Mobile exergaming in Type 2 Diabetes mellitus – innovative ways to overcome physical inactivity and increase exercise adherence

Background Type 2 diabetes has developed into a worldwide pandemic in recent years that is associated with vast comorbidity and mortality and has created an enormous financial strain on health care systems all around the globe. Physical inactivity is known to be one of the most important risk factors for the development of type 2 diabetes and responsible for much of the diabetes‐related comorbidity. An increase in regular physical activity is therefore an essential component of a successful type 2 diabetes treatment. However, despite the proven benefits of regular physical activity, the vast majority of patients with type 2 diabetes remain inactive – often due to low motivation and lack of physical activity enjoyment. A recent and promising approach to motivate sedentary individuals to be more physically active and sustainably adhere to regular physical activity is exergames. These games integrate physical activity and personal health information into a game or game‐like setting and thereby promote physical activity through playful and enjoyable challenges. Aims The aims of this Ph.D. project were: (1) to systematically review the current evidence for the effectiveness of exergaming in overweight and type 2 diabetes and (2) to evaluate the suitability of the Wii Fit Plus exergame to improve cardiorespiratory fitness in individuals with type 2 diabetes. The aim was further (3) to develop a behavior change technique‐based smartphone game that delivers individualized exercise and physical activity promotion with the intention to motivate inactive type 2 diabetes patients to become sustainably physically active and to plan a 24‐week randomized controlled trial evaluating the game’s effectiveness. In addition, it was aimed (4) to assess the accuracy of a commercial activity wristband and of iOS and Android smartphones to measure steps during various walking conditions as those devices were intended to be used to measure the primary outcome (steps per day) in the 24‐week randomized controlled trial. Finally, the aims were (5) to examine the effectiveness of the smartphone game to increase daily physical activity and improve glycemic control and aerobic capacity as well as (6) to evaluate the game’s suitability to increase the intrinsic physical activity motivation and elicit sustained improvements in physical activity adherence in inactive individuals with type 2 diabetes over a 24‐week period. Methods In this Ph.D. project, one systematic review and three studies were conducted. In the systematic review, electronic bibliographic databases (PubMed, Embase, Web of Science, OpenGrey, and the Cochrane Central Register of Controlled Trials) were searched up to March 2015. Randomized controlled trials and cross‐sectional studies published in English in peer‐reviewed journals were included. Included studies were required to have analyzed the effects of exergames on objectively measured intensity parameters of physical activity (oxygen uptake, energy expenditure, and heart rate) in overweight adults with and without type 2 diabetes. In study 1, data collected from a study conducted by Prof. Schmidt‐Trucksäss before the start of my Ph.D. was analyzed to evaluate the cardiorespiratory exertion (maximum and mean oxygen uptake) of 12 elderly individuals with type 2 diabetes during 10‐minute bouts of different Wii Fit Plus exercises. Oxygen uptake values were compared to the maximally reached values during a previously conducted cardiopulmonary exercise test on a treadmill. Correlations between oxygen uptake values reached during exergame activity and those reached during the all‐out exercise test were analyzed using Spearman’s rank correlation coefficient. Following this preparatory work and considering its results, I collaborated with an international team consisting of sports scientists, gamification researchers, professional game developers, and clinical professionals in developing an innovative smartphone game with the aim to encourage a healthier, more active lifestyle through gamified physical activity in inactive type 2 diabetes patients. To evaluate the effectiveness of the game to sustainably increase physical activity in the target group, I planned a 24‐week randomized controlled trial with daily physical activity (steps per day) as the primary outcome. To verify the validity of the devices used to measure the primary outcome (steps per day) in the 24‐week intervention study, I conducted a validation study in an additional investigation of this Ph.D. project. In the study, 20 participants were equipped with 3 iPhone SE smartphones (placed in pants pocket, shoulder bag, and backpack), 1 Samsung Galaxy S6 Edge (pants pocket), 1 Garmin Vivofit 2 wristband, and 2 ActiGraph wGTX+ devices (worn at wrist and hip) and instructed to walk for five minutes at four predefined walking speeds (1.6, 3.2, 4.8, and 6.0 km/h) and to complete an outdoor walking course. Video observation was used as gold standard. Validity was evaluated by comparing each device with the gold standard using mean absolute percentage errors. In the main study (ClinicalTrials.gov identifier NCT02657018) of this Ph.D. project, 36 inactive, overweight type 2 diabetes patients between 45 and 70 years of age were randomly assigned to either the intervention group or the control group. Participants in the intervention group received the self‐developed smartphone game, and participants in the control group were instructed to implement the recommendations from the baseline lifestyle counseling autonomously during the 24‐week intervention period. Before and after the intervention period, steps per day were objectively measured during six consecutive days. In addition, glycemic control (HbA1c) was measured by analysis of venous blood, and aerobic capacity (oxygen uptake at the first ventilatory threshold) was assessed during an all‐out exercise test on a bike ergometer. Intrinsic physical activity motivation was assessed with an abridged 12‐item version of the Intrinsic Motivation Inventory (IMI). In the intervention group, adherence to the game‐proposed physical activity recommendations during the intervention period was additionally assessed via the phonerecorded game usage data. Analyses of covariance with adjustment for the respective preintervention values were used to compare changes in outcome parameters (steps per day, HbA1c, oxygen uptake at the first ventilatory threshold, and IMI score) between the two groups. Correlations between game use (min) and change in steps per day as well as change in workload (W) at the first ventilatory threshold were analyzed using Spearman’s rank correlation coefficient, and a linear regression model was used to assess the relationship between total in‐game training (min) and change in IMI total score. Results Publication 1: Effects of Exergaming on Physical Activity in Overweight Individuals. [1] The systematic review showed that exergames are able to increase physical activity among overweight individuals. However, the magnitude of this increase as well as the intensity of the exergame‐related physical activity and consequently their suitability to offer a guidelineconcordant training is greatly dependent on the console and the game mode as well on the duration of play. The majority of the included studies were of poor or moderate methodological quality. No studies exist that objectively assess the effect of exergames on daily physical activity in type 2 diabetes, and the cross‐sectional nature of all included studies does not permit judgement on whether exergames are suitable to increase physical activity in the long term. A general lack of adequate individualization of the intensity and difficulty level was noted for all exergames, making most game modes unsuitable for an effective training and potentially unsafe for inactive individuals with chronic diseases and a likely reduced fitness level. Publication 2: Cardiorespiratory Exertion While Playing Video Game Exercises in Elderly Individuals With Type 2 Diabetes. [2] In elderly type 2 diabetes patients, carefully selected Wii Fit Plus exercises elicit peak values in oxygen uptake that correspond to 60% of the maximally reached values during an all‐out treadmill test. Mean values were just above 40% for all exercises and were thus in a range that corresponds to current exercise guidelines. A moderate‐to‐strong positive correlation between the peak oxygen uptake during exergame play and the maximal value reach during the exercise test was found, indicating that subjects with a higher fitness level were able to exercise at a higher intensity during exergame play than individuals with a lower fitness level. Publication 3: Mobile Exergaming for Health – Effects of a Serious Game Application for Smartphones on Physical Activity and Exercise Adherence in Type 2 Diabetes Mellitus – Study Protocol for a Randomized Controlled Trial. [3] The self‐developed and innovative game takes the proven motivational benefit of exergames into consideration and further extends them by integrating established behavior change techniques into an elaborate storyline. Shortcomings with regard to the suitability and effectiveness of the exercise regimen of current exergames are addressed by offering a fitness level‐adjusted training with an individualized rate of intensity progression that is based on the performance in established and in‐game‐conducted exercise tests. Publication 4: Validity of Activity Trackers, Smartphones, and Phone Applications to Measure Steps in Various Walking Conditions. [4] The Garmin Vivofit 2 and iPhone SE showed good accuracy for treadmill walking ≥3.2 km/h (<3% deviation from video recordings) and for free walking thus being suitable to measure steps at normal, fast, and even slow walking speeds. The Samsung Galaxy S6 Edge showed good accuracy (<3% deviation from video recordings) for treadmill walking ≥4.8 km/h and for free walking, demonstrating suitability to measure steps during normal and fast walking. The good validity of the iPhone SE was found independently of the phone’s position (pants pocket, backpack, shoulder bag), suggesting a broad versatility of the device for physical activity measurement in various settings. Publication 5: Publication 5 Behavior Change Technique‐based Smartphone Game Sustainably Increases Daily Physical Activity in Type 2 Diabetes Patients – A Randomized Controlled Trial. [5] In persistently inactive type 2 diabetes patients, a novel self‐developed smartphone game that follows a cognitive/behavioral approach and incorporates individualized exercise regimens and physical activity recommendations elicited significant and clinically meaningful increases in daily physical activity (+4,000 steps per day) over a 24‐week period, classifying the participants as sufficiently active post‐intervention (average of 9,782 steps per day). The increase in daily physical activity was accompanied by an increase in aerobic capacity with a significantly higher oxygen uptake and workload at the first ventilatory threshold. Total duration of in‐game training was positively correlated with the change in steps per day and the change in workload at the first ventilatory threshold. Glycemic control (HbA1c) did not change during the intervention period; however, as indicated by the significant adjusted difference in HbA1c of ‐0.9 percentage points in favor of the intervention group, there is reason to assume that regular use of the game supports the stabilization of glycemic control in medically well‐controlled patients. In the control group, none of the outcome parameters changed significantly during the intervention period. Publication 6: Effectiveness of a Behavior Change Technique‐based Smartphone Game to Improve Intrinsic Motivation and Physical Activity Adherence in Type 2 Diabetes Patients: A Randomized Controlled Trial. [6] The 24‐week randomized controlled trial further showed that participants in the intervention group significantly increased their IMI‐measured intrinsic physical activity motivation during the intervention period. Participants in the control group did not show any significant changes in their intrinsic physical activity motivation. The analysis of the usage data revealed that participants in the intervention group used the game for an average of 143.1 (SD 59.1) minutes of in‐game training per week, which underlines the game’s potential in motivating formerly inactive type 2 diabetes patients to meet and sustainably adhere to established physical activity recommendations. Conclusions A novel smartphone game that incorporates established motivational elements and personalized physical activity recommendations into an elaborate storyline elicits clinically relevant increases in daily physical activity and aerobic capacity and contributes to a medically well‐regulated glycemic control in persistently inactive type 2 diabetes patients. The game is therefore a suitable treatment option to motivate inactive individuals to increase daily physical activity that may be relevant for other inactive target groups with and without chronic diseases. Future research should further refine the game design as well as the motivational and physical activity‐related content to make it an even more comprehensive treatment tool for various target groups

Contribution of Exergaming Behaviour to Physical Activity: Toward Better Understanding the Role of Motivation

Physical activity (PA) is associated with numerous health benefits. Because PA patterns established early in life track into adulthood, it is important that children develop and sustain healthy PA habits. Current guidelines recommend that youth accumulate ≥ 60 minutes of moderate to vigorous intensity PA daily, but many youth do not attain this level. Evaluation of public health interventions that aim to promote PA provide little evidence of sustained positive effects over time. This could relate, at least in part, to interventions lacking a strong conceptual foundation and, in particular, to a lack of underpinnings that recognize the central role of motivation in PA. It is important that effective strategies to increase and sustain healthy PA levels in youth are identified. The Self-Determination Theory is used to explain why people adopt and maintain healthy PA behaviors and posits that sustained PA relates to natural or intrinsic tendencies or motivations to behave in healthy and effective ways. Positive PA experiences in school, at home and in community settings may foster an internal desire or motivation to sustain PA participation simply for its challenges or for enjoyment. Lack of sustained PA among youth could reflect a scarcity of enjoyable PA options that fit with the sophisticated technetronic expectations of youth today. PA interventions must “keep up with the times,” by acknowledging young peoples’ prevailing interests and by incorporating advancements in technology that heighten interest and motivation for PA. Exergaming, a type of non-sedentary videogame that requires players to be physically active in order to attain a series of incrementally challenging goals, is increasingly viewed as an enjoyable PA option among today’s technology-immersed youth. However, although critical to informing the design, implementation and sustainability of exergaming interventions, evidence on exergaming-related motivation, preferences, intentions and sustainability is lacking. Research in this domain is needed to ascertain whether exergaming interventions can help youth become and remain physically active, and which facets of exergaming hold the most promise in sustaining positive PA change. More specifically, using “gamified augmented reality” such as exergaming could help youth attain recommended PA levels and promote sustainable healthy behaviour, while at the same time contributing to enjoyment of PA. The three studies described in this thesis examine motivation and exergaming in-depth using SDT and its tenants as a theoretical guide and a common theme across studies. Thus, the role of motivation and intentions in exergaming behaviour and how they contribute to PA in the general population of youth is a key contribution of this dissertation. Study 1, a review of reviews on exergaming, provides background for the next two studies, each of which was conducted in population-based (as opposed to clinical or experimental) settings. Twenty-five reviews spanning 2009 to 2016 were retained, each of which incorporated between 5 and 100 articles. A positive relationship between exergaming and energy expenditure (EE) was well-documented, but whether exergaming increases PA or changes body composition was not established. There is however, evidence that exergaming (i.e., as a non-sedentary use of screens) is a healthy alternative to sedentary behaviour, that it improves cognitive function, that it is an interesting and enjoyable pastime in youth, that it shows promise as a PA option by adding variety and alternative PA forms in health and dietary interventions and finally that it is likely more health-promoting than traditional videogames because of higher EE and possibly improved physical fitness, body composition and cognitive health. However, more research and specifically, longitudinal studies are needed to assess whether exergaming can be sustained to obtain these benefits over time. Study 2 identified correlates of sustained exergaming. We reported that almost 50% of grade 9 students sustained exergaming for 2-3 years. Study results suggest that in non-clinical settings, exergaming may be a practical approach to help adolescents maintain PA during adolescence. Study 3 examined the psychometric properties of a new scale to assess reasons for exergaming (i.e., the Reasons to Exergame (RTEX) scale). This study also examined whether and how the scale relates to the timing, intensity and duration of past-month exergaming. RTEX items were developed in consultation with PA and exergaming experts and using key exergaming constructs, including PA, general interest in videogames and enjoyment of exergaming. RTEX was found to be a reliable and valid assessment of reasons to exergame. However, further studies should replicate these initial findings in larger, more diverse samples

Memory bites and games - environmental and mental elements affect brain health for elderly

This bachelor’s thesis is part of the Research and Development (R&D) project “Memory Bites and Games” at Lahti University of Applied Sciences. The aim of that project is to develop a new social game application which can be web-based or/and mobile based.  The function of the application is helping to train and maintain brain health, to identify early signs of cognitive malfunction or impairment.    The purpose: This literature review is to find out what are the mental, environmental elements which have affected on the development of brain diseases and how these aspects should be taken into account in preventing them. The method: Data was collected through systematic database search. The study consisted of international studies and articles were selected by peer reviewed. A qualitative literature review was used as the research method, inductive content analysis was used for data analysis. The findings: From environmental perspective, there are six factors containing lifestyle, residency, social networks, games, radiation and pollution were found to affect elder adult’s brain health. From mental perspective, five factors including lifestyle, social status, medical intervention, disease and art were found to dedicate to the quality of brain health of elderly people. In conclusion: The literature review is involved in environmental and mental elements which effect brain health of elderly people, the follow-up study about physical and cognitive elements effecting brain health is recommended in future.Tämä opinnäytetyö on osa tutkimus ja kehitys projektia " Muistin Puraisut ja Pelit " Lahden ammattikorkeakoulussa. Kyseisen projektin tavoitteena on kehittää uusi sosiaalinen pelisovellus joka voi olla selain ja/tai kännykkä pohjainen sovellus. Ohjelman tarkoituksena on auttaa harjoittelemaan, ylläpitämänä aivojen kuntoa ja tunnistamaan varhaisia merkkejä kognitiivisestä heikentymisestä tai vajaatoiminnasta. Tarkoitus: Tämä kirjallisuuskatsaus selvittää mitkä ovat psyykkisiä ja ympäristöllisiä tekijöitä, jotka vaikuttavat aivosairauksien kehittymiseen ja mitenkä nämä pitäisi huomioida niiden ehkäisemiseksi. Menetelmä: Tiedot kerättiin systemaattisesti etsimällä tietokannasta. Tutkimus sisälti kansainvälisiä tutkimuksia ja artikkeleita, jotka valittiin Melinda, Masto-finna, Academic search elite (EBSCO), Medic ja PubMed tietokannoista. Kuvaistavaa kirjallisuuskatsomusta käytettiin aineiston lähteenä ja määrällistä sisällön analyysia käytettiin analysoinnissa. Havainnot: Ympäristöllisesti on kuusi tekijää. Elämäntapa, asuinpaikka, sosiaaliset verkostot, pelit, säteily ja saaste havaittiin vaikuttavan vanhuksen aivojen terveyteen. Psyykkisiä tekijöitä oli viisi tekijää. elämäntavat, sosiaalinen asema, lääkinnällinen apu, taudit ja taide havaittiin vaikuttavan vanhusten aivoterveyteen. Yhteenveto: Kirjallisuuskatsauksessa liittyvät ympäristöllisiin ja psyykkisiin tekijöihin jotka vaikuttavat vanhusten aivojen terveyteen. Jatkotutkimus fyysisestä ja kognitiiviststa tekijöistä, jotka vaikuttavat aivojen terveyteen on suositeltavaa tulevaisuudessa.        

People, Place, and Pokémon: How Location-Based Games Enhance Well-Being

Social connections and relationships are a critical component of overall human flourishing and well-being. Over time, the structure of physical spaces and how we engage with each other has changed. This paper explores how social ties impact well-being and how advances in technology have shifted people’s conception of public and private spaces and how we interact with each other in them It also examines both the positive and negative effects of video games on social connections and well-being with a focus on location-based games like Pokémon Go which blur the line between physical and virtual reality. It concludes with suggestions for how the disconnected disciplines of new media, place, and positive psychology can come together to explore the potential of location-based games to improve human well-being at scale

Game Changer: Investing in Digital Play to Advance Children's Learning and Health

Based on a literature review and interviews with digital learning experts, explores how digital games can foster skills and knowledge for better academic performance and health. Makes recommendations for government research, partnerships, and media

Occupational Therapy for Adolescents: A Nature-Based Interventions Approach

PURPOSE: The first purpose of this scholarly project was to address current trends in relation to adolescents’ increased reliance on technology, decreased exposure to natural settings, and utilization of nature in adolescent occupational therapy care. The second purpose of the scholarly project was to provide occupational therapists with an interventions guide for nature-based activities to be used with the adolescent population. METHOD: A literature review was conducted on adolescents, technology and nature using PubMed, CINAHL, AJOT, OT Search, MESH, Google Scholar, and textbooks. RESULTS: A review of the literature indicated that the target population, Generation Z, had grown up with increased exposure and availability to technology. Adolescents who engaged in online activities and video games were observed to have increased negative psychosocial and physical effects. With an increased reliance and dependence on technology a decrease in engagement in nature-based activities was observed. Nature has been found to have many positive physical and psychosocial effects. Therefore, occupational therapists can use nature as a medium to benefit adolescent clients physically and psychosocially. CONCLUSION: Due to the decreased engagement in nature-based activities within Generation Z and the positive psychosocial and physical changes generated through nature-based activities, a manual was developed comprised of nature-based occupational therapy interventions. These interventions were designed for skilled occupational therapists to implement within adolescent group or individual therapy settings using the Person Environment Occupation Model to guide the intervention process. Many positive aspects of nature were incorporated into the therapeutic interventions and were an influential force in the development of this manual. The benefits of nature include but are not limited to: relaxation, restoration, and increased awareness to sensory stimulation and self. Therefore, the nature-based manual is a useful tool for occupational therapists to address these areas of concern

Sustainable Technology and Elderly Life

The coming years will see an exponential increase in the proportion of elderly people in our society. This accelerated growth brings with it major challenges in relation to the sustainability of the system. There are different aspects where these changes will have a special incidence: health systems and their monitoring; the development of a framework in which the elderly can develop their daily lives satisfactorily; and in the design of intelligent cities adapted to the future sociodemographic profile. The discussion of the challenges faced, together with the current technological evolution, can show possible ways of meeting the challenges. There are different aspects where these changes will have a special incidence: health systems and their monitoring; the development of a framework in which the elderly can develop their daily lives satisfactorily; and in the design of intelligent cities adapted to the future sociodemographic profile. This special issue discusses various ways in which sustainable technologies can be applied to improve the lives of the elderly. Six articles on the subject are featured in this volume. From a systematic review of the literature to the development of gamification and health improvement projects. The articles present suggestive proposals for the improvement of the lives of the elderly. The volume is a resource of interest for the scientific community, since it shows different research gaps in the current state of the art. But it is also a document that can help social policy makers and people working in this domain to planning successful projects