Games for Health 09 Criticisms of Exergaming Talk


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Games for Health 09 Criticisms of Exergaming Talk

  1. 1. 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
  2. 2. What I’m playing
  3. 3. 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
  4. 4. Overview <ul><li>Most common criticisms of exergaming </li></ul><ul><ul><li>General: exergaming as a concept </li></ul></ul><ul><ul><li>Specific: current exergames, research, and implementation </li></ul></ul><ul><li>Evidence base of criticisms </li></ul><ul><li>Recommendations for addressing the criticisms </li></ul>
  5. 5. Common Sources of Criticisms <ul><li>Mainstream media </li></ul><ul><li>Online media </li></ul><ul><li>Exercise/fitness professionals </li></ul><ul><li>Researchers </li></ul><ul><li>Providers </li></ul><ul><li>Advocacy groups </li></ul><ul><li>Parents </li></ul><ul><li>Weight loss experts </li></ul><ul><li>Weight loss “experts” </li></ul>
  6. 6. Broad Categories of Criticisms <ul><ul><li>Exergames do not produce health benefits that may result from other types of exercise </li></ul></ul><ul><ul><li>Exergames encourage screen time and displace exercise </li></ul></ul><ul><ul><li>Exergames do not produce sufficient motivation to encourage sustained exercise over time </li></ul></ul>
  7. 7. Outline <ul><li>For each criticism, there are several things to discuss </li></ul><ul><ul><li>Examples </li></ul></ul><ul><ul><li>Research evidence </li></ul></ul><ul><ul><li>Relevance </li></ul></ul><ul><ul><li>How to investigate the criticism </li></ul></ul><ul><ul><li>How to use the criticism to improve research, development, and implementation </li></ul></ul>
  8. 8. <ul><li>Exergames do not produce health-related benefits of other types of exercise </li></ul><ul><ul><li>Lower Intensity </li></ul></ul><ul><ul><li>Don’t Improve Fitness </li></ul></ul><ul><ul><li>Don’t Produce Weight Loss </li></ul></ul>Major criticism 1
  9. 9. Examples <ul><li>“ 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.” </li></ul><ul><li>Stephen Cabral, diet/weight loss blogger </li></ul><ul><li>“ Wii gaming actually turns over more energy than sedentary gaming, but not as much as authentic sports .” </li></ul><ul><li>Gareth Stratton, researcher </li></ul>
  10. 10. Exergames produce varying intensity levels <ul><li>12 published lab studies of console games </li></ul><ul><ul><li>All showed significant energy expenditure increases </li></ul></ul><ul><ul><ul><li>Highest intensity: Jackie’s Action Run (Xavix), 9.0 METs (Mellecker & McManus, 2008) </li></ul></ul></ul><ul><ul><ul><li>Eyetoy and Dance Dance Revolution produced moderate-vigorous exercise </li></ul></ul></ul><ul><ul><li>Some found increases during sedentary game play over rest or TV watching </li></ul></ul><ul><ul><li>Stationary cycling plus gaming increases activity intensity (Warburton et al., 2009) </li></ul></ul>
  11. 11. 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
  12. 12. Light intensity activity is also beneficial <ul><ul><li>Light activity is independently negatively associated with markers of CVD/diabetes risk (Healy et al., 2007) </li></ul></ul><ul><ul><li>Even light, short breaks in sedentary behavior have positive health impacts (Healy & Dunstan, 2008) </li></ul></ul><ul><ul><li>Non-exercise light-intensity activities like fidgeting and standing are associated with weight (Levine et al., 2005) </li></ul></ul>
  13. 13. Is this criticism relevant? <ul><li>Yes </li></ul><ul><ul><li>Not all exergames produce MVPA </li></ul></ul><ul><ul><li>Even ones found to produce MVPA may not do so for everyone </li></ul></ul><ul><ul><li>Playing games while exercising may increase intensity </li></ul></ul><ul><li>Strong evidence that exergames can produce moderate to vigorous intensity physical activity levels - but will they? </li></ul><ul><ul><li>Unclear if these results can be replicated outside of the laboratory </li></ul></ul>
  14. 14. Intensity: research directions <ul><li>What we know </li></ul><ul><ul><li>Some games can produce moderate-vigorous intensity activity; others produce light intensity activity </li></ul></ul><ul><ul><li>Both intensity levels show health benefits </li></ul></ul><ul><li>Where do we go from here? </li></ul><ul><ul><li>How are exergames played outside of the lab, in the real world? </li></ul></ul>
  15. 15. Fitness benefit?: limited evidence <ul><li>Few studies have included fitness as an outcome </li></ul><ul><ul><li>A small study of DDR play in children found improvements in VO 2 max and exercise testing time (Murphy et al., 2009) </li></ul></ul><ul><ul><li>Studies of stationary cycling while gaming have shown improvements in VO 2 max (Warburton et al., 2008) </li></ul></ul><ul><li>Some exergames increase heart rate to levels indicative that, over time, play would improve fitness levels </li></ul><ul><ul><li>Many lab studies do not include heart rate measures </li></ul></ul><ul><ul><li>We don’t know if these intensity levels are maintained over time </li></ul></ul>
  16. 16. Is this criticism relevant? <ul><li>Yes – limited evidence suggests that some games can increase fitness, but… </li></ul><ul><ul><li>Intervention studies of exergames show equivocal effects on physical activity (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008) </li></ul></ul><ul><ul><ul><li>Possibly due to sharp declines in play over time </li></ul></ul></ul><ul><ul><li>Exergaming adherence mediated the relationship between condition and fitness in the other study (Warburton et al., 2008) </li></ul></ul><ul><li>Both intensity and adherence are concerns </li></ul>
  17. 17. Fitness: research strategies <ul><li>Lab studies </li></ul><ul><ul><li>More lab studies of the acute cardiovascular effects of various forms of exergaming </li></ul></ul><ul><ul><li>Improve methodological rigor </li></ul></ul><ul><li>Randomized controlled trials </li></ul><ul><ul><li>Include fitness testing as an outcome </li></ul></ul><ul><ul><li>Longer follow-up periods </li></ul></ul><ul><ul><li>Wider variety of exergames </li></ul></ul><ul><ul><li>Measures of adherence to exercise protocol </li></ul></ul>
  18. 18. Can exergaming lead to weight loss? <ul><li>Preliminary intervention studies of console exergames </li></ul><ul><ul><li>Three did not find significant weight losses (Madsen et al., 2007; Maloney et al., 2008; Ni Mhurchu et al., 2008) </li></ul></ul><ul><ul><li>One study found less weight gain in a group of children assigned to a Dance Dance Revolution exercise protocol (Murphy et al., 2009) </li></ul></ul><ul><li>No evidence of weight losses </li></ul><ul><li>Possible weight gain prevention </li></ul>
  19. 19. Relevance of the criticism <ul><li>Somewhat relevant </li></ul><ul><ul><li>Traditional exercise interventions lead to very small weight losses if not combined with dietary change </li></ul></ul><ul><ul><ul><li>Weight loss from exergaming alone is a tall order </li></ul></ul></ul><ul><ul><li>Consumers have expectations for weight loss </li></ul></ul><ul><ul><ul><li>“ Wii Sports Experiment” and other online testimonials </li></ul></ul></ul><ul><ul><ul><li>Game names include words like “Fit” and “Cardio” and “Weight Loss Coach” </li></ul></ul></ul>
  20. 20. Weight loss research strategies <ul><li>More long-term studies with weight as an outcome </li></ul><ul><ul><li>More comprehensive measurements of possible mediators </li></ul></ul><ul><ul><ul><li>Epstein et al. (2008) found that decreasing sedentary screen time reduced weight by decreasing energy intake , not expenditure </li></ul></ul></ul><ul><ul><ul><li>Daily weighing and self-monitoring may also be mediators </li></ul></ul></ul>
  21. 21. Moving forward… <ul><li>Several strategies for addressing these criticisms: </li></ul><ul><ul><li>Manage expectations </li></ul></ul><ul><ul><li>Provide more comprehensive weight loss and fitness programs as part of the games </li></ul></ul><ul><ul><ul><li>Include a dietary component </li></ul></ul></ul><ul><ul><ul><li>Strength training and cardio </li></ul></ul></ul><ul><ul><ul><li>Use evidence-based behavioral strategies </li></ul></ul></ul><ul><ul><li>Create a solid evidence base </li></ul></ul><ul><ul><ul><li>Base decisions on empirical evidence </li></ul></ul></ul>
  22. 22. <ul><li>Exergames encourage screen time and displace exercise </li></ul>Major criticism 2
  23. 23. Examples <ul><li>“ More screen time for kids is not the answer – and could be a distraction from real exercise.” </li></ul><ul><li> Josh Golin, associate director of Campaign for a Commercial Free Childhood </li></ul><ul><li>“ 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.” </li></ul><ul><li> Michael Torchia, lifestyle/fitness coach </li></ul>
  24. 24. SST/displacement evidence base: limited <ul><li>No evidence that exergaming increases SST </li></ul><ul><li>Limited evidence that exergaming decreases SST (Maloney et al., 2008) </li></ul><ul><li>Limited evidence that exergaming is preferred over a similar traditional video game or traditional exercise (Epstein et al., 2007) </li></ul><ul><li>No evidence on the effects of exergaming on other exercise activities </li></ul>
  25. 25. Is this criticism relevant? <ul><ul><ul><li>Not enough evidence to confirm or rebut either criticism </li></ul></ul></ul><ul><ul><ul><ul><li>If true, both would have important health implications </li></ul></ul></ul></ul><ul><ul><ul><li>Sedentary screen time and specifically TV watching increases risk of many negative health outcomes, even in active individuals </li></ul></ul></ul><ul><ul><ul><ul><li>American adults spend more time watching TV than any other activity after sleep and work (US Dept of Labor, 2007) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>If exergames replace some SST – particularly TV – they could have a large public health impact </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Impact on exercise unclear – but whether this matters is also unclear </li></ul></ul></ul></ul>
  26. 26. Behavioral Choice Theory <ul><li>Substitute healthier behaviors for less healthy ones </li></ul><ul><ul><li>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) </li></ul></ul><ul><ul><li>For many, exercise is not reinforcing </li></ul></ul><ul><ul><ul><li>Exergames, in theory, are a tool for making exercise reinforcing enough to compete with TV watching </li></ul></ul></ul>
  27. 27. Video games vs. TV <ul><li>If exergaming encourages more video game-based screen time over TV, that may be beneficial </li></ul><ul><ul><li>In children, traditional games increase activity over rest and represent light activity levels </li></ul></ul><ul><ul><ul><li>Light activity has many benefits, and sedentary behavior has many negative health outcomes </li></ul></ul></ul><ul><ul><li>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) </li></ul></ul>
  28. 28. SST/displacement: research strategies <ul><li>Behavioral choice: how behaviors are substituted for one another </li></ul><ul><ul><li>How reinforcing is exergaming, compared to exercise or TV </li></ul></ul><ul><ul><li>How do exergames differ in their reinforcing power </li></ul></ul><ul><li>Effects of exergaming on other types of exercise </li></ul><ul><ul><li>In addition to objective measurement of exercise, investigate the breakdown of activity types </li></ul></ul><ul><ul><li>Compare effects in different populations (frequent exercisers, less frequent exercisers, etc.) </li></ul></ul>
  29. 29. Moving forward… <ul><li>Effort should be put towards producing and disseminating products that make exercise more fun than TV </li></ul><ul><ul><li>Would have health benefits both by increasing activity and decreasing sedentariness </li></ul></ul><ul><ul><li>May also affect eating behavior </li></ul></ul><ul><li>The key is ensuring that these games are not just enjoyable, but as/more enjoyable than sedentary alternatives </li></ul>
  30. 30. <ul><li>Exergames are insufficiently motivating to produce sustained exercise over time </li></ul><ul><ul><li>Not as immersive as other games </li></ul></ul><ul><ul><li>Aren’t as fun or motivating as other games </li></ul></ul>Major criticism 3
  31. 31. Examples <ul><li>“ 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.” </li></ul><ul><li>“ It felt pointless. I was only trying to get the highest score and afterwards I didn’t feel like playing it anymore .” </li></ul><ul><li>“ I don’t think it accurately represents dancing.” </li></ul><ul><li>PRESENCE study participants </li></ul>PRESENCE study funded by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research initiative
  32. 32. Presence evidence base: moderate <ul><li>Presence impacts motivation to play </li></ul><ul><ul><li>Presence is the failure to perceive technological mediation – the feeling of “being there” </li></ul></ul><ul><ul><li>Presence predicts motivation to play a game, and motivation predicts play (Ryan et al., 2006) </li></ul></ul><ul><ul><li>Presence has been found to increase energy expended during exergame play (Ijsselsteijn et al., 2006) </li></ul></ul>
  33. 33. Distraction is necessary for many <ul><li>Exercise is more aversive for sedentary and overweight individuals at a lower level of intensity than for fit, normal weight individuals (Ekkekakis & Lind, 2006) </li></ul><ul><ul><li>Distraction during exercise may be particularly important for sedentary and overweight individuals, because exercise is more difficult and less enjoyable </li></ul></ul>
  34. 34. Do exercise-themed games distract? <ul><li>Presence is, essentially, distraction from the real world </li></ul><ul><li>Games used in studies of gaming as distraction from exertion were not exercise-themed </li></ul><ul><ul><li>Can an exercise-themed game distract from exertion? </li></ul></ul><ul><ul><li>If you feel present in an unpleasant activity, how does that affect motivation? </li></ul></ul><ul><ul><li>Would the exergaming discipline be better off obscuring the exercise components of these games? </li></ul></ul>
  35. 35. Are these criticisms relevant? <ul><li>One of the major reasons for combining gaming and exercise is to make exercise more motivating </li></ul><ul><ul><li>Need to improve the experience of exercise for those who find it aversive </li></ul></ul><ul><ul><li>Enjoyment, pleasure, and mood are important factors that predict future behavior </li></ul></ul><ul><li>From a behavioral choice perspective, the reinforcing power of a game is important </li></ul>
  36. 36. Presence/motivation research strategies <ul><li>How does presence affect motivation and energy expenditure, and does this differ across games? </li></ul><ul><ul><li>PRESENCE study currently underway </li></ul></ul><ul><li>What characteristics of regular games increase presence, and how could these be applied to exergames? </li></ul><ul><ul><li>Partly being studied in PRESENCE </li></ul></ul><ul><li>Do exercise-themed exergames affect presence/enjoyment differently than games in which exertion is disguised? </li></ul>PRESENCE funded by grant 64438 from the Robert Wood Johnson Foundation’s Health Games Research
  37. 37. Give me a reason to run! <ul><li>Running in exergames </li></ul><ul><ul><li>EA Sports Active – run on track, random other people </li></ul></ul><ul><ul><li>Wii Fit – run through cartoon environment, other Miis </li></ul></ul><ul><ul><li>Shape boxing – run, punch bears </li></ul></ul>
  38. 38. Moving forward… <ul><li>So many reasons to run, bike, dance </li></ul><ul><ul><li>Paperboy 2K9 – bike and throw papers, but watch out for the grim reaper </li></ul></ul><ul><ul><li>Arashi vs. Zombies: Dance Battle – your band is menaced by zombies, and your only weapon is the power of dance </li></ul></ul><ul><ul><li>Velociraptors </li></ul></ul>
  39. 39. Novelty and boredom <ul><li>Both exercise and exergames become boring over time </li></ul><ul><ul><li>Equipment  clothes hanger, animal bed </li></ul></ul><ul><li>Motivation is important, but can only do so much </li></ul>
  40. 40. Other related criticisms <ul><li>Common criticisms not covered </li></ul><ul><ul><li>Exergames are more expensive than other activities </li></ul></ul><ul><ul><li>Exergames offer fewer opportunities for children to be creative than free play </li></ul></ul><ul><ul><li>Exergames discourage outdoor exercise </li></ul></ul><ul><ul><li>Exergames are a gimmick </li></ul></ul><ul><li>There are also many generalized arguments that virtual anything is inherently less worthy than “the real thing” </li></ul><ul><li>Ideal vs. harm reduction </li></ul>
  41. 41. Motivation and social ritual <ul><li>“ 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.” </li></ul><ul><li>Ian Bogost, serious games scholar </li></ul>
  42. 42. Major take-home points <ul><li>For many people, exercise is aversive </li></ul><ul><li>The addition of gaming to exercise can make it less aversive </li></ul><ul><li>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 </li></ul>
  43. 43. Major take-home points <ul><li>Across the board, there is a need for more research </li></ul><ul><li>There is room for improvement in exergame development and implementation </li></ul><ul><ul><li>Find a way to integrate the compelling gameplay of regular games and the improved activity and interactivity of exergames </li></ul></ul>
  44. 44. Acknowledgements <ul><li>Ben Sawyer & Games for Health </li></ul><ul><li>Health Games Research, Robert Wood Johnson Foundation </li></ul><ul><li>Deborah Tate </li></ul><ul><li>Fellow “exergaming evangelists” </li></ul>
  45. 45. <ul><li>Elizabeth Lyons, MPH </li></ul><ul><li>Gillings School of Global Public Health </li></ul><ul><li>Lineberger Comprehensive Cancer Center </li></ul><ul><li>The University of North Carolina at Chapel Hill </li></ul><ul><li>[email_address] </li></ul>Contact information