Virtual fitness buddy ecosystem: a mixed reality precision health physical activity intervention for children.

6-11-year-old children provide a critical window for physical activity (PA) interventions. The Virtual Fitness Buddy ecosystem is a precision health PA intervention for children integrating mixed reality technology to connect people and devices. A cluster randomized, controlled trial was conducted across 19 afterschool sites over two 6-month cohorts to test its efficacy in increasing PA and decreasing sedentary behavior. In the treatment group, a custom virtual dog via a mixed reality kiosk helped children set PA goals while sharing progress with parents to receive feedback and support. Children in the control group set PA goals using a computer without support from the virtual dog or parents. 303 children had 8+ hours of PA data on at least one day of each of the 3 intervention time intervals. Conversion of sedentary time was primarily to light-intensity PA and was strongest for children with low baseline moderate-to-vigorous PA than children above 45 min of baseline moderate-to-vigorous PA. Findings suggest that the VFB ecosystem can promote sustainable PA in children and may be rapidly diffused for widespread public health impact.

Agreement between Fitbit and ActiGraph Estimates of Physical Activity in Young Children.

Physical activity (PA) estimates from the Fitbit Flex 2 were compared to those from the ActiGraph GT9X Link in 123 elementary school children. Steps and intensity-specific estimates of PA and 3-month PA change were calculated using two different ActiGraph cut-points (Evenson and Romanzini). Fitbit estimates were 35% higher for steps compared to the ActiGraph. Fitbit and ActiGraph intensity-specific estimates were closest for sedentary and light PA while estimates of moderate and vigorous PA varied substantially depending upon the ActiGraph cut-points used. Spearman correlations between device estimates were higher for steps (rs=.70) than for moderate (rs =.54 to .55) or vigorous (rs =.29 to .48) PA. There was low concordance between devices in assessing PA changes over time. Agreement between Fitbit Flex 2 and ActiGraph estimates may depend upon the cut-points used to classify PA intensity. However, there is fair to good agreement between devices in ranking children's steps and MVPA.

Virtual reality-based distraction on pain, performance, and anxiety during and after moderate-vigorous intensity cycling.

PURPOSE: To determine whether increased visual perceptual load (PL) within an immersive virtual environment may help explain previously shown pain-relieving effects of virtual reality (VR) during high intensity cycling. METHODS: Using a within-subjects design, participants cycled at a perceptually "hard" intensity for 10 min on three separate occasions. The first session did not use VR (i.e., no perceptual load - NPL). Subsequent sessions employed VR during cycling with either a low or high perceptual load (LPL or HPL). Quadriceps pain intensity (PI) was reported by participants throughout cycling. RESULTS: Data were analyzed for 43 healthy participants (20 females, mean age 21  [SD 1.4]). For PI, ANOVA showed there were significant main effects of condition (F = 13.458, df =1.579, 66.334, p<0.001) and time (F = 113.045, df =1.618, 227.683, p<0.001). At every time point, t-tests revealed mean PI was significantly lower in the NPL than in the LPL condition (t(42)=4.737, p<0.001, d = 0.472) and HPL condition (t(42)=3.380, p = 0.002, d = 0.391). Dependent t-tests showed that more work (kilojoules) was performed during the LPL condition than the NPL (t(42)=2.992, p = 0.005) and HPL (t(42)=5.810, p<0.001) conditions. CONCLUSIONS: Compared to a traditional 10-minute bout of cycle ergometry (NPL), individuals who cycled in the LPL condition chose to exercise at a higher intensity despite greater PI. Those who cycled in the HPL condition did not change their exercise intensity, but did report higher PI, possibly, because of the greater mental effort/energy requirement.

Scaling the Virtual Fitness Buddy Ecosystem as a School-Based Physical Activity Intervention for Children.

Childhood obesity is a growing concern as it can lead to lifelong health problems that carry over into adulthood. A substantial contributing factor to obesity is the physical activity (PA) habits that are formed in early childhood, as these habits tend to sustain throughout adulthood. To aid children in forming healthy PA habits, we designed a mixed reality system called the Virtual Fitness Buddy ecosystem, in which children can interact with a virtual pet agent. As a child exercises, their pet becomes slimmer, faster, and able to play more games with them. Our initial deployment of this project showed promise but was only designed for a short-term intervention lasting three days. More recently, we have scaled it from a pilot grade study to a 9-month intervention comprised of 422 children. Ultimately, our goal is to scale this project to be a nationwide primary prevention program to encourage moderate to vigorous PA in children. This article explores the challenges and lessons learned during the design and deployment of this system at scale in the field.

Using virtual agents to increase physical activity in young children with the virtual fitness buddy ecosystem: Study protocol for a cluster randomized trial.

BACKGROUND: Designing and implementing a truly self-determined physical activity (PA) intervention has required excessive amounts of labor and expenses that, until recently, have made it prohibitively costly to implement in the field at scale. METHODS: Guided by self-determination theory, and harnessing the power of consumer-grade interactive technologies, we developed the Virtual Fitness Buddy (VFB) Ecosystem. Designed to foster intrinsic motivation toward adopting PA as a lifestyle change in 6-10-year-old children, the Ecosystem features a mixed-reality kiosk which houses a personalized virtual pet for each user. Each time a child visits the kiosk, the pet (a mid-sized dog) automatically detects its owner based on the data from a child's Fitbit, assists the child in setting daily PA goals and provides tailored feedback on the child's PA progress. The pet alerts parents in real-time by sending text messages and relaying the parents' response to the child, so that parents and children can remain connected about the child's PA progress even when they are physically apart. We aim to implement the kiosk in 12 after-school sites, plus use 12 additional sites as controls, where children can still set and view progress toward their PA goals without access to a virtual pet. CONCLUSION: The VFB Ecosystem represents a new generation of technology-mediated health interventions for children to promote sustainable PA lifestyle changes. Because the VFB Ecosystem is a cost- and labor-effective solution that integrates consumer-grade technology with low barriers for continued use, it has the potential for rapid diffusion and widespread public health impact.

Using Virtual Agents and Activity Monitors to Autonomously Track and Assess Self-Determined Physical Activity Among Young Children: A 6-Week Feasibility Field Study.

The majority of youth fail to get the recommended amount of physical activity (PA), and there is a precipitous decline in PA among children as they get older. Guided by self-determination theory and social cognitive theory, we designed an interactive, mixed reality PA intervention for 6-10-year-old children. Capitalizing on the features of consumer-grade interactive communication technologies, the intervention features a kiosk-based system that houses a virtual agent programmed to encourage children to set self-determined PA goals. This intervention aims to resolve many practical challenges in designing and administering a personalized, intrinsically motivated PA intervention for this age group. We pilot tested the feasibility of this kiosk across 6 weeks with n = 42 child/parent dyads. The kiosk tracked and logged children's daily PA and engagement with the intervention without having to rely on human reporting, provided tailored evaluation and feedback whenever children requested it, informed parents about their child's PA progress, and employed a virtual agent (a dog) to offer social support to children. The virtual agent prompted users to set PA goals, and as children met these goals over time, their personalized dog became happier, more fit, and better at tricks. Each time a child engaged with the kiosk the system automatically sent a text message to his/her parent with details about the child's PA progress. The current study demonstrated the kiosk's feasibility in the field over 6 weeks, illustrating the potential of using interactive technologies as tools for disseminating self-sufficient, and truly self-determined health interventions for children at scale.

The Paradox of Interactive Media: The Potential for Video Games and Virtual Reality as Tools for Violence Prevention.

Interactive media such as video games and virtual reality (VR) provide users with lived experiences that may be dangerous or even impossible in daily life. By providing interactive experiences in highly authentic, detail-rich contexts, these technologies have demonstrated measurable success in impacting how people think, feel, and behave in the physical world. At the same time, violent interactive media content has been historically connected with a range of antisocial effects in both popular press and academic research. Extant literature has established a small-but-statistically significant effect of interactive media violence on aggressive thoughts and behaviors, which could serve as a risk factor for interpersonal violence. However, left unexplored is the seemingly paradoxical claim that under some conditions, interactive media experiences might protect against interpersonal violence. Drawing on advances in media theory and research and the evolution of interactive media content and production practices, the current manuscript suggests ways in which interactive media violence may be leveraged to lower the likelihood of real-world violence experiences. For example, research on both violent and non-violent games has found that players can (a) express guilt after committing violent acts, (b) report reflective and introspective emotional reactions during gameplay, and (c) debate the morality of their actions with others. Regarding VR, studies have demonstrated that (a) witnessing physical violence in immersive spaces led participants to take the perspective of victims and better understand their emotional state and (b) controlled exposure to traumatic or violent events can be used for treatment. Broadly, studies into video games and VR demonstrate that the impact of actions in virtual worlds transfer into the physical worlds to influence (later) attitudes and behaviors. Thus, how these experiences may be potentially harnessed for social change is a compelling and open consideration, as are side-effects of such interventions on vulnerable groups. The current manuscript summarizes emerging research perspectives (as well as their limitations) to offer insight into the potential for interactive media violence to protect against real-world violence victimization and perpetration.

Using immersive virtual reality to improve the beliefs and intentions of influenza vaccine avoidant 18-to-49-year-olds: Considerations, effects, and lessons learned.

OBJECTIVE: Only one-third of adults 18-49 years old in the United States receive a recommended annual influenza vaccination. This study examined whether supplementing vaccine information statements (VIS) with an immersive virtual reality (VR), short video or electronic pamphlet story designed to convey the community immunity benefits of influenza vaccination would improve influenza vaccine avoidant participants' influenza-related perceptions as well as their influenza vaccination-related beliefs, confidence and intentions. METHOD: A one-way between-subjects experimental design compared the effects of adding a supplemental education experience prior to VIS exposure with flu vaccine avoidant 18-to-49-year-olds. The 171 participants recruited from the community were randomly assigned to one of three modality treatment conditions [VR, video, or e-pamphlet (i.e., story board presented via electronic tablet)] or a VIS-only control condition. RESULTS: Compared to the modalities, the VR intervention created a stronger perception of presence (i.e., feeling of "being there" in the story), which, in turn, increased participants' concern about transmitting influenza to others and raised vaccination intention. Increased concern about transmitting influenza to others was associated with positive effects on influenza vaccination-related beliefs, including confidence that one's flu vaccination would protect others. Neither the e-pamphlet nor the video intervention were able to elicit a sense of presence nor were they able to improve the impact of the VIS on the outcome measures. CONCLUSIONS: Immersive VR has much potential to increase understanding of key immunization concepts, such as community immunity, through creative executions that increase a sense of presence. Given the need to increase influenza vaccination uptake among 18-to-49-year-olds, and the projected growth in VR accessibility and use, additional applications and assessments related to vaccination communication and education are needed and warranted. By increasing the ability to convey key vaccine and immunization concepts, immersive VR could help address vaccination hesitancy and acceptance challenges.

Interactive Virtual Reality Reduces Quadriceps Pain during High-Intensity Cycling.

PURPOSE: Brief, high-intensity cycling is popular because physiological benefits accrue with a short workout time, but burning pain in the quadriceps is a potential barrier to engaging in this type of exercise. Virtual reality (VR) can temporarily decrease pain, but its effect on muscle pain during high-intensity exercise is unknown. The primary purpose of this experiment was to test whether adding interactive VR (I-VR) to high-intensity cycling could reduce quadriceps pain or improve performance. METHODS: Ninety-four adults who were physically active in their leisure time and age 18 to 29 yr completed three 30-s sprint interval cycling trials at a high resistance (0.085- and 0.075-kg resistance to the flywheel per kilogram body weight for men and women, respectively). In this randomized between-subject experiment, participants cycled while wearing a head-mounted display and viewing either (i) a dynamically changing cityscape perceived as interactively cycling through a virtual city (I-VR group) or (ii) a static picture of the cityscape with instructions to mentally imagine cycling through that city (static VR/motor imagery control group). RESULTS: Sphericity-adjusted 2 × 3 (group-time) ANOVA revealed a significant group-time interaction (F = 4.568; df = 1.499, 133.301; ηp = 0.047, P = 0.021) for pain intensity. With I-VR, pain intensities were 13.3% (mean, 4.60 vs 5.31; d = 0.28) and 11.8% (mean, 5.68 vs 6.44; d = 0.27) lower at sprint trials 2 and 3, respectively. The group-time interaction (P = 0.412) was not significant for total work. CONCLUSION: Compared with a static VR/motor imagery control condition, I-VR during brief, high-intensity, fatigue-inducing leg cycling attenuates quadriceps pain intensity without reducing performance.

Points-Based Reward Systems in Gamification Impact Children's Physical Activity Strategies and Psychological Needs.

Gamification is an increasingly popular form of health intervention but its efficacy remains elusive due to a lack of clarity in its conceptualization and operationalization. This study aimed to isolate and determine the direct causal effect of one of the most popular game elements used in gamified interventions, the points-based reward system, on physical activity (PA) in children. A 72-hour field study with children aged 9 to 13 ( N = 67) was conducted using a digital PA intervention featuring a virtual dog, with and without a points-based reward system. PA was assessed with an activity monitor, and overall PA, three levels of PA intensity, and PA strategies during the 3-day intervention were measured. Guided by self-determination theory, the impact of the points-based reward system on children's basic psychological needs was also investigated. Results indicated that the points-based reward system briefly increased PA engagement but did not significantly affect overall PA over time. When given equal number of points regardless of intensity, children approached the PA intervention strategically by engaging in significantly more light intensity and significantly less vigorous intensity PA than children who did not receive points. Results also suggested that the points-based reward system might promote perceptions of relatedness with the virtual agent featured in the gamified intervention.

Feeling the weight of calories: using haptic feedback as virtual exemplars to promote risk perception among young females on unhealthy snack choices.

Virtual simulations allow users to feel and manipulate objects as they would in the physical world. Guided by exemplification theory and risk communication research, a virtual exemplar was developed to allow users to feel the weight of the caloric density of unhealthy snacks (e.g., potato chips) to heighten risk perceptions on snack choices. A 3 (base-rate statistics, print exemplar, virtual exemplar) × 3 (Time 1, Time 2, Time 3) mixed design experiment (N = 152) compared the effect of three mediated modes of delivering health information at baseline, immediately after, and 1 week after treatments. Virtual exemplars led to greater spatial presence, issue involvement, and recommended health behavior than did base-rate statistics or print exemplars, but had no effect on perceived vividness. Heightened perceived susceptibility following virtual exemplars persisted for 1 week. Findings emphasized the importance of spatial presence elicited by an exemplar in heightening the perceived susceptibility of health risks both immediately after and 1 week after exposure. The role of spatial presence and vividness in the context of virtual exemplars that afford the illusion of firsthand experiences is discussed and compared against traditional exemplification research that has focused on the impact of secondhand experiences.

How Does Neighborhood Quality Moderate the Association Between Online Video Game Play and Depression? A Population-Level Analysis of Korean Students.

The main objective of our study is to assess the relationship between playing online video games and mental wellbeing of adolescents based on a nationally representative sample. Data come from the Korean Children and Youth Panel Survey (KCYPS), a government-funded multiyear research project. Through a secondary analysis of W2 and W3 of data collected in 2011 and 2012, we examine the extent to which time spent playing online games is related to depression, as measured by a battery of items modeled after the abridged version of Center for Epidemiologic Studies Depression Scale Revised (CESD-R). For proper temporal ordering, the outcome variable is drawn from the latter wave (W3), whereas all time-lagged covariates are taken from the earlier wave (W2). Multilevel regression models show that more game playing is associated with greater depression. Findings also indicate that, net of individual-level variables (e.g., gender, health, family background), living in a community with more divorced families adds to adolescent depression. Finally, a cross-level interaction is observed: the positive association between game playing and depression is more pronounced in an area characterized by a lower aggregate divorce rate.

Using Virtual Pets to Increase Fruit and Vegetable Consumption in Children: A Technology-Assisted Social Cognitive Theory Approach.

A virtual pet in the form of a mid-sized dog was developed based on the framework of social cognitive theory and tested as a vehicle for promoting fruit and vegetable (F&V) consumption in children. Three groups of children (N = 68) between the ages of 7 and 13 years were studied: baseline (no treatment), computer only, and virtual dog. Children in the virtual dog condition interacted with the virtual dog for 3 days, setting F&V consumption goals and receiving evaluation and reinforcement based on whether they met their self-set goals. Children vicariously experienced future health outcomes of F&V consumption by seeing, hearing, and feeling their virtual dog's physical and mental health improve or deteriorate based on their F&V consumption in the physical world. Children in the computer only condition interacted with a computer system that presented equivalent features, but without the virtual dog. Children in the baseline condition did not receive any experimental treatment. Results indicated that children in the virtual dog condition chose to be served significantly more F&V than those in the computer only or baseline conditions did. However, children in the virtual dog condition were unable to consume significantly more F&V than those in the computer only condition, although children in those two conditions consumed more F&V than the baseline condition. Food preferences did not differ significantly across the three conditions before and after the experimental treatments. Theoretical and practical potentials of using a virtual pet to promote F&V consumption systematically in children are discussed.

Using Virtual Pets to Promote Physical Activity in Children: An Application of the Youth Physical Activity Promotion Model.

A virtual pet was developed based on the framework of the youth physical activity promotion model and tested as a vehicle for promoting physical activity in children. Children in the treatment group interacted with the virtual pet for three days, setting physical activity goals and teaching tricks to the virtual pet when their goals were met. The virtual pet became more fit and learned more sophisticated tricks as the children achieved activity goals. Children in the control group interacted with a computer system presenting equivalent features but without the virtual pet. Physical activity and goal attainment were evaluated using activity monitors. Results indicated that children in the treatment group engaged in 1.09 more hours of daily physical activity (156% more) than did those in the control group. Physical activity self-efficacy and beliefs served as mediators driving this increase in activity. Children that interacted with the virtual pet also expressed higher intentions than children in the control group to continue physical activity in the future. Theoretical and practical potentials of using a virtual pet to systematically promote physical activity in children are discussed.

Incorporating immersive virtual environments in health promotion campaigns: a construal level theory approach.

In immersive virtual environments (IVEs), users may observe negative consequences of a risky health behavior in a personally involving way via digital simulations. In the context of an ongoing health promotion campaign, IVEs coupled with pamphlets are proposed as a novel messaging strategy to heighten personal relevance and involvement with the issue of soft-drink consumption and obesity, as well as perceptions that the risk is proximal and imminent. The framework of construal level theory guided the design of a 2 (tailoring: other vs. self) × 2 (medium: pamphlet only vs. pamphlet with IVEs) between-subjects experiment to test the efficacy in reducing the consumption of soft drinks over 1 week. Immediately following exposure, tailoring the message to the self (vs. other) seemed to be effective in reducing intentions to consume soft drinks. The effect of tailoring dissipated after 1 week, and measures of actual soft-drink consumption 1 week following experimental treatments demonstrated that coupling IVEs with the pamphlet was more effective. Behavioral intention was a significant predictor of actual behavior, but underlying mechanisms driving intentions and actual behavior were distinct. Results prescribed a messaging strategy that incorporates both tailoring and coupling IVEs with traditional media to increase behavioral changes over time.

Mixed reality virtual pets to reduce childhood obesity.

Novel approaches are needed to reduce the high rates of childhood obesity in the developed world. While multifactorial in cause, a major factor is an increasingly sedentary lifestyle of children. Our research shows that a mixed reality system that is of interest to children can be a powerful motivator of healthy activity. We designed and constructed a mixed reality system that allowed children to exercise, play with, and train a virtual pet using their own physical activity as input. The health, happiness, and intelligence of each virtual pet grew as its associated child owner exercised more, reached goals, and interacted with their pet. We report results of a research study involving 61 children from a local summer camp that shows a large increase in recorded and observed activity, alongside observational evidence that the virtual pet was responsible for that change. These results, and the ease at which the system integrated into the camp environment, demonstrate the practical potential to impact the exercise behaviors of children with mixed reality.

Differential changes in functional activity of organic cation transporters in rats with uranyl nitrate-induced acute renal failure.

We studied the impact of experimental kidney failure on the pharmacokinetics of a model organic cation and investigated the underlying mechanism(s) of the organic cation transporters. The systemic pharmacokinetics and tissue distribution of triethylmethylammonium (TEMA), a model organic cation, were characterized after intravenous doses of 0.3-30 µmol/kg in rats with or without uranyl nitrate-induced acute renal failure (UN-ARF). To study the effect of endogenous substrates in plasma from UN-ARF rats on organic cation transport, rOCT- or rOCT2-dependent uptake of tetraethylammonium (TEA) was studied in rOCT1-transfected or rOCT2-transfected LLC-PK1 cells, respectively. As a result, the AUC for TEMA was increased, probably because of decreased total clearance, and the tissue-to-plasma concentration ratio (T/P ratio) of TEMA was unchanged in the liver but decreased significantly in the kidneys of UN-ARF rats. In vitro, the uptake of TEA was decreased significantly by adding UN-ARF plasma, compared with control plasma, in rOCT2-overexpressing LLC-PK1 cells, but not in rOCT1-overexpressing LLC-PK1 cells. These observations suggest that the induction of UN-ARF leads to an accumulation of endogenous organic cation(s), probably rOCT2 substrate(s), in the plasma, thereby affecting the TEMA pharmacokinetics and distribution to the kidneys in rats.

Testosterone-independent down-regulation of Oct2 in the kidney medulla from a uranyl nitrate-induced rat model of acute renal failure: effects on distribution of a model organic cation, tetraethylammonium.

Although acute renal failure (ARF) has been an area of extensive research in recent decades, our understanding of ARF is far from complete. Organic cations (OCs) are primarily excreted via vectorial transport by various renal organic cation transporters (OCTs). It is reasonable to assume that ARF may alter the expression profiles of these transporters. In a rat ARF model, induction of ARF by uranyl nitrate (UN) treatment significantly decreased the levels of Oct2 (slc22a2) mRNA and protein in the kidney medulla. mRNA expression of the other OCTs was not appreciably altered. The plasma level of testosterone, a well-known regulator of Oct2, was not changed, suggesting that the Oct2 down-regulation is testosterone-independent. The effect of reduced Oct2 expression on the distribution of a model OC, tetraethylammonium (TEA), in various rat tissues including kidney cortex and kidney medulla was investigated during steady state plasma TEA concentrations. The steady state tissue-to-plasma (T/P) TEA ratio was decreased in the kidney medulla (approximately 15-fold) during ARF. These results indicate that, in a rat model of ARF, reduced Oct2 expression in the kidney medulla results in decreased distribution of TEA to the kidney medulla, thereby reducing renal clearance of TEA in UN-ARF rats.