Save the Nobbies!

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Game-based learning and data collection can be used to track behavioral risk factors for obesity in children. By using smartphone GPS technology, behaviors can be tracked by location.

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Save the Nobbies!

  1. 1. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone GameSummary StatementWe propose an avatar-based smartphone game that can be used to assess obesity behavioralrisk factors in children and can be deployed in the healthcare or community setting.Prologue for Avatar A long time ago, before cars and skyscrapers, the land of lakes was filled with small elf-like creatures known as The Nobbies. The Nobbies lived in trees and spent their days carving fruits and vegetables for the woodland creatures. You may have never heard of The Nobbies before, but there are three things about them you may need to know: (1) The Nobbies look a lot like you and me, but their eyes are huge, their ears are pointy and they are barely bigger than your pinky finger, (2) they require healthy behaviors to survive, and, (3) they need your help before they disappear forever.Scientific BackgroundIn 2007, the American Academy of Pediatrics (AAP) published recommendations thatpediatricians assess all children for behavioral risk factors that have been associated withchildhood obesity and unhealthy weight gain into adulthood.1 These risk factors aresummarized below: 3 Avoid skipping meals, eat 3 meals a day (breakfast, lunch, dinner) and up to 3 snacks a day. Eat family meals prepared at home. 2 No more than 2 hours of screen time per day and no TV in the bedroom. 1 At least 1 hour of moderate to vigorous physical activity 0 Zero sugar-sweetened beverages. Drink un-flavored milk or water.In 2011, following the publication of the 2007 AAP Recommendations, the USDA (United StatesDepartment of Agriculture) published the dietary guidelines of ChooseMyPlate.gov,recommending that half of the diet should consist of fruits or vegetables.<sup>2</sup>Combining the AAP and USDA recommendations could theoretically create a campaign suchas the following: For a healthy weight…3-2-1-0 and half a plate!Childhood rates of overweight and obesity remain high.3 Few studies exist examining howmany pediatricians in the U.S. are screening for the behavioral risk factors related to obesity orhow many providers are using that information to provide customized anticipatory guidance inregards to nutrition, physical activity, and sedentary behavior.4 Often, studies rely on self-report,5–7 which can misestimate screening practices.8 Previous studies have shown that earlyidentification of risk is the key to providing adequate and timely behavioral therapy.9 Treatmentefficacy is highest under the age of 10 and success rates of weight and behavioral change dropprecipitously as children approach puberty.10 Children under the age of ten are developmentallyvery receptive to messages delivered through stories and cartoon characters. Therefore, thismay prove an effective strategy for assessing health information at this developmental age.11,12   1  
  2. 2. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone Game Software DescriptionWe propose an avatar-based game aimed at children under the age of 10 and their parents, tobe launched on smartphone platforms using adorable cartoon characters known as TheNobbies. The Nobbies are loosely based upon The Little People of Wisconsin Native AmericanFolklore and were created and tested for likability in pilot studies by Dr. Tracy Flood MD, PhD ofPlayingDoctor, LLC (unpublished data). These avatars simultaneously engage users (childrenand parent dyads) and collect data on key obesity behavioral risk factors by creating an avatarenvironment and then conducting a series of five mini-games that can be completed by childrenalongside of parents. The smartphone-based platform was chosen because 1 in every 2parents owns a smartphone device and users span all ethnicities and sociodemographics.13The design of the software includes orientation and five mini-games. During orientation, userschoose an avatar and design an environment. Players can then give their avatar health pointsvia mini-games. Mini-games are designed to be brief and fun assessments (lasting less than 2minutes each) of the child’s obesity behavioral risk factors. After the completion of a mini-game,users receive immediate feedback from the avatar and a conglomerate score of the avatar’s“health and happiness”. Avatar health is able to change over time, as mini-games are repeatedand behavioral risk factors change. These scores are compared to the scores and trends ofother users in the region.OrientationIt is important to give users (i.e. the child) a strong sense of avatar in order to create a greatersense of immersion within the game space. Upon opening the game, users create a Nobbiethat resembles their own likeness using a system similar to that seen in the Wii Mii system.After the child has created their own avatar, they are prompted to create an immediate family,reflective of their own family, within the Nobbieworld. During this initial process, backgroundinformation can also be collected on covariates such as the child’s age, sex, and self- or parent-reported height and weight, as well as placing a “pin” on the GPS coordinates of their home.Once the user has been prompted to design an avatar, which will serve as their personalanalog within the game environment, they are encouraged to make a few choices that willinform the basic layout of the living quarters of their Nobbie. While Nobbies live in trees ratherthan houses and their “backyards” are on the limbs of trees, users will form the imaginary worldof their avatar to be modeled after their own home. Users populate the indoor and outdoor livingspace with furniture, toys, and electronic devices. This step provides background data on thenumber of electronic devices (i.e. television, gaming system) and their placement, such as a TVplaced in the child’s bedroom. It also provides information on their immediate recreationalspace (i.e. backyards, playgrounds, adjacent parks).The final step of orientation is to stock the root cellar of the Nobbie with a few select items seenin the user’s kitchen. This includes drinks (e.g. milk, 100% juice, sugar-sweetened beverages)and fruit and vegetable representations that include commonly consumed, non-name brandrepresentations of fresh, frozen, canned, and dried fruits and vegetables. This provides data onhome availability of foods that are related to the AAP recommendations.   2  
  3. 3. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone GameAfter completing orientation, users have created an avatar, a family, and a home environmentreflective of their own lives. Now, upon opening the application, users shall see the avatar“living” in the space. The space can be updated by users at any time. The homescreen showingthe avatar also displays stats on Health and Happiness as well as highlighted navigationbuttons directing users to the mini-games. Mini-games are ways in which players can collectpoints to increase their avatar’s health and happiness.Mini-GamesMini-Games that are age-appropriate are used to directly assess five behavioral risk factorsoutlined by the campaign: For a healthy weight…3-2-1-0 and half a plate! Games are visualrepresentations of previously validated questionnaire measures. Players receive points forscores of healthful behavior and those points contribute to the avatars Health and Happiness.On their first entry, users are given no feedback as to what behaviors generate maximal pointsso as not to bias the initial responses. After the user has completed all five games once, abutton is made available to suggest ways to improve the avatar’s health and happiness score.Younger children need to complete mini-games accompanied by parents, preferably at the endof the day to recall the events of the day. The game is programmed to automatically time-stampmini-game scores with a time, date, and day to give longitudinal data and the ability todiscriminate between weekdays and weekends. Making the Games Age AppropriateAge-data from the orientation input automatically initiates one of two different gaming “styles” inorder to create a game experience that is age-appropriate. One play style appeals more to the"twitch" style of game, most often preferred by older children, while the second will appeal tothe "casual" style of game, which is appropriate for younger players. Users can also choose tochange this manually in Game Settings if they wish. Regardless of gaming “style”, datacollected will be same and scores will not be lost. Mini-Game “Meals”3 Avoid skipping meals, eat 3 meals a day (breakfast, lunch, dinner) and up to 3 snacks a day.Eat family meals prepared at home.In this mini-game, the avatar asks users recount the meals of the day (with the help of theirparents). Children are asked by the avatar when they ate their first meal of the day (i.e. did theyeat breakfast), where they ate lunch, where they ate (or will eat) dinner, was it at home or at arestaurant, and if they had snacks. As they answer, the avatar draws a diagram of the dayoutlining their responses. The diagram will look similar to a sticker-chart with color-codes andicons.Responses are scored and users receive points for eating breakfast, regular meals, and mealsat home.   3  
  4. 4. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone Game Mini-Game “Screentime”2 No more than 2 hours of screen time per day and no TV in the bedroom.This mini-game assesses the number of hours a child watches TV in a day. The avatar asks thequestion: What did you do today? Did you watch TV? If the child answers yes, they areprompted to answer on a sliding scale including 30 minutes, 1 hour, 2 hours, and 3 or morehours. As the child answers, the avatar points along sliding scale along a measuring tape toassess the child’s response.Points are given for not watching TV and any number less than 2 hours a day.BONUS POINT: Whether or not there is a TV in the bedroom is assessed during orientationwhen the user creates the avatar’s home environment. If there is no TV in the bedroom, usersreceive a bonus point. Mini-Game “Physical Activity”1 At least 1 hour of moderate to vigorous physical activityThis mini-game uses a similar structure to the one outlined for “screentime”, but assessesphysical activity and active play. The avatar asks: What did you do today? Did you play? If thechild answers yes, they are prompted to answer on a sliding scale ranging from 30 minutes, to3 or more hours.Points are given for 60 or more minutes of physical activity. Mini-Game “Sugar-Sweetened Beverages”0 Zero sugar-sweetened beverages. Drink un-flavored milk or water.During this game, users are asked to “feed” the avatar what they themselves had to drink thatday. Players “drag” the drinks over to the avatar who makes drinking noises. Options includepictures of what is currently in the avatar’s root cellar as well as soda, sports drinks, skim milk,whole milk, chocolate milk, strawberry milk, fruit cocktail, 100% fruit juice, and water. Playerscan give avatars multiple drinks.Points are given for feeding the avatar milk and water. Mini-Game “Half a plate”Half a plate of fruits and vegetables.During this mini-game, users are asked a single question by the avatar: Today, how many fruitand vegetables did you eat? Players are shown four plates to choose from containing differing   4  
  5. 5. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone Gameamounts fruits and vegetables: A little (10% of the plate), a medium amount (25%), a lot (50%),or mostly fruits and vegetables (90%).Users get points for choosing “a lot” or “mostly”. Health and Happiness ScoresAfter the completion of each mini-game, players receive points that affect the health of theiravatar in the game-environment. The avatar’s “mood” is reflected by the number of points theyhave. If they have few points, the avatar looks sickly, sad, and grey. If they have a high numberof points, they are happy, spritely, and colorful. Each mini-game can be played only once dailyas games assess the events of that day. The next day, users have the opportunity to improvethe health of their avatar. Users can see trends of their own scores as well as the scores ofothers by region. Thus neighborhoods are in competition for having the healthiest Nobbies. Inregards to confidentiality, user health scores and precise GPS locations are all de-identified andremain confidential, but users may invite others with the game to see their changing scores.Additional SoftwarePhysicians, community workers, and other allied health professionals can be invited to seescores and are provided software that gives a “dashboard” of the itemized scores of individualusers within their patient population. Healthcare providers can also track patient and regionaldata over time by and may be granted to ability to input health information into individualaccounts (either manually or automatically via electronic medical records) in order to updatemeasures of height and weight for the purpose of tracking body mass index (BMI) percentilecharts. Healthcare providers can then see how their region and patient population compares toothers.   5  
  6. 6. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone GameData Generation DescriptionUsing an avatar-based gaming experience allows for data collection of both novel andpreviously-used measures of obesity behavior risk factors. Table 1 outlines the data measuresthat are collected during the gaming experience. While longitudinal data is available from users,it is likely that the most accurate assessment will be the initial one that occurs prior to the userreceiving any avatar feedback or points. More data is needed to assess the reliability andvalidity of using avatar-environments to reflect real-world environments and whether changes inbehavior are valid and reliable with real behaviors. Table 1. Variables Collected During Gamification AAP Recommendations Gamification Measures Related (mapped geographically by GPS coordinates) Population Measures Covariates Age, sex Height, weight, calculated BMI percentile Parental height, weight, and BMI Location of primary home 3 Avoid skipping meals, eat 3 Frequency of skipping breakfast AdHealth meals a day (breakfast, lunch, Frequency of skipping lunch or dinner Survey dinner) and up to 3 snacks a Snacking frequency day. Eat family meals prepared Frequency of meals eaten outside of the home at home. Frequency of family meals 2 No more than 2 hours of Daily television usage IPAQ14 screen time per day and no TV in TV in bedroom (via avatar environment) the bedroom. 1 At least 1 hour of moderate to Daily physical activity IPAQ14 vigorous physical activity 0 Zero sugar-sweetened Sugar-sweetened beverage consumption FFQ15 beverages. Drink un-flavored Milk and water consumption milk or water. “Other” beverage consumption Half a plate of fruits and Proportion of fruits and vegetables eaten unknown vegetables. AAP: American Academy of Pediatrics Adhealth: Adolescent Health Survey FFQ: Food Frequency Questionnaire BMI: Body mass index IPAQ: Physical Activity Questionnaire TV: Television   6  
  7. 7. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone Game Community-Deployment ApproachDeployment will first occur in the state of Wisconsin. There is a robust network of childhoodobesity coalitions within the state. Coalitions are present in 70 of the 72 Wisconsin communitiesand include faculty and staff of University of Wisconsin Extension, community-basedorganizations, childcare providers, educators in schools, government employees, and alliedhealth professionals (e.g. nurses, dieticians, physical therapists, physicians). Childhood obesitycoalitions in the state of Wisconsin are supported by the Wisconsin Community TransformationGrant. The smartphone software will be available as a free download in respective onlinestores. Coalitions will aid with the initial dissemination of the “dashboard” software within thehealthcare setting.The Aligning Forces dataset includes 19 Health Systems in the state of Wisconsin. In order toidentify individual practitioners within each system, databases housed at the Wisconsin MedicalSociety (which contains information on approximately 80% of all physicians statewide) will beused to identify physicians in family medicine and pediatrics. If a practice adopts a tool, they willbe given handouts for patients with information on how to download the app and a QR code willbe on the handout so patients can scan it and be directed immediately to the download.While the primary focus of the game is to provide healthcare providers with the behavioralassessment recommended by the AAP, parents may also wish to use the app even if it has notbeen recommended to them by an allied health professional. Childhood obesity coalitions mayaid with dissemination to schools and childcare settings. Parents may also be reached viaonline advertising and the building of a social network by integrating it with networking platformslike FaceBook, Google+ and Twitter. Users will be able to share their scores on these platformsand track their improvement, if they desire. Peer feedback will in turn drive the motivation ofthose peers with the game to do the same.Future DirectionsAs technology is validated and made more readily available and affordable, self-assessmentscan be replaced with direct assessments such as an accelerometer (e.g. Zamzee) or shoe-based device (e.g. Nike+) to assess when a child is active during the day. There may also be adevice that is attachable to the TV to measure number of hours the television was on. Scoresfrom those measurements can be used to get points and, therefore, directly improve the healthof the avatar.Overall, we recognize that more studies are needed to assess the validity and reliability ofgame-based measures and game-measured behavioral change. Building the games is avaluable first step.Thank you so much for the opportunity.Tracy Flood, MD, PhD, PlayingDoctor, LLCMichael Diedrick, Byte Studios, Inc.   7  
  8. 8. Save The Nobbies! Mapping Obesity Behavioral Risk Factors as Children Play an Avatar-based Smartphone Game References1. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of childand adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl :S164–92. Available at:http://www.ncbi.nlm.nih.gov/pubmed/18055651. Accessed March 20, 2012.2. Agriculture USD of. ChooseMyPlate.gov. 2012:http://www.choosemyplate.gov.3. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among USchildren and adolescents, 1999-2010. JAMA : the journal of the American Medical Association. 2012;307(5):483–90. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22253364. Accessed October 29, 2012.4. Eneli IU, Keast DR, Rappley MD, Camargo CA. Adequacy of two ambulatory care surveillance systems fortracking childhood obesity practice patterns. Public health. 2008;122(7):700–7. Available at:http://www.ncbi.nlm.nih.gov/pubmed/18313702. Accessed January 31, 2013.5. Story MT, Neumark-Stzainer DR, Sherwood NE, et al. Management of child and adolescent obesity: attitudes,barriers, skills, and training needs among health care professionals. Pediatrics. 2002;110(1 Pt 2):210–4. Availableat: http://www.ncbi.nlm.nih.gov/pubmed/12093997. Accessed February 22, 2013.6. Dunlop AL, Leroy Z, Trowbridge FL, Kibbe DL. Improving providers’ assessment and management of childhoodoverweight: results of an intervention. Ambulatory pediatrics : the official journal of the Ambulatory PediatricAssociation. 7(6):453–7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17996840. Accessed January 31, 2013.7. Jonides L, Buschbacher V, Barlow SE. Management of child and adolescent obesity: psychological, emotional,and behavioral assessment. Pediatrics. 2002;110(1 Pt 2):215–21. Available at:http://www.ncbi.nlm.nih.gov/pubmed/12093998. Accessed January 31, 2013.8. Rhodes ET, Finkelstein JA, Marshall R, et al. Screening for type 2 diabetes mellitus in children and adolescents:attitudes, barriers, and practices among pediatric clinicians. Ambulatory pediatrics : the official journal of theAmbulatory Pediatric Association. 6(2):110–4. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16530149.Accessed February 22, 2013.9. O’Brien SH, Holubkov R, Reis EC. Identification, evaluation, and management of obesity in an academicprimary care center. Pediatrics. 2004;114(2):e154–9. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15286251.Accessed January 31, 2013.10. Danielsson P, Kowalski J, Ekblom O, Marcus C. Response of Severely Obese Children and Adolescents toBehavioral Treatment. Archives of pediatrics & adolescent medicine. 2012;166(12):1–6. Available at:http://www.ncbi.nlm.nih.gov/pubmed/23108856. Accessed January 29, 2013.11. Couse L, Chen D. A tablet computer for young children? Exploring its viability for early childhood education.Journal of Research on Technology in Education. 2010;43(1):75–98.12. Verenikina I, Kervin L. IPads digital play and preschoolers. He Kupu The Word. 2011;5(2):144.13. Neilson Wire. State of the Appnation – A Year of Change and Growth in U.S. Smartphones.2012:http://blog.nielsen.com/nielsenwire/online_mobile/.14. Booth M. Assessment of physical activity: an international perspective. Research quarterly for exercise andsport. 2000;71(2 Suppl):S114–20. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10925833. AccessedFebruary 23, 2013.15. Willett WC, Reynolds RD, Cottrell-Hoehner S, Sampson L, Browne ML. Validation of a semi-quantitative foodfrequency questionnaire: comparison with a 1-year diet record. Journal of the American Dietetic Association.1987;87(1):43–7. Available at: http://www.ncbi.nlm.nih.gov/pubmed/3794132. Accessed February 23, 2013.   8  

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