know

Some games can produce moderate-vigorous intensity activity; others produce light intensity activity

Both intensity levels show health benefits

Where do we go from here?

How are exergames played outside of the lab, in the real world?

Fitness benefit?: limited evidence Few studies have included fitness as an outcome A small study of DDR play in children found improvements in VO 2 max and exercise testing time (Murphy et al., 2009) Studies of stationary cycling while gaming have shown improvements in VO 2 max (Warburton et al., 2008) Some exergames increase heart rate to levels indicative that, over time, play would improve fitness levels Many lab studies do not include heart rate measures We don’t know if these intensity levels are maintained over time

Few studies have included fitness as an outcome

A small study of DDR play in children found improvements in VO 2 max and exercise testing time (Murphy et al., 2009)

Studies of stationary cycling while gaming have shown improvements in VO 2 max (Warburton et al., 2008)

Some exergames increase heart rate to levels indicative that, over time, play would improve fitness levels

Many lab studies do not include heart rate measures

We don’t know if these intensity levels are maintained over time

Is this criticism relevant? Yes – limited evidence suggests that some games can increase fitness, but… Intervention studies of exergames show equivocal effects on physical activity (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008) Possibly due to sharp declines in play over time Exergaming adherence mediated the relationship between condition and fitness in the other study (Warburton et al., 2008) Both intensity and adherence are concerns

Yes – limited evidence suggests that some games can increase fitness, but…

Intervention studies of exergames show equivocal effects on physical activity (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008)

Possibly due to sharp declines in play over time

Exergaming adherence mediated the relationship between condition and fitness in the other study (Warburton et al., 2008)

Both intensity and adherence are concerns

Fitness: research strategies Lab studies More lab studies of the acute cardiovascular effects of various forms of exergaming Improve methodological rigor Randomized controlled trials Include fitness testing as an outcome Longer follow-up periods Wider variety of exergames Measures of adherence to exercise protocol

Lab studies

More lab studies of the acute cardiovascular effects of various forms of exergaming

Improve methodological rigor

Randomized controlled trials

Include fitness testing as an outcome

Longer follow-up periods

Wider variety of exergames

Measures of adherence to exercise protocol

Can exergaming lead to weight loss? Preliminary intervention studies of console exergames Three did not find significant weight losses (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008) One study found less weight gain in a group of children assigned to a Dance Dance Revolution exercise protocol (Murphy et al., 2009) No evidence of weight losses Possible weight gain prevention

Preliminary intervention studies of console exergames

Three did not find significant weight losses (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008)

One study found less weight gain in a group of children assigned to a Dance Dance Revolution exercise protocol (Murphy et al., 2009)

No evidence of weight losses

Possible weight gain prevention

Relevance of the criticism Somewhat relevant Traditional exercise interventions lead to very small weight losses if not combined with dietary change Weight loss from exergaming alone is a tall order Consumers have expectations for weight loss “ Wii Sports Experiment” and other online testimonials Game names include words like “Fit” and “Cardio” and “Weight Loss Coach”

Somewhat relevant

Traditional exercise interventions lead to very small weight losses if not combined with dietary change

Weight loss from exergaming alone is a tall order

Consumers have expectations for weight loss

“ Wii Sports Experiment” and other online testimonials

Game names include words like “Fit” and “Cardio” and “Weight Loss Coach”

Weight loss research strategies More long-term studies with weight as an outcome More comprehensive measurements of possible mediators Epstein et al. (2008) found that decreasing sedentary screen time reduced weight by decreasing energy intake , not expenditure Daily weighing and self-monitoring may also be mediators

More long-term studies with weight as an outcome

More comprehensive measurements of possible mediators

Epstein et al. (2008) found that decreasing sedentary screen time reduced weight by decreasing energy intake , not expenditure

Daily weighing and self-monitoring may also be mediators

Moving forward… Several strategies for addressing these criticisms: Manage expectations Provide more comprehensive weight loss and fitness programs as part of the games Include a dietary component Strength training and cardio Use evidence-based behavioral strategies Create a solid evidence base Base decisions on empirical evidence

Several strategies for addressing these criticisms:

Manage expectations

Provide more comprehensive weight loss and fitness programs as part of the games

Include a dietary component

Strength training and cardio

Use evidence-based behavioral strategies

Create a solid evidence base

Base decisions on empirical evidence

Exergames encourage screen time and displace exercise Major criticism 2

Exergames encourage screen time and displace exercise

Examples “ More screen time for kids is not the answer – and could be a distraction from real exercise.” Josh Golin, associate director of Campaign for a Commercial Free Childhood “ Young and old are putting away their gym clothes and shying away from going outdoors to play sports , because [of] the addictive appeal to the Wii game products.” Michael Torchia, lifestyle/fitness coach

“ More screen time for kids is not the answer – and could be a distraction from real exercise.”

Josh Golin, associate director of Campaign for a Commercial Free Childhood

“ Young and old are putting away their gym clothes and shying away from going outdoors to play sports , because [of] the addictive appeal to the Wii game products.”

Michael Torchia, lifestyle/fitness coach

SST/displacement evidence base: limited No evidence that exergaming increases SST Limited evidence that exergaming decreases SST (Maloney et al., 2008) Limited evidence that exergaming is preferred over a similar traditional video game or traditional exercise (Epstein et al., 2007) No evidence on the effects of exergaming on other exercise activities

No evidence that exergaming increases SST

Limited evidence that exergaming decreases SST (Maloney et al., 2008)

Limited evidence that exergaming is preferred over a similar traditional video game or traditional exercise (Epstein et al., 2007)

No evidence on the effects of exergaming on other exercise activities

Is this criticism relevant? Not enough evidence to confirm or rebut either criticism If true, both would have important health implications Sedentary screen time and specifically TV watching increases risk of many negative health outcomes, even in active individuals American adults spend more time watching TV than any other activity after sleep and work (US Dept of Labor, 2007) If exergames replace some SST – particularly TV – they could have a large public health impact Impact on exercise unclear – but whether this matters is also unclear

Not enough evidence to confirm or rebut either criticism

If true, both would have important health implications

Sedentary screen time and specifically TV watching increases risk of many negative health outcomes, even in active individuals

American adults spend more time watching TV than any other activity after sleep and work (US Dept of Labor, 2007)

If exergames replace some SST – particularly TV – they could have a large public health impact

Impact on exercise unclear – but whether this matters is also unclear

Behavioral Choice Theory Substitute healthier behaviors for less healthy ones In order to substitute exercise for a sedentary behavior, the exercise activity must be as or more reinforcing than the sedentary one (Epstein et al., 2004) For many, exercise is not reinforcing Exergames, in theory, are a tool for making exercise reinforcing enough to compete with TV watching

Substitute healthier behaviors for less healthy ones

In order to substitute exercise for a sedentary behavior, the exercise activity must be as or more reinforcing than the sedentary one (Epstein et al., 2004)

For many, exercise is not reinforcing

Exergames, in theory, are a tool for making exercise reinforcing enough to compete with TV watching

Video games vs. TV If exergaming encourages more video game-based screen time over TV, that may be beneficial In children, traditional games increase activity over rest and represent light activity levels Light activity has many benefits, and sedentary behavior has many negative health outcomes There is preliminary evidence that gaming may be healthier than TV watching due to lower energy intake (Epstein et al., 2002) and that more interactive controllers are associated with lower intake (Bloom et al., 2008)

If exergaming encourages more video game-based screen time over TV, that may be beneficial

In children, traditional games increase activity over rest and represent light activity levels

Light activity has many benefits, and sedentary behavior has many negative health outcomes

There is preliminary evidence that gaming may be healthier than TV watching due to lower energy intake (Epstein et al., 2002) and that more interactive controllers are associated with lower intake (Bloom et al., 2008)

SST/displacement: research strategies Behavioral choice: how behaviors are substituted for one another How reinforcing is exergaming, compared to exercise or TV How do exergames differ in their reinforcing power Effects of exergaming on other types of exercise In addition to objective measurement of exercise, investigate the breakdown of activity types Compare effects in different populations (frequent exercisers, less frequent exercisers, etc.)

Behavioral choice: how behaviors are substituted for one another

How reinforcing is exergaming, compared to exercise or TV

How do exergames differ in their reinforcing power

Effects of exergaming on other types of exercise

In addition to objective measurement of exercise, investigate the breakdown of activity types

Compare effects in different populations (frequent exercisers, less frequent exercisers, etc.)

Moving forward… Effort should be put towards producing and disseminating products that make exercise more fun than TV Would have health benefits both by increasing activity and decreasing sedentariness May also affect eating behavior The key is ensuring that these games are not just enjoyable, but as/more enjoyable than sedentary alternatives

Effort should be put towards producing and disseminating products that make exercise more fun than TV

Would have health benefits both by increasing activity and decreasing sedentariness

May also affect eating behavior

The key is ensuring that these games are not just enjoyable, but as/more enjoyable than sedentary alternatives

Exergames are insufficiently motivating to produce sustained exercise over time Not as immersive as other games Aren’t as fun or motivating as other games Major criticism 3

Exergames are insufficiently motivating to produce sustained exercise over time

Not as immersive as other games

Aren’t as fun or motivating as other games

Examples “ One of my big things is that it could use a graphics upgrade. Graphics and sound play a big part in the immersion , really getting involved in the game.” “ It felt pointless. I was only trying to get the highest score and afterwards I didn’t feel like playing it anymore .” “ I don’t think it accurately represents dancing.” PRESENCE study participants PRESENCE study funded by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research initiative

“ One of my big things is that it could use a graphics upgrade. Graphics and sound play a big part in the immersion , really getting involved in the game.”

“ It felt pointless. I was only trying to get the highest score and afterwards I didn’t feel like playing it anymore .”

“ I don’t think it accurately represents dancing.”

PRESENCE study participants

Presence evidence base: moderate Presence impacts motivation to play Presence is the failure to perceive technological mediation – the feeling of “being there” Presence predicts motivation to play a game, and motivation predicts play (Ryan et al., 2006) Presence has been found to increase energy expended during exergame play (Ijsselsteijn et al., 2006)

Presence impacts motivation to play

Presence is the failure to perceive technological mediation – the feeling of “being there”

Presence predicts motivation to play a game, and motivation predicts play (Ryan et al., 2006)

Presence has been found to increase energy expended during exergame play (Ijsselsteijn et al., 2006)

Distraction is necessary for many Exercise is more aversive for sedentary and overweight individuals at a lower level of intensity than for fit, normal weight individuals (Ekkekakis & Lind, 2006) Distraction during exercise may be particularly important for sedentary and overweight individuals, because exercise is more difficult and less enjoyable

Exercise is more aversive for sedentary and overweight individuals at a lower level of intensity than for fit, normal weight individuals (Ekkekakis & Lind, 2006)

Distraction during exercise may be particularly important for sedentary and overweight individuals, because exercise is more difficult and less enjoyable

Do exercise-themed games distract? Presence is, essentially, distraction from the real world Games used in studies of gaming as distraction from exertion were not exercise-themed Can an exercise-themed game distract from exertion? If you feel present in an unpleasant activity, how does that affect motivation? Would the exergaming discipline be better off obscuring the exercise components of these games?

Presence is, essentially, distraction from the real world

Games used in studies of gaming as distraction from exertion were not exercise-themed

Can an exercise-themed game distract from exertion?

If you feel present in an unpleasant activity, how does that affect motivation?

Would the exergaming discipline be better off obscuring the exercise components of these games?

Are these criticisms relevant? One of the major reasons for combining gaming and exercise is to make exercise more motivating Need to improve the experience of exercise for those who find it aversive Enjoyment, pleasure, and mood are important factors that predict future behavior From a behavioral choice perspective, the reinforcing power of a game is important

One of the major reasons for combining gaming and exercise is to make exercise more motivating

Need to improve the experience of exercise for those who find it aversive

Enjoyment, pleasure, and mood are important factors that predict future behavior

From a behavioral choice perspective, the reinforcing power of a game is important

Presence/motivation research strategies How does presence affect motivation and energy expenditure, and does this differ across games? PRESENCE study currently underway What characteristics of regular games increase presence, and how could these be applied to exergames? Partly being studied in PRESENCE Do exercise-themed exergames affect presence/enjoyment differently than games in which exertion is disguised? PRESENCE funded by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research

How does presence affect motivation and energy expenditure, and does this differ across games?

PRESENCE study currently underway

What characteristics of regular games increase presence, and how could these be applied to exergames?

Partly being studied in PRESENCE

Do exercise-themed exergames affect presence/enjoyment differently than games in which exertion is disguised?

Give me a reason to run! Running in exergames EA Sports Active – run on track, random other people Wii Fit – run through cartoon environment, other Miis Shape boxing – run, punch bears

Running in exergames

EA Sports Active – run on track, random other people

Wii Fit – run through cartoon environment, other Miis

Shape boxing – run, punch bears

Moving forward… So many reasons to run, bike, dance Paperboy 2K9 – bike and throw papers, but watch out for the grim reaper Arashi vs. Zombies: Dance Battle – your band is menaced by zombies, and your only weapon is the power of dance Velociraptors

So many reasons to run, bike, dance

Paperboy 2K9 – bike and throw papers, but watch out for the grim reaper

Arashi vs. Zombies: Dance Battle – your band is menaced by zombies, and your only weapon is the power of dance

Velociraptors

Novelty and boredom Both exercise and exergames become boring over time Equipment  clothes hanger, animal bed Motivation is important, but can only do so much

Both exercise and exergames become boring over time

Equipment  clothes hanger, animal bed

Motivation is important, but can only do so much

Other related criticisms Common criticisms not covered Exergames are more expensive than other activities Exergames offer fewer opportunities for children to be creative than free play Exergames discourage outdoor exercise Exergames are a gimmick There are also many generalized arguments that virtual anything is inherently less worthy than “the real thing” Ideal vs. harm reduction

Common criticisms not covered

Exergames are more expensive than other activities

Exergames offer fewer opportunities for children to be creative than free play

Exergames discourage outdoor exercise

Exergames are a gimmick

There are also many generalized arguments that virtual anything is inherently less worthy than “the real thing”

Ideal vs. harm reduction

Motivation and social ritual “ But all of these games and the studies that laud them celebrate the exercise potential of games, divorced from any cultural context in which exercise might happen naturally. And this division poses a real danger for this emerging genre. If exergames don’t start wrapping physical activity in credible social experiences , they will become as miserable and forgettable as any session with the exercise bike or treadmill.” Ian Bogost, serious games scholar

“ But all of these games and the studies that laud them celebrate the exercise potential of games, divorced from any cultural context in which exercise might happen naturally. And this division poses a real danger for this emerging genre. If exergames don’t start wrapping physical activity in credible social experiences , they will become as miserable and forgettable as any session with the exercise bike or treadmill.”

Ian Bogost, serious games scholar

Major take-home points For many people, exercise is aversive The addition of gaming to exercise can make it less aversive There is a place for exergaming in a healthy lifestyle even if some of the discussed criticisms are true, as a substitute for TV watching and/or an adjunct to exercise/sport/play

For many people, exercise is aversive

The addition of gaming to exercise can make it less aversive

There is a place for exergaming in a healthy lifestyle even if some of the discussed criticisms are true, as a substitute for TV watching and/or an adjunct to exercise/sport/play

Major take-home points Across the board, there is a need for more research There is room for improvement in exergame development and implementation Find a way to integrate the compelling gameplay of regular games and the improved activity and interactivity of exergames

Across the board, there is a need for more research

There is room for improvement in exergame development and implementation

Find a way to integrate the compelling gameplay of regular games and the improved activity and interactivity of exergames

Acknowledgements Ben Sawyer & Games for Health Health Games Research, Robert Wood Johnson Foundation Deborah Tate Fellow “exergaming evangelists”

Ben Sawyer & Games for Health

Health Games Research, Robert Wood Johnson Foundation

Deborah Tate

Fellow “exergaming evangelists”

Elizabeth Lyons, MPH Gillings School of Global Public Health Lineberger Comprehensive Cancer Center The University of North Carolina at Chapel Hill [email_address] Contact information

Elizabeth Lyons, MPH

Gillings School of Global Public Health

Lineberger Comprehensive Cancer Center

The University of North Carolina at Chapel Hill

[email_address]