Twelve Weeks of Dance Exergaming in Overweight and Obese Adolescent

ARTICLE IN PRESS JSHS344_proof ■ 6 December 2016 ■ 1/8

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1bs_bs_query Q2 Original article

2bs_bs_query

3bs_bs_query Twelve weeks of dance exergaming in overweight and obese adolescent

4bs_bs_query

5bs_bs_query girls: Transfer effects on physical activity, screen time, and self-efﬁcacy

6bs_bs_query Q1 7bs_bs_query Amanda E. Staiano *, Robbie A. Beyl, Daniel S. Hsia, Peter T. Katzmarzyk, Robert L. Newton Jr

8bs_bs_query Pennington Biomedical Research Center, Baton Rouge, LA 70808, USA

9bs_bs_query Received 29 June 2016; revised 3 August 2016; accepted 5 September 2016

10bs_bs_query Available online

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12bs_bs_query Background: Given the low levels of physical activity (PA) among adolescent girls in the US, there is a need to identify tools to motivate increased

13bs_bs_query PA. Although there is limited evidence that adolescents transfer PA from one context to another, exergames (i.e., video games that require gross

14bs_bs_query motor activity) may act as a gateway to promote overall PA outside game play. The purpose of this study was to examine potential transfer effects

15bs_bs_query (i.e., inﬂuences on external behaviors and psychological constructs) of a 12-week exergaming intervention on adolescent girls’ PA, screen time,

16bs_bs_query and self-efﬁcacy toward PA, as well as the intrinsic motivation of exergaming. ≥ 17bs_bs_query Methods: Participants were 37 girls aged 14–18 years (65% African American, 35% white) who were overweight or obese (body mass index 85th

18bs_bs_query percentile) and were recruited from the community via school, physicians, news media, and social media sites. Adolescents were randomly

19bs_bs_query assigned to a 12-week group exergaming intervention (36 60-min sessions of group-based dance exergaming in a research laboratory using Kinect

20bs_bs_query for Xbox 360; Microsoft Corporation, Redmond, WA, USA) or to a no-treatment control group. Outcome variables included objectively measured

21bs_bs_query PA (total) and self-reported leisure-time PA (discretionary time only) 1 week before vs. 1 week after the intervention; selected type and intensity

22bs_bs_query of PA when placed in a gym setting for 30 min (“cardio free choice”); screen time; self-efﬁcacy toward PA; and intrinsic motivation toward

23bs_bs_query exergaming.

24bs_bs_query Results: Attendance at the exergaming sessions was high (80%). Compared with the control group, the intervention group self-reported an = = 25bs_bs_query increase in PA (p 0.035) and fewer hours watching television or videos (p 0.01) after the intervention, but there were no signiﬁcant differences

26bs_bs_query in sedentary, light, moderate, or vigorous PA measured by accelerometry. The intervention group signiﬁcantly improved self-efﬁcacy toward PA = 27bs_bs_query (p 0.028). The intervention group highly rated intrinsic motivation toward exergaming.

28bs_bs_query Conclusion: Exergaming for 12 weeks was associated with positive impacts on adolescent girls’ self-reported PA, television viewing, self-efﬁcacy,

29bs_bs_query and intrinsic motivation. Future research is warranted to leverage exergames as an enjoyable, motivating, and effective PA tool.

31bs_bs_query license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

32bs_bs_query

33bs_bs_query Keywords: Active video games; Leisure activity; Motivation; Screen time; Self-efﬁcacy; Television

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35bs_bs_query 1. Introduction Leveraging adolescents’ interest in video games is an inno- 50bs_bs_query

36bs_bs_query vative approach to combating pediatric obesity and physical 51bs_bs_query

37bs_bs_query The average American adolescent spends 62 h each week in inactivity, but motivation to be physically active remains a 52bs_bs_query Q3 1 38bs_bs_query front of a screen. In contrast, only 8% of 12-to15-year-olds 5 major barrier. New-generation video games (i.e., exergames) 53bs_bs_query

39bs_bs_query meet national physical activity (PA) guidelines of 1 h of daily 2 require whole body movement, thereby yielding light to mod- 54bs_bs_query 40bs_bs_query moderate-to-vigorous PA, with adolescent girls having particu- erate levels of energy expenditure and elevated heart rate, which 55bs_bs_query Q4 3 41bs_bs_query larly low levels of PA. Insufﬁcient PA is a major contributor to 3 could potentially contribute to weight loss and cardiovascular 56bs_bs_query 42bs_bs_query obesity, which affects 18% of adolescent girls in the USA and 6 health beneﬁts. Exergames, or active video games, are popular 57bs_bs_query

43bs_bs_query 61% of obese adolescents with at least 1 risk factor for cardio- 4 among youth: in a study of 1241 adolescents (mean age 58bs_bs_query 44bs_bs_query vascular disease. ± 16.80 0.05 years), 24% reported playing exergames with an 59bs_bs_query 7 45bs_bs_query average play time of 50 min per session 2 days per week. It is 60bs_bs_query

important that systematic reviews and meta-analyses indicate 61bs_bs_query

46bs_bs_query

that exergaming can reach criteria of moderate- to vigorous- 62bs_bs_query 47bs_bs_query Peer review under responsibility of Shanghai University of Sport. 8–10 intensity activity. Whole body movement while exergaming, 63bs_bs_query 48bs_bs_query * Corresponding author.

49bs_bs_query E-mail address: [email protected] (A.E. Staiano) such as during dance exergames, can reach levels of moderate 64bs_bs_query

http://dx.doi.org/10.1016/j.jshs.2016.11.005 2095-2546/© 2016 Production and hosting by Elsevier B.V. on behalf of Shanghai University of Sport. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: Amanda E. Staiano, Robbie A. Beyl, Daniel S. Hsia, Peter T. Katzmarzyk, Robert L. Newton Jr, Twelve weeks of dance exergaming in overweight and obese adolescent girls: Transfer effects on physical activity, screen time, and self-efﬁcacy, Journal of Sport and Health Science (2016), doi: 10.1016/j.jshs.2016.11.005 ARTICLE IN PRESS JSHS344_proof ■ 6 December 2016 ■ 2/8

2 A.E. Staiano et al.

9,10 1 65bs_bs_query intensity, and exergaming that involves lower body move- complete data for the accelerometry and were included in the 123bs_bs_query

66bs_bs_query ment produces higher energy expenditure than exergaming that present analysis. 124bs_bs_query 8 125bs_bs_query 67bs_bs_query uses just the arms.

2.2. Procedures 126bs_bs_query 68bs_bs_query Despite the extensive evidence that exergaming can reach 127bs_bs_query

69bs_bs_query levels of moderate-intensity PA, it is not known whether being These data were collected as secondary outcomes in a trial 128bs_bs_query

70bs_bs_query physically activity by means of an exergame may inﬂuence an designed to examine the effects of exergaming on body com- 129bs_bs_query

71bs_bs_query adolescent to become more physically activity outside game position and cardiovascular risk factors; a complete description 130bs_bs_query 20 72bs_bs_query play (i.e., “transfer effects”). There is limited evidence that of the intervention and study methods is published elsewhere. 131bs_bs_query

73bs_bs_query adolescents transfer PA from one context to another. Prior Study procedures were approved by the Pennington Biomedical 132bs_bs_query

74bs_bs_query data indicate that obese children aged 10–17 years experienced Research Center Institutional Review Board. Parents and ado- 133bs_bs_query

75bs_bs_query signiﬁcantly increased self-reported PA and decreased screen lescents provided written consent and assent, respectively. Par- 134bs_bs_query

76bs_bs_query time after a 12-week exercise trial involving 2 supervised ticipants completed a baseline clinic visit. At the end of the 135bs_bs_query 11 77bs_bs_query and 1 home-based 45-to60-min exercise sessions per week. clinic visit, participants were randomly assigned to the inter- 136bs_bs_query

78bs_bs_query However, these exercises involved traditional gym equipment, vention or a no-treatment control group. 137bs_bs_query

79bs_bs_query including aerobic and resistance exercises. One randomized In the intervention condition, participants attended 60-min 138bs_bs_query

80bs_bs_query within-subjects trial in 26 male adolescents found higher levels group exergaming sessions 3 times per week for 12 weeks, 139bs_bs_query

81bs_bs_query of energy expenditure measured by indirect calorimetry during whereas the control group was instructed to maintain current 140bs_bs_query

82bs_bs_query a1-h exergaming session on the Kinect for Xbox 360 vs. a1-h level of activity for 12 weeks. The intervention occurred outside 141bs_bs_query

83bs_bs_query seated video game, yet there were no signiﬁcant condition dif- school time in a dance studio at Pennington Biomedical, where 142bs_bs_query

84bs_bs_query ferences measured by accelerometry on boys’ PA levels over 3 3 to 4 exergaming stations were available, each equipped with 143bs_bs_query 12 85bs_bs_query subsequent days. The potential inﬂuence of a longer duration the Kinect for Xbox 360 gaming console, a television, and the 144bs_bs_query

86bs_bs_query of exergaming on adolescents’ activity choices, screen behav- following exergames: Just Dance(Just Dance 3, Just Dance 4, 145bs_bs_query

87bs_bs_query iors, or habitual PA is not known. Just Dance 2014, and Just Dance Greatest Hits; Ubisoft, 146bs_bs_query

88bs_bs_query In addition to limited evidence of behavioral transfer from Rennes, France) and Dance Central (Dance Central 2 and 147bs_bs_query

89bs_bs_query exergaming, there is also limited evidence of psychological trans- Dance Central 3; Microsoft Game Studios, Redmond, WA, 148bs_bs_query

90bs_bs_query fer of exergaming to improve adolescents’ psychosocial health. USA). Exergames focused on dancing were selected to encour- 149bs_bs_query 13 14 91bs_bs_query Specifically, both self-efficacy and intrinsic motivation have age whole-body movement and moderate-intensity energy 150bs_bs_query 9,10 92bs_bs_query been identified as targeted mediators to promote adolescent girls’ expenditure. Three “gaming coaches” were present to super- 151bs_bs_query

93bs_bs_query PA. Exergaming, particularly in a group setting, may increase vise the sessions, and 2–12 participants were present at any 152bs_bs_query 15 16 94bs_bs_query self-efﬁcacy related to PA and exergaming, as well as intrinsic given time. Participants self-selected the games, songs, dance 153bs_bs_query 17 18 95bs_bs_query motivation. According to social cognitive theory, behavioral mode, intensity level, and dance partner. All participants com- 154bs_bs_query

96bs_bs_query change results from links among behaviors (e.g., exergame play), pleted ﬁnal measurements in week 13, which was 1 week after 155bs_bs_query

97bs_bs_query the environment (e.g., social interaction), and psychosocial vari- the intervention ended. 156bs_bs_query 6 98bs_bs_query ables (e.g., self-efﬁcacy). Group cohesion in digital game play 157bs_bs_query

2.3. Measures 158bs_bs_query 99bs_bs_query may appeal to obese youth, who are less likely to engage in

19 159bs_bs_query 100bs_bs_query traditional sports owing to weight criticism. Group exergame 2.3.1. Anthropometry 160bs_bs_query

101bs_bs_query play may, therefore, improve the poor psychosocial health often Height and weight were measured using standardized clinic 161bs_bs_query

102bs_bs_query experienced by overweight youth and thereby facilitate increased 162bs_bs_query 6 procedures. 103bs_bs_query total PA levels. 163bs_bs_query

104bs_bs_query The aim of this study was to examine potential transfer 2.3.2. PA 164bs_bs_query

105bs_bs_query effects, that is, inﬂuences of exergaming on external behaviors Intervention participants wore Omron GoSmart pedometers 165bs_bs_query

106bs_bs_query (PA levels, screen time) and psychological constructs (self- (Omron Healthcare Inc., Bannockburn, IL, USA) during 166bs_bs_query

107bs_bs_query efﬁcacy), of a 12-week exergaming intervention, as well as exergaming and recorded steps at the end of each session. 167bs_bs_query + 108bs_bs_query adolescents’ intrinsic motivation related to exergaming. Accelerometry (ActiGraph GT3X ; ActiGraph Inc., Fort 168bs_bs_query

bs_bs_query 109 Walton Beach, FL, USA) was used to assess habitual PA at 169bs_bs_query

bs_bs_query 110 2. Methods baseline and follow-up. Participants were instructed to wear the 170bs_bs_query

111 bs_bs_query accelerometer on a belt around their waist during all waking 171bs_bs_query 112 bs_bs_query 2.1. Participants

hours for 7 full days. Accelerometers were worn 1 week prior to 172bs_bs_query 113 bs_bs_query

114 bs_bs_query Forty-two overweight or obese adolescent girls participated the intervention and 1 week after the end of intervention (there- 173bs_bs_query

115 bs_bs_query in an exergaming intervention or were placed in a no-treatment fore after exergaming sessions had ended). Whereas the accel- 174bs_bs_query

116 bs_bs_query care control group. Participants were recruited from the greater erometer captured total daily PA, the Godin-Shephard Leisure- 175bs_bs_query 21 117 bs_bs_query Baton Rouge, LA, area via schools, health clinics, community Time PA Questionnaire was used to speciﬁcally capture PA 176bs_bs_query

118 bs_bs_query events, e-mail listservs, news media, and social media websites. during leisure time (i.e., discretionary time). This self-report 177bs_bs_query

119 bs_bs_query Participants were female, between 14 and 18 years of age, and instrument has been validated against the Caltrac accelerometer Q5 178bs_bs_query ≥ = < = 120bs_bs_query postmenarcheal; had a body mass index percentile 85; and (r 0.45; p 0.01) and other self-report surveys (e.g., r 0.61 179bs_bs_query 22 121bs_bs_query were free of serious medical conditions that contraindicated with the Baecke PA Questionnaire). Participants estimated the 180bs_bs_query

122bs_bs_query exercise or video game play. Thirty-seven participants had number of sessions of PA in the prior week based on mild, 181bs_bs_query

Exergaming transfer effects 3

182bs_bs_query moderate, or strenuous levels of intensity and were provided questions such as “I enjoyed doing this activity very much.” The 239bs_bs_query

183bs_bs_query with examples to illustrate intensity level. instrument has demonstrated adequate reliability and internal 240bs_bs_query α = 26 184bs_bs_query Exercise transfer effects were examined at baseline and at consistency ( 0.85). Each intervention participant was 241bs_bs_query

185bs_bs_query follow-up via behavioral observation (“cardio free choice”). asked additional questions, such as whether she thought 242bs_bs_query

186bs_bs_query Participants were alone in a room for 30 min with a variety of exergaming was PA, whether exergaming made her more physi- 243bs_bs_query

187bs_bs_query exercise equipment, including a treadmill, stationary bike, cally active, and whether she would continue playing the 244bs_bs_query

188bs_bs_query elliptical machine, upper extremity trainer, Cardio Kids Star exergames after the study ended. 245bs_bs_query

bs_bs_query 189bs_bs_query Walker (Kidsﬁt, Huger, SC, USA), ski/snowboard machine, 246

bs_bs_query 190bs_bs_query jump rope, hula hoop, abdominal ﬂoor mat, stability ball, and 2.4. Statistical analysis 247

248bs_bs_query 191bs_bs_query exergaming console. The observer gave the following instruc- Step counts during exergaming sessions were classiﬁed as 249bs_bs_query

192bs_bs_query tions: “This room contains various exercise equipment. This moderate-intensity activity if greater than or equal to 100 250bs_bs_query 193bs_bs_query equipment includes (items listed and pointed out). You will be 27 steps/min. Accelerometry data were processed using 15-s 251bs_bs_query

194bs_bs_query allowed to play in this room for 30 min. You may use this time epochs, and valid wear time was considered to be at least 10 h 252bs_bs_query

195bs_bs_query however you wish. There is a clock on the wall if you wish to for at least 3 days. Established cut-points were used to classify 253bs_bs_query 196bs_bs_query monitor your time. I will be sitting in the adjoining observation ≤ accelerometry data as follows: sedentary, 25 counts per min 254bs_bs_query 197bs_bs_query room and recording your activity through this mirror.” Partici- ≤ < ≤ (cpm); 26 cpm light activity 574 cpm; 574 cpm moderate 255bs_bs_query 198bs_bs_query pants self-selected how to use the 30-min period while an < ≥ 28 activity 1003 cpm; and vigorous activity 1003 cpm. A 256bs_bs_query

199bs_bs_query assessor observed through a 2-way mirror and recorded the linear mixed-effect model was used to obtain estimated mean of 257bs_bs_query

200bs_bs_query participant’s choice of equipment in 15-s intervals. All asses- the 2 conditions after adjusting for body mass index and mean 258bs_bs_query

201bs_bs_query sors were extensively trained on this observation method, and wear time (only for accelerometry data). The t tests based on the 259bs_bs_query

202bs_bs_query 15% of visits were rated by 2 assessors as inter-rater reliability linear model were used to examine both differences at baseline 260bs_bs_query

203bs_bs_query checks. The 2 assessors averaged 89% agreement across all and differences in change between each condition for screen 261bs_bs_query

204bs_bs_query observations. This assessment method was adapted from the 23 time, self-reported PA, accelerometer-measured PA, self- 262bs_bs_query 205bs_bs_query System for Observing Play and Leisure Activity in Youth. efﬁcacy, and intrinsic motivation toward exergaming. 263bs_bs_query

206bs_bs_query Finally, participants wore an accelerometer during the 30-min 264bs_bs_query

207bs_bs_query cardio free choice to objectively quantify levels of PA. 3. Results 265bs_bs_query

bs_bs_query 208 Participants answered a self-report survey with 16 multiple 266bs_bs_query

bs_bs_query 209bs_bs_query choice questions to retrospectively report typical media use and 3.1. Participant characteristics 267

268bs_bs_query 210bs_bs_query familiarity with exergames. Exergaming questions were devel- See Table 1 for participant characteristics at baseline. Par- 269bs_bs_query

211bs_bs_query oped for this study and included the following: “Have you ever ticipants did not vary by condition for baseline self-reported or 270bs_bs_query

212bs_bs_query played the Kinect for Xbox 360 games? If yes, how often do accelerometer-measured PA, self-efﬁcacy scores, or media use. 271bs_bs_query

213bs_bs_query you play the Kinect?” Response options included “just once or There was a baseline difference by condition for proportion of 272bs_bs_query

214bs_bs_query twice,” “every now and then,” “once a week,” “a few times a time spent playing Kinect vs. other choices at baseline in the 273bs_bs_query 215bs_bs_query week,” “just about every day,” and “none, I’ve never played the ± cardio free choice (64.0% 29.7% for intervention vs. 36.3 274bs_bs_query 216bs_bs_query Kinect before.” These questions were repeated for Dance ± = % 38.8% for control; p 0.019). 275bs_bs_query

217bs_bs_query Central and Just Dance games. Media use questions were from

218bs_bs_query the National Health and Nutrition Examination Survey (2009– 276bs_bs_query

219bs_bs_query 2010) questionnaire and were similar to reliable and valid self-

24 Table 1 277bs_bs_query 220bs_bs_query report questions used in prior studies. Examples include Participant baseline characteristics. 278bs_bs_query

221bs_bs_query “During the past 30 days, on average how many hours did you

Intervention Control 279bs_bs_query 222bs_bs_query sit and watch television or videos?” and “Over the past 30 days, = = (n 19) (n 18) 280bs_bs_query

223bs_bs_query on average how many hours did you use a computer of play ± ± Age, years 15.3 1.3 16.1 1.3 281bs_bs_query

224bs_bs_query computer games outside of school?” Race 282bs_bs_query

225bs_bs_query Self-efficacy toward PA was measured using the PA compo- African American, % 68 61 283bs_bs_query 25 226bs_bs_query nent of the Self-Efficacy for Healthy Eating and PA measure, White, % 32 39 284bs_bs_query ± ± Height, cm 160.1 6.3 164.7 6.1 285bs_bs_query 227bs_bs_query a 13-item self-report survey with items based on a 5-point ± ± Weight, kg 98.2 28.5 103.0 26.9 286bs_bs_query 228bs_bs_query Likert scale. Items measure confidence to exercise given spe- ± ± Body mass index Z-score 2.2 0.5 2.2 0.5 287bs_bs_query 229bs_bs_query cific obstacles, such as “I can be physically active during my ± ± Body mass index percentile 97.7 2.6 97.4 3.0 288bs_bs_query

230bs_bs_query free time on most days” or during adverse conditions or time Self-reported physical activity 289bs_bs_query * bs_bs_query ± ± 231 constraints. Each statement is followed by a scale from 1 to 5, Days/week 2.8 2.5 2.6 1.7 290bs_bs_query * ± ± α Mild bouts/week 3.7 3.5 2.8 3.5 291bs_bs_query 232bs_bs_query from “disagree a lot” to “agree a lot.” Cronbach’s alpha ( ) for * ± ± α > 25 Moderate bouts/week 3.2 3.1 2.5 3.5 292bs_bs_query 233bs_bs_query internal consistency of the survey is good at 0.70. * ± ± Strenuous bouts/week 2.9 4.9 2.6 3.6 293bs_bs_query

234bs_bs_query Finally, intervention participants completed an exit survey Screen time 294bs_bs_query

235bs_bs_query that contained the Intrinsic Motivation Inventory to assess their * ± ± Television viewing, h/day 2.9 1.7 3.1 2.3 295bs_bs_query 26 * bs_bs_query ± ± 236 enjoyment and experience of playing the exergames. The Video game play, h/day 0.8 1.1 1.0 2.1 296bs_bs_query * ± ± Computer use, h/day 1.7 2.8 1.5 2.1 297bs_bs_query 237bs_bs_query instrument contains 11 questions using the 7-point Likert scale * = 238bs_bs_query from1to7, from “not at all true” to “very true,” and includes n 18 for the intervention group for indicated variables. 298bs_bs_query

4 A.E. Staiano et al. 1

= 299bs_bs_query Fig. 1. Pedometer-assessed step counts per session during all 60-min exergaming sessions for the intervention participants (n 19 participants over 36 gaming

300bs_bs_query sessions).

301bs_bs_query

302bs_bs_query 3.2. PA during exergaming intervention light, moderate, or vigorous PA in the 1 week after the inter- 339bs_bs_query

303bs_bs_query ± vention (see Fig. 2A). The average proportion of time spent in 340bs_bs_query 304bs_bs_query Attendance averaged 80.1% 22.9% for the 36 exergaming each category in the overall sample averaged across both time 341bs_bs_query

305bs_bs_query sessions in the intervention condition. Participants took on ± points was 70.8% sedentary, 26.6% light, 2.2% moderate, and 342bs_bs_query 306bs_bs_query an average of 2766 865 steps per 1-h exergaming session 0.4% vigorous. 343bs_bs_query

307bs_bs_query (range 1363–4816 steps per session; Fig. 1). Only 0.7% of all 344bs_bs_query

308bs_bs_query exergaming sessions reached the moderate-intensity category ≥ 3.5. Cardio free choice intensity and selection 345bs_bs_query 309bs_bs_query on average for 1 h ( 100 steps per min on average). 346bs_bs_query

bs_bs_query 310 There were no signiﬁcant differences by condition for 347bs_bs_query

311bs_bs_query 3.3. Media use change in accelerometer-measured sedentary, light, moderate, 348bs_bs_query

312bs_bs_query

or vigorous PA during the 30-min cardio free choice observa- 349bs_bs_query 313bs_bs_query The majority of adolescents (64.9%) had a television in the

tion (Fig. 2B). The average proportion of time spent in each 350bs_bs_query 314bs_bs_query bedroom. Approximately half the participants had previously

category in the overall sample averaged across the 2 time points 351bs_bs_query 315bs_bs_query played the Kinect (45.9%), including 13 “just once or twice” or

was 16.4% sedentary, 57.6% light, 13.4% moderate, and 12.6% 352bs_bs_query 316bs_bs_query “every now and then”; 3 reported “once a week” or “a few times

vigorous. 353bs_bs_query 317bs_bs_query a week,” and 1 reported “just about every day.” Almost half

There was no signiﬁcant change in proportion of time spent 354bs_bs_query 318bs_bs_query (48.6%) had played Dance Central before, including 9 “every + ± playing Kinect in either condition ( 12.1% 34.9% for inter- 355bs_bs_query 319bs_bs_query now and then” and 9 “just once a week” to “a few times a ± vention, −9.1% 38.2% for control). However, the intervention 356bs_bs_query 320bs_bs_query week.” Finally, the majority (81.1%) had played Just Dance

participants spent signiﬁcantly more time playing Kinect after 357bs_bs_query 321bs_bs_query before; 21 reported playing “just once or twice” or “every now ± the intervention (76.0% 25.4% for intervention vs. 45.0 358bs_bs_query 322bs_bs_query and then,” 6 reported “once a week” or “a few times a week,” ± = % 43.9% for control; p 0.012). 359bs_bs_query 323bs_bs_query and 2 reported “just about every day.”

360bs_bs_query 324bs_bs_query There was a signiﬁcant increase in watching television or

3.6. Self-efficacy and intrinsic motivation 361bs_bs_query 325bs_bs_query videos reported 1 week prior to the intervention vs. 1 week after + 362bs_bs_query 326bs_bs_query the intervention in the control condition ( 0.90 h/day) vs. the There was no difference by condition in Self-Efficacy for 363bs_bs_query = 327bs_bs_query intervention (−0.13 h/day) (p 0.01) but no difference by con- Healthy Eating and PA score. However, there was a significant 364bs_bs_query

328bs_bs_query dition for time spent using the computer or playing computer difference by condition for self-efﬁcacy related to PA (“I can be 365bs_bs_query

329bs_bs_query games or playing video games outside of school. + physically active during my free time on most days”; 0.37 for 366bs_bs_query 330bs_bs_query = intervention vs. −0.44 for control; p 0.028). In the exit survey, 367bs_bs_query 331bs_bs_query 3.4. Habitual free-living PA

17 of the 19 intervention participants reported that playing 368bs_bs_query 332bs_bs_query

333bs_bs_query Participants in the intervention group reported an increase in dance exergames “really” or “sort of ” made the participant 369bs_bs_query > + 334bs_bs_query days per week of PA of 60 min ( 1.0 days per week in the have more conﬁdence in her ability to exercise. 370bs_bs_query

335bs_bs_query intervention group vs. −0.3 days per week in the control group; On the Intrinsic Motivation Inventory, intervention partici- 371bs_bs_query = 336bs_bs_query p 0.035), but there was no difference in self-reported mild, pants scored high on enjoyment of the exergaming activity 372bs_bs_query

337bs_bs_query moderate, or strenuous levels of PA. There were no signiﬁcant (58.3 of 70 total points), with the highest scores for enjoyment, 373bs_bs_query

338bs_bs_query differences by condition in accelerometer-measured sedentary, fun, effort, and perception that exergaming promotes ﬁtness 374bs_bs_query

Exergaming transfer effects 5

> 375bs_bs_query Fig. 2. Accelerometer-measured physical activity of 60 min (A) and in the 30-min free choice session (B) at week 0 and week 13.

376bs_bs_query

377bs_bs_query (Table 2). Eighteen of the 19 intervention participants said a week or just about every day. All indicated that they would 399bs_bs_query

378bs_bs_query dance exergaming “really is PA” or “sort of is PA.” Seventeen like to play dance exergames in physical education class (16 of 400bs_bs_query

379bs_bs_query reported that dance exergaming “really” or “sort of ” made the 19 “really” and 3 of 19 “sort of ”). 401bs_bs_query

402bs_bs_query 380bs_bs_query participant more physically active. The majority (16 of 19) 4. Discussion 403bs_bs_query

381bs_bs_query indicated that if they had access to a Kinect they would continue 404bs_bs_query

bs_bs_query 382bs_bs_query playing Dance Central and Just Dance exergames a few times The primary aim of this study was to examine transfer 405

effects on adolescent girls’ PA, screen time, and self-efﬁcacy 406bs_bs_query

383bs_bs_query after a 12-week exergaming intervention. It was promising that 407bs_bs_query

the intervention group reported a decrease in television viewing 408bs_bs_query 384bs_bs_query Table 2

and did not increase time spent playing video games or using 409bs_bs_query 385bs_bs_query Intrinsic motivation to play exergames as reported by intervention group

= bs_bs_query 386bs_bs_query (n 19). the computer after the intervention. These are among the ﬁrst 410

results indicating that involving adolescents in a screen-based 411bs_bs_query 387bs_bs_query Variable Score

PA intervention reduced their amount of screen time outside the 412bs_bs_query 388bs_bs_query This activity was fun to do. 6.6

intervention. Taking into consideration that the adolescents in 413bs_bs_query 389bs_bs_query I enjoyed doing this activity very much. 6.5 29 390bs_bs_query After working at this activity for a while, I felt pretty competent. 6.5 this study reported higher television viewing and similar 414bs_bs_query 7 391bs_bs_query I put a lot of effort into this activity. 6.1 gaming habits at baseline than previously reported in adoles- 415bs_bs_query

392bs_bs_query I think doing this activity could help me to stay in shape. 6.1 cent populations, when designing health interventions that use 416bs_bs_query

393bs_bs_query I believe doing this activity could be beneﬁcial to me. 6.0

screens, it is important not to inadvertently increase screen time 417bs_bs_query 394bs_bs_query I think I did pretty well at this activity, compared to other students. 5.7 30 such that the adolescent’s use exceeds recommendations. 418bs_bs_query 395bs_bs_query I thought this was a boring activity. 1.7

396bs_bs_query This was an activity that I couldn’t do very well. 1.5 Results were mixed for transfer effects of exergaming on 419bs_bs_query

397bs_bs_query I didn’t put much energy into this. 1.7 adolescents’ PA: there was no objective evidence of an increase 420bs_bs_query

398bs_bs_query Note: The ﬁnal 3 responses were reverse-coded to calculate the total score. in PA levels in the 1 week after the exergaming intervention, 421bs_bs_query

6 A.E. Staiano et al.

1422bs_bs_query which contradicted the girls’ self-reported increase. There are after being exposed to 36 h of exergaming. However, there was 479bs_bs_query

423bs_bs_query minimal data available on whether a structured exergaming a similar difference at baseline, and the change was not statis- 480bs_bs_query

424bs_bs_query intervention acts as a “gateway” to promote PA once the inter- tically signiﬁcant. Furthermore, there was no difference in self- 481bs_bs_query

425bs_bs_query vention ends. A prior experiment involving a single exergaming selected intensity of play by condition. There is limited 482bs_bs_query

426bs_bs_query session in 26 male adolescents did not result in differences evidence that adolescents transfer PA from one context to 483bs_bs_query

427bs_bs_query in accelerometry-measured energy expenditure in the 3-day another. 484bs_bs_query 12 428bs_bs_query period after the exergaming. However, this 3-day period The adolescents in the intervention group reported high 485bs_bs_query

429bs_bs_query included the exergaming session and may reﬂect a compensa- intrinsic motivation to play the exergames, and they signiﬁ- 486bs_bs_query

430bs_bs_query tory response whereby adolescents have no net change in total cantly increased self-efﬁcacy toward PA. Furthermore, the 487bs_bs_query 31,32 431bs_bs_query energy expenditure. By contrast, the present study examined exit survey indicated that the adolescents highly enjoyed the 488bs_bs_query

432bs_bs_query PA for the 1 week after the exergaming sessions ended. Because exergaming and would likely play the exergames again. 489bs_bs_query

433bs_bs_query the exergaming was played in a lab setting, once the interven- Improving these psychosocial constructs is important because 490bs_bs_query

434bs_bs_query tion ended the adolescents no longer had access to the same there is evidence that self-efﬁcacy and enjoyment mediate the 491bs_bs_query 13,34 435bs_bs_query setting, equipment, or social interaction and support from the effect of PA interventions on adolescent girls’ PA. Intrinsic 492bs_bs_query

436bs_bs_query other participants and the coaches to continue their PA. The motivation is particularly relevant as an inﬂuence on PA levels 493bs_bs_query 35,36 437bs_bs_query higher PA self-reported by adolescents in the intervention may during exergame play. These are among the ﬁrst results to 494bs_bs_query

438bs_bs_query be a result of social desirability. Additionally, although adoles- indicate increased self-efﬁcacy and high enjoyment in a 495bs_bs_query

439bs_bs_query cents were asked to report on the 1 week prior to the ﬁnal visit, context where adolescents self-selected game play and inten- 496bs_bs_query

440bs_bs_query which did not include exergaming sessions, the adolescents sity. A 20-week exergaming intervention among adolescents 497bs_bs_query 15 441bs_bs_query may have taken into account the PA during the exergaming aged 15–19 years observed improved self-efﬁcacy toward PA 498bs_bs_query 17 442bs_bs_query intervention, whereas the accelerometry data were collected and high levels of intrinsic motivation to play the exergame, 499bs_bs_query

443bs_bs_query after the exergaming intervention had been completed. but the gaming routine was prescribed and adolescents did not 500bs_bs_query

444bs_bs_query Whereas prior exergaming interventions prescribed choose intensity of play. Similarly, a 10-week group dance- 501bs_bs_query 15 445bs_bs_query exergaming routines, this 12-week exergaming trial used a based exergaming intervention that monitored heart rate to 502bs_bs_query

446bs_bs_query novel approach that balanced structure with choice. Speciﬁ- ensure that adolescents were in a targeted zone improved ado- 503bs_bs_query 37 447bs_bs_query cally, the intervention provided a structured gaming environ- lescent girls’ perceived competence to exercise regularly. 504bs_bs_query

448bs_bs_query ment with peer and coach support and required adolescents to Giving adolescents an opportunity to choose their own inten- 505bs_bs_query

449bs_bs_query participate for approximately 180 min/week over 12 weeks, but sity of play may have further increased their feelings of com- 506bs_bs_query

450bs_bs_query the adolescents had free choice of intensity and game play petency and enjoyment. 507bs_bs_query

451bs_bs_query among selected dance exergames. As such, the intervention was The study ﬁndings may be applied to practical settings such 508bs_bs_query

452bs_bs_query well attended by adolescent girls, which responds to the call for as physical education courses, where teachers allow students to 509bs_bs_query 12 453bs_bs_query entertaining exergames that promote sustained game play. self-select intensity and type of game play. It is important that 510bs_bs_query

454bs_bs_query However, allowing the adolescents to self-select intensity 100% of the exergaming participants noted that they would be 511bs_bs_query

455bs_bs_query resulted in low levels of PA, with less than 1% of sessions willing to play the exergame in a school physical education 512bs_bs_query

456bs_bs_query qualiﬁed as moderate-intensity PA for the whole hour. The class. However, there is mixed evidence whether exergaming 513bs_bs_query 6 37,38 457bs_bs_query pedometer steps were captured over 1 full hour of gaming, so it does or does not substantially contribute to PA levels during 514bs_bs_query

458bs_bs_query is not known whether cadence (steps per minute) was higher at physical education courses. The present study indicates that 515bs_bs_query

459bs_bs_query shorter intervals throughout each session. Furthermore, the when given a choice, adolescents will choose a low intensity 516bs_bs_query

460bs_bs_query pedometer may not completely capture PA during dancing, of PA while exergaming, but this experience will lead to 517bs_bs_query

461bs_bs_query which involves upper body movement rather than the traditional improvements in self-efﬁcacy with high levels of enjoyment 518bs_bs_query

462bs_bs_query steps associated with walking. Upper body movement contrib- and motivation. Future research should identify ways to provide 519bs_bs_query

463bs_bs_query utes to total energy expenditure during exergaming, especially adolescents with choice of game play in an enjoyable and 520bs_bs_query 33 464bs_bs_query when movement of both arms is encouraged, such as in dance- conﬁdence-building manner while ensuring adequate levels of 521bs_bs_query

465bs_bs_query based exergaming. The adolescents had very low levels of moderate-intensity PA. 522bs_bs_query

466bs_bs_query moderate-to-vigorous PA both during the free-living period and There were several strengths and limitations of the study. 523bs_bs_query

467bs_bs_query when placed in a gym with cardio equipment. Placing the A key strength was the sample of youth at high risk for 524bs_bs_query

468bs_bs_query adolescents in a group setting with peers and coaches and chronic disease: all participants were overweight or obese, 525bs_bs_query

469bs_bs_query providing them with access to dance exergames were not suf- and the majority were ethnic minorities. Both objective and 526bs_bs_query

470bs_bs_query ﬁcient to achieve moderate PA levels during the gaming ses- self-report measures were used to assess transfer effects, 527bs_bs_query

471bs_bs_query sions or 1 week after the intervention had ended. which is understudied in the PA and gaming literature. Ado- 528bs_bs_query

472bs_bs_query A unique assessment of this intervention was the cardio free lescents were allowed to self-select intensity, which leads to 529bs_bs_query

473bs_bs_query choice, during which adolescents were placed in a gym and excellent external validity for effectiveness but limited inter- 530bs_bs_query

474bs_bs_query could choose among several exercise equipment options as well nal validity for efﬁcacy given the range of intensities of play. 531bs_bs_query

475bs_bs_query as intensity of play. Compared with the control group, the Another limitation is the use of pedometers to assess PA 532bs_bs_query

476bs_bs_query intervention group spent proportionately more time playing the during dance exergaming, which may not have captured the 533bs_bs_query

477bs_bs_query Kinect vs. other equipment after the intervention, indicating complete range of motion, and the small sample size limits 534bs_bs_query

478bs_bs_query that they had a higher preference toward the exergame even generalizability. 535bs_bs_query

Exergaming transfer effects 7

7. O’Loughlin EK, Dugas EN, Sabiston CM, O’Loughlin JL. Prevalence and bs_bs_query 536bs_bs_query 5. Conclusion 600

bs_bs_query 537bs_bs_query correlates of exergaming in youth. Pediatrics 2012;130:806–14. 601

538bs_bs_query Exergaming for 12 weeks was associated with positive 8. Barnett A, Cerin E, Baranowski T. Active video games for youth: 602bs_bs_query

a systematic review. J Phys Act Health 2011;8:724–37. 603bs_bs_query 539bs_bs_query impacts on adolescent girls’ television viewing, self-efﬁcacy,

9. Biddiss E, Irwin J. Active video games to promote physical activity in 604bs_bs_query 540bs_bs_query and intrinsic motivation. Evidence for transfer effects on PA

children and youth: a systematic review. Arch Pediatr Adolesc Med 605bs_bs_query

541bs_bs_query was limited: although adolescents self-reported higher PA after 2010;164:664–72. 606bs_bs_query

542bs_bs_query the intervention ended, the accelerometry data did not indicate 10. Peng W, Lin JH, Crouse J. Is playing exergames really exercising? A 607bs_bs_query

543bs_bs_query a signiﬁcant difference. Exergaming was a highly enjoyed activ- meta-analysis of energy expenditure in active video games. Cyberpsychol 608bs_bs_query

Behav Soc Netw 2011;14:681–8. 609bs_bs_query 544bs_bs_query ity, yet future research should investigate ways to improve ado-

11. Gow ML, van Doorn N, Broderick CR, Hardy LL, Ho M, Baur LA, et al. 610bs_bs_query 545bs_bs_query lescents’ experiences and responses to exergaming to increase

Sustained improvements in ﬁtness and exercise tolerance in obese 611bs_bs_query

546bs_bs_query the effectiveness of exergaming as a PA promotion tool. adolescents after a 12 week exercise intervention. Obes Res Clin Pract 612bs_bs_query

547bs_bs_query 2016;10:178–88. 613bs_bs_query 548bs_bs_query Acknowledgments 12. Gribbon A, McNeil J, Jay O, Tremblay MS, Chaput JP. Active video games 614bs_bs_query 549bs_bs_query

and energy balance in male adolescents: a randomized crossover trial. Am 615bs_bs_query 550bs_bs_query The authors gratefully acknowledge Arwen Marker and the

J Clin Nutr 2015;101:1126–34. 616bs_bs_query

551bs_bs_query staff of Pennington Biomedical, who assisted with this trial, as 13. Dishman RK, Motl RW, Saunders R, Felton G, Ward DS, Dowda M, 617bs_bs_query

552bs_bs_query well as the adolescents who participated. AES and PTK are et al. Self-efﬁcacy partially mediates the effect of a school-based 618bs_bs_query

553bs_bs_query supported, in part, by the U54 GM104940 grant from the physical-activity intervention among adolescent girls. Prev Med 2004; 619bs_bs_query

38:628–36. 620bs_bs_query 554bs_bs_query National Institute of General Medical Sciences of the US

14. Gillison FB, Standage M, Skevington SM. Relationships among 621bs_bs_query 555bs_bs_query National Institutes of Health, which funds the Louisiana Clini-

adolescents’ weight perceptions, exercise goals, exercise motivation, 622bs_bs_query

556bs_bs_query cal & Translational Science Center. PTK is supported, in part, quality of life and leisure-time exercise behaviour: a self-determination 623bs_bs_query

557bs_bs_query Q6 by the Marie Edana Corcoran Endowed Chair in Pediatric theory approach. Health Educ Res 2006;21:836–47. 624bs_bs_query

558bs_bs_query Obesity and Diabetes. This work was partially supported by 15. Staiano AE, Abraham AA, Calvert SL. Adolescent exergame play for 625bs_bs_query

weight loss and psychosocial improvement: a controlled physical activity 626bs_bs_query 559bs_bs_query NORC Center Grant # P30DK072476 entitled “Nutritional Pro-

intervention. Obesity (Silver Spring) 2013;21:598–601. 627bs_bs_query 560bs_bs_query gramming: Environmental and Molecular Interactions.”

16. Gao Z, Zhang T, Stodden D. Children’s physical activity levels and 628bs_bs_query 561bs_bs_query

psychological correlates in interactive dance versus aerobic dance. J Sport 629bs_bs_query 562bs_bs_query Authors’ contributions

Health Sci 2013;2:146–51. 630bs_bs_query 563bs_bs_query

bs_bs_query 564bs_bs_query AES conceived of the study, designed and coordinated the 17. Staiano AE, Abraham AA, Calvert SL. Motivating effects of cooperative 631

exergame play for overweight and obese adolescents. J Diabetes Sci 632bs_bs_query 565bs_bs_query study, performed statistical analysis and interpretation, and

Technol 2012;6:812–19. 633bs_bs_query 566bs_bs_query wrote the initial draft of the manuscript. RAB performed the 18. Bandura A. Self-efﬁcacy: the exercise of control. NewYork:W.H.Freeman; 634bs_bs_query

567bs_bs_query randomization and statistical analysis. DSH provided medical 1997. 635bs_bs_query

bs_bs_query 568 oversight. PTK and RLN provided scientiﬁc guidance for the 19. Faith MS, Leone MA, Ayers TS, Heo M, Pietrobelli A. Weight criticism 636bs_bs_query

bs_bs_query 569bs_bs_query design and coordination of the study and interpretation of during physical activity, coping skills, and reported physical activity in 637

children. Pediatrics 2002;110:e23. 638bs_bs_query 570bs_bs_query results. All authors provided critical feedback to the manu-

20. Staiano AE, Marker AM, Beyl RA, Hsia DS, Katzmarzyk PT, Newton RL. 639bs_bs_query 571bs_bs_query script, read and approved the ﬁnal version of the manuscript, A randomized controlled trial of dance exergaming for exercise training 640bs_bs_query

572bs_bs_query and agree with the order of presentation of the authors. in overweight and obese adolescent girls. Pediatr Obes 2016;doi:10 641bs_bs_query

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575bs_bs_query community. Can J Appl Sport Sci 1985;10:141–6. 644bs_bs_query 576bs_bs_query None of the authors declare competing ﬁnancial interests. 22. Miller DJ, Freedson PS, Kline GM. Comparison of activity levels using the 645bs_bs_query 577bs_bs_query

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