articles
nature publishing group
inteRVENTION AND pREVENTION
A Pilot of a Video Game (DDR) to Promote
Physical Activity and Decrease Sedentary
Screen Time
Ann E. Maloney1, T. Carter Bethea2, Kristine S. Kelsey3, Julie T. Marks4, Sadye Paez5,
Angela M. Rosenberg5, Diane J. Catellier6, Robert M. Hamer2,6 and Linmarie Sikich2
Objective: We examined the feasibility of Dance Dance Revolution (DDR), a dance video game, in participants’ homes,
to increase physical activity (PA) and to decrease sedentary screen time (SST).
Methods and Procedures: Sixty children (7.5 ± 0.5 years) were randomized in a 2:1 ratio to DDR or to wait-list control
(10-week delay). DDR use was logged, PA was measured objectively by accelerometry. SST was self-reported at
weeks 0 and 10. At week 28, after both groups had access to DDR, accelerometry and SST were repeated.
Results: Mean use of DDR was 89 ± 82 (range 0–660 min) min per week (mpw). The DDR group showed increased
vigorous PA and a reduction in light PA; the control group showed no increase in moderate and/or vigorous PA (MVPA)
although they also had a reduction in light PA. Differences between the groups were not observed. The DDR group
also reported a decrease in SST of –1.2 ± 3.7 h per week (hpw) (P < 0.05), whereas the controls reported an increase
of +3.0 ± 7.7 hpw (nonsignificant). The difference in SST between the groups was significant, with less SST in the DDR
group. Between weeks 10 and 28, numeric reductions in SST were reported in both groups. In the DDR group, SST at
week 28 (8.8 ± 6.0 hpw) was lower than baseline (10.5 ± 5.5 hpw; P < 0.03).
Discussion: This pilot study suggests that DDR reduces SST and may facilitate slight increases in vigorous PA. Further
study is needed to better characterize children and contexts in which DDR may promote a healthy lifestyle.
Obesity (2008) 16, 2074–2080. doi:10.1038/oby.2008.295
INTRODUCTION
The escalating epidemic of childhood overweight stems from
multiple factors including decreased moderate and/or vigorous physical activity (MVPA) and increased sedentary behaviors (1).
A study of objectively monitored MVPA found that only 3%
of youth in first to third grade met the “Healthy People 2010”
guidelines of engaging in 20-min bouts of vigorous activity at
least 3 days per week (2). Multiple barriers to MVPA have been
reported. Many families feel that it is not safe to play outdoors
in their neighborhoods (3,4). Others view the distance to the
nearest open play area or reliance upon working parents for
transportation to MVPA opportunities as prohibitive (5,6).
These issues may be particularly problematic in rural areas and
among low-income families.
In contrast, youth are exposed to many appealing sedentary
screen time (SST) options (7,8). Further, caregivers often regard
screen activities in the home as a safe and inexpensive form of
child entertainment (9). In the United States, school-age children
spend an estimated 3 h per day watching television (TV) and
~60 min per day (mpd) playing video games (10). Multiple studies correlate TV time with overweight status (11–15). TV may
contribute to adiposity not only by displacing PA, but also by
increasing snacking on unhealthy foods, which are frequently
advertised on TV. In a large study of youth, each hour increase of
TV watching was associated with an additional energy intake of
167 kcals/day (16). However, among children <8 years of age, the
amount of traditional video game play was even more strongly
associated with obesity than TV watching (17).
Most efforts to reduce overweight have focused on increasing
MVPA, decreasing sedentary behaviors or both (18–20). In a
year-long cohort study of 11,887 youth 10–15 years old, BMI
decreased by –0.06 kg/m2 in girls and –0.22 kg/m2 in boys each
hour increase in daily MVPA and BMI increased by +0.05 kg/m2
with each hourly increase in SST in girls (21). Further models
in which an hour of SST was replaced by an hour of MVPA
showed reductions of ~0.5 BMI units in youth except lean boys.
Department of Psychiatry, Center for Psychiatric Research, Maine Medical Center Research Institute, Scarborough, Maine, USA; 2Department of Psychiatry, University
of North Carolina, Chapel Hill, North Carolina, USA; 3Department of Nutrition, University of North Carolina, Chapel Hill, North Carolina, USA; 4Constella Group, Durham,
North Carolina, USA; 5Department of Allied Health Sciences, University of North Carolina, Chapel Hill, North Carolina, USA; 6Department of Biostatistics, University of
North Carolina, Chapel Hill, North Carolina, USA. Correspondence: Ann E. Maloney (malona1@mmc.org)
1
Received 27 March 2007; accepted 29 October 2007; published online 3 July 2008. doi:10.1038/oby.2008.295
2074
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intervention and Prevention
Effects were greater in overweight youth. Interestingly, it may be
easier to reduce sedentary behaviors than to increase MVPA. In
the Stanford Girls Enrichment Multisite Study of 8–10-year-old
African-American girls, the intervention group was provided
access to dance classes 5 days per week at local community centers and was taught strategies to reduce TV viewing, whereas the
control group received health education talks and newsletters
(7). There was a significant reduction in household TV viewing
in the intervention group as compared to the control group. In
contrast, both groups showed indistinguishable reductions in
MVPA, despite expectations that MVPA would increase in the
intervention group. In another study, there was no difference
in the efficacy of coupling a dietary intervention with efforts to
increase MVPA or with efforts to reduce sedentary behaviors;
both strategies led to a 10.9% reduction in overweight among
90 children aged 8–12 over a 2-year period, although objective
measures of MVPA and sedentary behaviors are not provided
to determine whether they in fact changed (12).
Dance Dance Revolution (DDR) is a popular active video
game initially introduced in arcades and now available for
home use. Numerous studies have demonstrated that individuals engage in MVPA while playing DDR (22–24). Children
aged 8–12 years increased their resting energy expenditure
by 172% while playing DDR (25), which was greater than the
increases observed while playing the Eye-Toy (Sony Computer
Entertainment, Foster City, CA), walking on a treadmill,
or dancing to music (26). Thus, DDR may be an innovative
strategy for increasing MVPA in youth that does not require
significant changes in the environment of youth. In addition,
DDR may displace some SST, which also may have health benefits. However, it is essential to rigorously evaluate the utility
of DDR in promoting a healthy lifestyle given marketing pressures and the enthusiasm of the lay press.
Madsen et al. (2007) recently published results of a feasibility study examining whether 30 youth aged 9–18 years with
BMIs above the 95th percentile (mean BMI 38.3 ± 9 kg/m2)
would engage in DDR consistently over a 6-month period
and whether DDR use in this population was correlated with
change in BMI (27). In this study, 12 of 26 (46%) children used
DDR at least twice weekly during the first 3 months. However,
this level of play was sustained in only 2 of 21 (9.5%) participants. Days of use of DDR were not associated with a change in
BMI. Limitations of Madsen’s study include selection of obese
youth who may be among the hardest to engage in MVPA, the
sample’s broad age range, and the absence of objective measures
of MVPA and SST. In addition, the analysis of BMI changes
may be confounded by two factors. First, because all participants were recruited from a pediatric obesity clinic, they were
likely receiving other intensive interventions that may be more
potent than DDR or compete for time with DDR. Second, the
decision to characterize DDR use as days of DDR play rather
than duration of ongoing DDR play or DDR min per week
(mpw) fails to distinguish between those who play for 5 mpd
and those who play for more than an hour and those who
played throughout the intervention period from those who
played intensively for a much shorter period. It remains to be
obesity | VOLUME 16 NUMBER 9 | SEPTEMBER 2008
determined whether DDR may have more appeal for younger
children or children who have not yet developed severe obesity.
In addition, future studies will benefit from assessment of SST,
more direct assessment of MVPA and a comparison group.
Additional work is also needed to identify situations in which
DDR may offer advantages over other forms of MVPA and
strategies that may facilitate the use of DDR. Although DDR
may be advantageous in reducing weight, its greatest benefit
may lie in developing healthy lifestyle habits early in life. Many
studies have suggested that MVPA is already decreasing as
children enter the second decade of life, so it may be beneficial
to explore the use of DDR during elementary school years. Our
study addresses some of these issues. First and foremost, it is
focused on directly assessing DDR’s effect on two aspects of a
healthy lifestyle—MVPA and SST—rather than on the more
distant outcome of weight loss. Further, it focuses on a population of young children who could be targeted for preventative interventions rather than on individuals who are already
obese. Finally, unlike the Madsen study, it includes a randomly
assigned comparison group without access to DDR. The objectives of our “proof of concept” pilot study were to determine
whether DDR could be used by young children in their homes
to increase MVPA and/or decrease SST. Information about
potential effects on body mass and vital signs, and factors that
may facilitate DDR play such as coaching, playing with others,
and parental involvement were also explored.
METHODS and procedures
Participants
Children between the ages of 7 and 8 were recruited through postings
in schools, libraries, malls, and email solicitation on the University of
North Carolina campus list serve. Those who had health issues that
could interfere with DDR, such as broken limbs, poorly controlled
exercise-induced asthma, significant abnormalities on screening physical exam, or who had previously played DDR more than two times were
excluded. After screening, youth were randomly assigned to the DDR
group or to the wait-list control group for 10 weeks for the primary
component of this trial. Subsequently, all participants were provided
with unlimited, in-home access to DDR with follow-up assessments
completed at 28 weeks. The purpose of the second interval of data collection from weeks 10 to 28 was to provide naturalistic information
about the sustainability of DDR in this age group. In addition, obtaining
data from the control group provided additional information regarding
behavioral changes associated with DDR use by children. This protocol and study consents and assents were reviewed and approved by the
University of North Carolina Biomedical Institutional Review Board.
All participants and guardians signed consent before participating in
any study assessments or procedures.
DDR intervention
After baseline assessments were completed, families in the intervention group were provided with all equipment necessary to play DDR in
the home (PlayStation2 game console (Sony Corporation of America,
New York, NY), DDR MAX2 game (Konami of America, Redwood City,
CA), and two padded dance mats). We provided two mats to encourage
social and competitive play in the family home. Children were given
a written physician prescription to play 120 mpw of DDR, preferably
divided over four sessions. (This was done to increase the participant’s
sense of obligation to play DDR. The 120 mpw goal was chosen because
it seemed attainable and we did not want DDR to displace other forms
of baseline MVPA). We provided logs to participants in which to record
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intervention and Prevention
the daily minutes of DDR play, asked parents to verify and co-sign the
reports and mail them to us at the end of each week in prepaid envelopes. Number of DDR games played (on each game console) was also
recorded on 8-MB Playstation2 memory cards which we collected at
week 10. Staff set up the equipment in the home, ensured it was operational, and provided the child and caregivers with a brief handout about
operation of the game and strategies for improving skills. Research team
members were available by pager to address equipment malfunctions.
Youth enrolled kept all of the equipment provided. Hand controllers
were not provided to encourage children to use the Playstation2 game
for weight-bearing activity only. Half the DDR group was randomly
selected to receive five weekly, 1:1 30-min coaching sessions to explore
whether coaching encouraged more DDR use. Between weeks 10 and
28, no specific instructions regarding DDR play were provided.
Wait-list control intervention
Children and families in the control group were asked not to play any
DDR, regardless of setting. After the initial 10 weeks were completed,
the control group was provided with DDR resources.
Assessments
Activity measures. PA was objectively assessed using the ActiGraph
accelerometer (MTI Health Systems, Ft. Walton Beach, FL), worn for
7 days during waking hours at weeks 0, 10, and 28. The ActiGraph
detects acceleration ranging in magnitude between 0.05 G and 2.00 G
with frequency response from 0.25 to 2.50 Hz and stores all data for
subsequent analysis. The ActiGraph is valid and reliable for characterizing various levels of PA in youth aged 7–15 years (28).
SST at week 0 (September 2004), week 10 (December 2004), and week
28 (April 2005) was assessed for a 7-day period using an instrument
modified from a study focused on reducing SST (18). Children and parents co-reported the amount of time the child spent in various sedentary
activities during the weekdays and weekends. This self-report measure
completed jointly by participants and their parents asks about the time
(in 15-min increments) the child spent in sleep, SST, light, moderate and
vigorous activity for each of the 7 days of the prior week. Examples are
provided of various levels of activity (e.g., doing crafts is “light,” walking
is “moderate,” and running and jumping are “vigorous”). Parental reports
of their children’s TV time have been shown to correlate well with objectively measured TV viewing (29,30).
Health-related measures. Research staff collected anthropometrics
and body composition data on participants using the Tanita TBF-310
scale and a stadiometer. Seated pulse and blood pressure were measured
using an Omron HEM-637 wrist sphygmomanometer. Staff performed
manual determinations on children with small wrist circumference.
Other measures. Youth wore open-faced pedometers during the
baseline week and the first 10 weeks of the study. They were asked
to record daily steps on self-report logs cosigned by their parents
and mailed in prepaid envelopes for family convenience on a weekly
basis. Participants in the study and their parents also completed a
satisfaction survey upon completion of the study. Fourteen youth
and their parents attended focus groups to provide additional feedback at the end of the study.
Data management
Data were analyzed using SAS (v9.1.2, Cary, NC). ActiGraph readings
were processed using methods similar to those reported by Puyau (31).
Occasional missing accelerometry data within a child’s 7-day record
were replaced by imputation based on the Expectation Maximization
algorithm (32). However, if there were valid data for <80% of waking
hours or no data from at least one weekend day, no imputation was
performed. Rather, all accelerometer data from that participant at that
time point were disregarded and considered missing. Analyses were
performed with and without imputation. ActiGraph data were reduced
by defining thresholds for four levels of activity based on the number of
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metabolic equivalents expended (Table 1). The sum of the times spent
in all four activity levels reflects the total time the ActiGraph was worn
since sedentary activity is also measured.
Statistical analyses
Within-group analyses were evaluated using paired t-tests. Betweengroup differences were evaluated using the Satterthwaite two-group t-test
method, which assumes that variances between groups are unequal. We
did not correct for multiple comparisons in this pilot study.
RESULTS
A total of 122 prospective participants were screened, and 60
children (30 boys, 30 girls, age 7.5 ± 0.5 years) signed consents
and participated in the study. The sample was predominantly
white, middle class, and of normal BMI (17.6 ± 2.7); z-score
0.56 ± 0.92. After baseline assessments, youth were randomized
into DDR (n = 40) and control (n = 20) groups. The intervention and control groups were similar in age, sex, race, anthropometric measurements, and family characteristics (Table 2).
The entire sample was retained at week 10 and 90% participated
at week 28. The children were highly compliant with most of
the assessment measures. ActiGraph wear times averaged 12.5,
10.2, and 9.3 h per day at weeks 0, 10, and 28, respectively. This
corresponds to ~90, 73, and 66% of waking hours. However,
the Actigraphs malfunctioned in 5 of 54 cases (~10%), resulting in missing data. At baseline, 39 youth in the intervention
group and 20 in the control group had valid ActiGraph readings. At 28 weeks, 37 youth in the intervention group and 14 in
the control group had valid ActiGraph results. In contrast, only
63% of participants completed all pedometer logs.
Table 1 ActiGraph criteria for types of activity
Type PA
METs
Cutpoints (counts per minute)
0–2
>100
>2–3.5
101–1,159
Moderate PA
>3.5–5.9
1,160–5,200
Vigorous PA
>6
>5,200
Sedentary PA
Light PA
METs, metabolic equivalents; PA, physical activity.
Table 2 Sample characteristics (n = 60)
Variable
Age (years)
Non-white/white
Height (inches)
Basic DDR (n = 40)
Wait list (n = 20)
Mean (s.d.)
Mean (s.d.)
7.5 (0.5)
7.6 (0.5)
10/40
5/15
49.4 (2.2)
51.0 (2.8)
Weight (pounds)
60.21 (11.4)
67.95 (17.6)
Female (no (%))
19 (48)
11 (55)
17.2 (2.4)
18.0 (3.3)
BMI (kg/m )
2
% College graduate parent
90
100
% Income ≥$60,000
73
70
7
3
TV/DVD or VCR child’s
bedroom
DDR, Dance Dance Revolution; DVD, digital versatile disc; TV, television; VCR,
videocassette recorder.
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intervention and Prevention
Use of DDR
Changes in SST
Self-reported DDR use was 89 ± 82 mpw over the first 10
weeks. Peak use occurred during the first week (147 ±
145 mpw) and gradually decreased to half the “prescribed”
level (60 ± 61 mpw) (Figure 1). Memory cards revealed that
all 40 youth played DDR and only one played an additional,
non-DDR game.
The DDR group showed a reduction in the amount of SST
between week 0 (10.5 ± 5.5 h per week (hpw)) and week 10
(9.3 ± 4.9 hpw; Δ = –1.2 ± 3.7 hpw, P < 0.05), whereas SST
increased in controls from 9.3 ± 5.7 hpw to 12.3 ± 7.2 hpw
(Δ = +3.0 ± 7.7 hpw, P < 0.09). The between-group patterns
of SST changes differed significantly (P < 0.03), corresponding
to an absolute reduction in ~4.2 hpw of SST for subjects relative to controls. Interestingly, SST decreased further by 1.0 ±
5.7 hpw in the DDR group over the next 18 weeks. From week
10 to week 28, access to DDR in the control group coincided
with a significant decline in SST (Δ = –2.9 ± 8.4 hpw, nonsignificant) as shown in Figure 2.
Changes in PA
Accelerometer measurements of PA are provided in Table 3.
There were no statistical differences between the intervention
and the control groups in vigorous, moderate, light, or sedentary PA, contrary to our expectations. However, there was a significant increase in vigorous PA in the intervention group (from
10.0 ± 7.7 mpw to 16.2 ± 11.8 mpw, P < 0.0005). No ­with­in-group
differences were seen in moderate PA in either group. However,
light PA decreased in both the DDR group and the control group
at week 10 (DDR: 15.6 ± 38.9 mpd, P < 0.02; control: 28.2 ± 54.8
mpd, P < 0.03). The increase in vigorous PA and reduction in
light PA persisted through week 28 and remained statistically
different from baseline in the intervention group (P < 0.01 and
P < 0.002). There were no within-group changes noted in moderate PA in either the intervention or control groups noted during the first 10 weeks. However, moderate PA did increase in
the control group once they were given access to DDR (from
112.1 ± 36.7 to 135.9 ± 31.4, P < 0.005).
Exploratory measures
Changes in anthropometrics. Children in all groups demon-
strated increases in BMI during the first 10 weeks consistent
with typical development. Across all groups, BMI z-scores
were stable from baseline to week 10. Week 28 attrition prohibited drawing conclusions about trends in total body mass
(Table 4). Systolic blood pressure increased significantly and
to a similar extent in both the DDR and control group between
week 0 and week 10 (4.9 ± 10.5 mm Hg, P < 0.006 and 10.6 ±
13.6 mm Hg, P < 0.003 respectively), with no between-group
differences. There were no significant differences in diastolic
blood pressure or pulse.
9
12
10
8
6
4
2
0
−2
−4
−6
−8
+
Intervention
Control
* Pre–post ∆ P < 0.05
** Pre–post ∆ P < 0.03
*
+ Between group ∆ P < 0.006
**
Week 10
10
8
Week 28
W
k
k
W
7
k
W
6
k
W
5
k
W
4
k
W
3
k
W
k
W
k
k
W
W
2
Hours/week
Change in sedentary screen time (Dennison)
1
DDR (min/wk)
Home DDR use
300
275
250
225
200
175
150
125
100
75
50
25
0
Figure 2 Dance Dance Revolution (DDR) reduces sedentary screen
time. All pre–post comparisons are from baseline.
Figure 1 Dance Dance Revolution (DDR) use in 7–8-year olds.
Table 3 Mean physical activity recorded by ActiGraph (minutes per day)
DDR group
Week Week
0
10
38
37
Δ
28–0
Week Week
Δ
Week
Δ
0
10
10–0
28
28–0
14
14
20
14
20
38
37
t = 0.06,
P < 0.95
Light PA
344.8 331.2 –15.6 321.5
(51.3) (34.3) (38.9) (50.1)
–22.8
(42.3)
t = 2.43,
P < 0.02
t = 3.27, 344.3 316.1 –28.2 313.9 –27.8 t = 2.3,
t = 2.5,
P < 0.002 (43.5) (49.5) (54.8) (59.5) (41.6) P < 0.033 P < 0.027
t = 1.01,
P < 0.31
Moderate 138.4. 131.2 –7.2 139.6
PA
(33.3) (33.4) (28.3) (30.0)
1.2
(33.0)
t = –0.05,
P < 0.96
t = –0.99, 116.4 112.1 –4.3 135.9 19.5
P < 0.33 (26.8) (36.7) (34.3) (31.4) (22.4)
t = 0.12, t = –3.36,
P < 0.91 P < 0.005
t = 0.14,
P < 0.89
Vigorous
PA
4.5
t = –3.8, t = –2.71,
(10.1) P < 0.0005 P < 0.01
t = –1.42, t = –0.01,
P < 0.173 P < 0.99
t = 0.91,
P < 0.37
14.9
(10.1)
20
Between
group
10–0
t = 0.12,
P < 0.91
6.0
(9.5)
20
Within
group
28–0
37
16.2
(11.8)
20
Within
group
10–0
–0.5
(48.4)
10.0
(7.7)
38
Week
28
Within
group
28–0 (P)
Sedentary 292.0 289.7 –0.8 290.9
PA
(62.0) (51.7) (43.0) (56.6)
n
39
Δ
10–0
Wait-list control group (access to DDR at w10–w28 only)
Within
group
10–0 (P)
318.7 309.8 –8.9 299.9 –28.5 t = 0.72, t = 2.69,
t = 0.61,
(50.0) (42.8) (55.2) (36.5) (39.7) P < 0.479 P < 0.019 P < 0.544
9.3
(5.7)
12.7
3.4
(10.1) (10.8)
10.2
(6.4)
0.0
(9.3)
All values are mean (s.d.). Boldface signifies P < 0.05.
DDR, Dance Dance Revolution; PA, physical activity.
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Table 4 Health-related measures
DDR group
Control group
Within
group
10–0 (P)
Within
group
28–0 (P)
Significance
between
group
10–0 (P)
Week 0
Week 10
Δ 10–0
Week 28
(n = 14)
NS
18.0
(3.3)
18.3
(4.0)
0.3
(1.7)
18.7
(3.6)
NS
57.2
(28.5)
NS
65.8
(24.4)
66.0
(24.2)
68.8
(26.4)
NS
0.54
(1.1)
NS
0.61
(0.93)
0.61
(0.90)
0.72
(0.98)
NS
4.9
(10.5)
t = –2.91,
P < 0.006
99.6
(12.7)
110.2
(11.8)
10.6
(13.6)
t = –3.4,
P < 0.003
t = –1.76,
P < 0.08
66.8
(9.0)
0.4
(11.5)
NS
64.1
(9.6)
67.1
(10.3)
3.1
(11.6)
NS
t = –0.84,
P < 0.41
92.0
(11.4)
1.7
(13.9)
NS
87.1
(12.0)
86.5
(19.4)
–1.2
(17.5)
NS
t = 0.67,
P < 0.51
Week 0
Week 10
Δ 10–0
Week 28
(n = 27)
BMI
17.1
(2.4)
17.4
(2.3)
0.3
(0.5)
16.8
(2.2)
BM%
65.5
(26.5)
66.5
(27.2)
BMI
z-score
0.54
(0.93)
0.57
(0.96)
SBP
102.9
(10.1)
107.8
(7.2)
DBP
66.5
(7.0)
Pulse
90.7
(12.6)
t = 0.08,
P < 0.93
All values are mean (s.d.).
DBP, diastolic blood pressure; DDR, Dance Dance Revolution; NS, nonsignificant; SBP, systolic blood pressure.
Satisfaction with DDR. We conducted two focus groups for
youth and two for parents, as well as satisfaction surveys for all
youth enrolled. We found that most youth described the game
as fun and learned it easily using the lesson mode, whereas a
few were frustrated with the pace. Most raised their scores and
were proud of their dancing success, using provided stickers and
logs and disposable cameras to help them track their improvements. Several parents commented that DDR was a nonviolent video game, and they enjoyed playing DDR with their
children. Several noted that peers and siblings played alongside the study subjects. In the satisfaction survey at the end of
the 28 weeks, 95% of youth endorsed liking DDR, and 93% of
parents agreed. We also found in surveys that 15 parents had
purchased pedometers on their own, with no prompting from
us, to promote encouragement or possibly comparisons with
their children who were keeping track of parent PA by counting steps. We had not predicted this pedometer-­purchasing
behavior, but it came to our attention from feedback sessions.
Further study is needed to find out about the effect, if any, on
children influencing parental behavioral, awareness of PA, or
even changes made as a family unit. More than half (54%) of
the parents believed that DDR ultimately did increase their
child’s PA and would recommend DDR to others.
DISCUSSION
This pilot study was successful in encouraging children aged
7–8 years to play DDR for a mean of 89 mpw in their homes,
with ~33% decline in use over 10 weeks. During this period,
youth in the DDR group also increased their vigorous PA significantly by 6 mpd (or 42 mpw), whereas no increase in vigorous PA was observed in the control group. Nonetheless, this
small pilot study failed to detect a difference between vigorous
PA in the DDR and control groups. In contrast, a significant
difference was detected in SST habits. The DDR group showed
a significant reduction in SST from 10.5 ± 5.5 hpw to 9.3 ±
4.9 hpw in comparison to the control group which showed an
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increase in SST from 9.3 ± 5.7 hpw to 12.3 ± 7.2 hpw (between
group P < 0.03). Further, children and their families reported
in focus groups enjoying DDR and scored themselves 2.9
on a scale of proficiency at DDR (anchors: 1 = not so great,
2 = solid beginner, 3 = advanced; doing pretty hard songs, and
4 = expert, could be in a contest). Coaching did not improve
results. Finally, even among this health conscious and middleclass sample, mean levels of vigorous PA were <20 mpd. As
expected, no significant changes were observed in anthropometric measures that were observed in this brief intervention
in nonobese youth in this pilot.
Our results are consistent with those of Epstein who found
that 8–12 year olds found DDR more appealing than dancing
to music, bicycling, or playing an interactive bicycle game with
7-point Likert ratings of 6.1 for DDR, 5.8 for the interactive
bicycle game, 4.9 for bicycling, and 3.3 for dancing to music
(26). Similarly, the initial amount of DDR play observed in
our sample was similar to that seen by Madsen (2007), 88 ±
16 mpw during the first 3 months and 63.3 mpw over the entire
6-month period (27). In contrast to this study, neither of these
studies specifically assessed SST or objectively assessed MVPA.
However, our study suggests that DDR may be an innovative
strategy for increasing MVPA in youth that does not require
significant changes in the environment of youth. In addition,
DDR may displace some SST, which also may have health
benefits.
Limitations
This pilot study has several limitations. The sample was small;
therefore, only large effects were detectable between groups,
and outliers can affect findings significantly. However, a sample size of ~500 would be required to demonstrate statistical
differences given the effect size of ~0.25 for vigorous PA suggested by this study, or at least ~240 to detect BMI changes,
had that been our goal (using methods based on this pilot’s
s.d. ratios of BMI) (33). The study is also limited somewhat
VOLUME 16 NUMBER 9 | SEPTEMBER 2008 | www.obesityjournal.org
articles
intervention and Prevention
by available outcome measures. Five of fifty-four Actigraphs
(~10%) malfunctioned resulting in missing data. Actigraphs
are known to be insensitive to some sorts of movement such as
bicycling and swimming. In addition, there are few measures
available other than self-reports for assessing SST and other
ways that individuals spend their time. Although self-report
measures may be subject to bias, they have been found to correlate adequately with video observation of children’s TV viewing (26,27). In contrast, there is no demonstrated relationship
between the SST self-report or video monitoring and sedentary PA as assessed using the Actigraph. Also, it is likely that
SST represents a relatively small proportion of sedentary and
light PA and accounts for little of its variance. The study also
would have been improved by monitoring the amount of DDR
play throughout the entire 28 weeks rather than just the initial 10 weeks. Although we had hypothesized that pedometer
data would complement Actigraph data, it is possible that they
actually skewed the baseline data by providing real-time feedback at a time of heightened awareness of the importance of
PA (or possible parental dyadic interactions we did not measure). Pedometers were meant to provide inexpensive information and to promote comparisons with the other measures,
but compliance in this age group with logs was a limiting factor. Another potential confound is the potential lack of generalizability of this pilot sample. Most participants were upper
middle class and already had numerous opportunities to participate in MVPA. Further, most parents were reported believing that healthy lifestyles and physical fitness were important
at baseline. Consequently, it is possible that DDR was less compelling than it would be for youth with fewer opportunities for
MVPA. In addition, seasonal variations in various types of PA
and SST among US children are not well defined. It is possible
that some of the within-group changes that appear encouraging in the DDR group reflect seasonal differences rather than
benefits of DDR, particularly because between-group differences were not observed.
This study found that DDR significantly reduced SST in
7–8-year-old youth. However, robust changes in MVPA were
not different between the treatment and control groups. This
study is consistent with other studies that have found it relatively difficult to increase MVPA in youth and somewhat easier
to reduce SST. The extent of relative reduction in SST (4.2 hpw)
was not seen by Robinson (7), although it is comparable to a
related outcome (reduction in family TV watching (4.9 hpw))
reported by Robinson. It should be noted that DDR likely
costs less than Robinson’s intervention program. Both studies
emphasize the challenges associated with enhancing a range
of healthy lifestyle behaviors especially with focused, singletechnique approaches.
It seems unlikely that DDR and other active home-based
video games will consistently facilitate a healthy lifestyle among
children. However, the fact that some individuals in the DDR
group did show marked increases in vigorous PA suggests that
DDR should be studied further to determine the characteristics of youth and communities that might benefit from its
use. Further, it is likely to be useful to see whether additional
obesity | VOLUME 16 NUMBER 9 | SEPTEMBER 2008
supports can be easily implemented to maintain interest and
enthusiasm in the game. Potential contexts might include use
of DDR in after-school programming or even during school
days (outside of physical education classes), using more varied songs, and using competition as a motivator. Investigations
could take place to evaluate the quality of the reinforcers and
supports needed at various developmental stages and settings, which may evolve with newer in versions of this kind of
active game.
Acknowledgments
We acknowledge the efforts of the children and parents who participated
in the DANCER study, the DDR trainers: Jamie Regulski, Hillary Smith,
Michael Bade, Justin Wilhelm, Jessie Campbell, and Silke Ullmann;
research assistants: Jonathan Bloom, Jonas Horowitz, Cathy Jones,
Amy Levine, Cheree Porter, Marta Rojas, Emily Williams, and Traci Yates.
We are grateful to Abby Sheer and Peter Robichaux for the database
development. Physical examinations were provided by Drs Adams, Ambler,
and Meikranz, as well as the other MD authors. We also acknowledge the
assistance of Manuel Matsikas (EB Games corporate) and Steve Trinkley
(HeartratemonitorsUSA). The Tanita Scale, used to obtain bioelectrical
impedance measures and weight, was loaned from the University of North
Carolina (UNC) Center for Nutrition Research Unit, Body Composition Core
National Institutes of Health (NIH)-DK056350. We thank Drs Bulik, Brownley,
Ward, and Stevens for reviews and suggestions, and the Subject Core lead
by J.M., and for ActiGraph data, capably transformed by Larry Johnston.
The Center for Development and Learning hosted the measurement events
for the protocol. This research was funded by an unrestricted grant from
“Get Kids in Action,” a partnership between the Gatorade Foundation via
the UNC at Chapel Hill, School of Public Health. Research support was
provided for A.E.M. in part by the NIH grant T32-MH19011 and Maine
Medical Center Research Institute and for T.C.B in part by the NIH grant
T32 HD 40127.
Disclosure
The authors declared no conflict of interest.
© 2008 The Obesity Society
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