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The Association of Exergaming and other Activities with the WHO Physical Activity Recommendations among Female Adolescents in Saudi Arabia

Authors:
Cloud Publications
International Journal of Advanced Nutritional and Health Science
2019, Volume 7, Issue 1, pp. 325-333
ISSN 2348-5140, Crossref: 10.23953/cloud.ijanhs.423
_____________________________________________________________________________________________________
The Association of Exergaming and other Activities with the WHO
Physical Activity Recommendations among Female Adolescents in
Saudi Arabia
Eiman M. Alghmdi, W. Lawrence Beeson, Ernesto Medina, Anna Nelson, Hildemar dos Santos
School of Public Health, Department of Healthy Lifestyle and Disease Prevention, Loma Linda University, United
States
Correspondence should be addressed to Eiman M. Alghmdi, ealghmdi@llu.edu
Publication Date: 2 August 2019
DOI: https://doi.org/10.23953/cloud.ijanhs.423
Copyright © 2019. Eiman M. Alghmdi, W. Lawrence Beeson, Ernesto Medina, Anna Nelson, Hildemar dos
Santos. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Abstract This cross-sectional study examined the association of the number of hours of exergaming
along with other activities and body mass index (BMI) among Saudi female adolescents and explored
the possibility of exergaming as an alternative to meet the World Health Organization (WHO) physical
activity recommendations. A sample of 200 female students age 10-14 years completed a self-
administered lifestyle questionnaire with their parents’ assistance after obtaining parental consent
letter. The survey instrument included scales adopted from the validated Adolescent Sedentary
Activity Questionnaire (ASAQ) and modified to include questions for exergaming. Anthropometric
measurements of height and weight were conducted at school after the completion of the survey. A
multiple linear regression model was conducted to examine the association of exergaming with other
sedentary activities and BMI. There was a significant association between the number of hours of
exergaming and lower BMI (p<0.001). Moreover, there was a significant difference between both
groups with 98% of the exergamers accumulating ≥60 minutes of physical activity daily vs. 0% among
non-exergamers (p<0.001). Exergaming may contribute to reducing sedentary behaviors and
increasing physical activity levels and could be an alternative solution to aid in meeting the WHO daily
recommendation of physical activities for Saudi girls.
Keywords Active video gaming; Physical activity; Sedentary lifestyle; Youth health
1. Introduction
Exergaming has been the new trend in research to assist in promoting physical activity in children and
to reduce sedentary behaviors (PolechoNski, Dwbska, & Dwbski, 2019). Recent studies have
explored different approaches to reduce sedentary behaviors that include replacing inactive screen
time (e.g., computer, television) with active gaming that requires children to participate in full body
motion to interact with the games (Graf et al., 2009; O'Loughlin et al., 2012; Witherspoon, 2013).
Increasing energy expenditure and oxygen consumption along with strength and flexibility have been
reported in the literature as some of the positive outcomes of exergaming (Bailey & McInnis, 2011;
Lau et al., 2016; Witherspoon, 2013).
Research Article
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In Saudi Arabia, the ban of a structured physical education program for females in public schools has
been the main obstacle to keep girls active (Abalkhail, 2002), especially with the high overweight and
obesity rates within this population (Alam, 2008; Alqarni, 2018). Also, sedentary behaviors among
Saudi children have been reported to be higher among female adolescents compared to males (Al-
Hazzaa et al., 2012; Alqarni, 2018).
The purpose of this study was to examine the association of the number of hours of exergaming along
with other activities and body mass index (BMI) among Saudi female adolescents. We also explored
the possibility of exergaming as an alternative to meet the World Health Organization (WHO) physical
activity recommendations (Physical Activity, 2018) to reduce sedentary behaviors in a population that
lacks the typical form of physical activities associated with social norms.
2. Methods
Participants and Recruitment
A total of 200 female students age 10-14 years completed a self-administered lifestyle questionnaire
with their parents’ assistance after obtaining the approval of the Ministry of Education (MOE) fr om
Saudi Arabia. For the choice of schools, five out of the 50 schools in Riyadh, Saudi Arabia were
randomly selected from different regions (i.e. north, south, east, west, central). Anthropometric
measurements of height and weight were conducted at school after the completion of the survey.
Ethical clearance and Institutional Review Board approval from the Loma Linda University was
granted before data collection.
Instrument
The questionnaire included items from a validated instrument known as the Adolescent Sedentary
Activity Questionnaire (ASAQ) (Hardy, Booth, & Okely, 2007) The instrument included sedentary
lifestyle questions such as watching TV, playing video games, using a computer and total sitting hours
on weekdays and weekend. It also included the assessment of dietary intake and other activity
questions such as exergaming and type and duration of sports. The survey was translated into Arabic
using the back-method translation (Beaton, Bombardier, Guillemin, & Ferraz, 2000).
The measurement for BMI was conducted by measuring the weight in kilograms (kg) using a medical
scale (Health O Meter) and the height in meters (m) using the portable Leicester Height Measure. The
calculation of BMI was conducted using the formula: weight (kg)/ (height (m))2. The CDC BMI for age
growth chart was used to convert BMI into centiles. Using the centile values, BMI was categorized into
four categories: Underweight for below 5th percentile normal for 5th to less than 85th percentile,
overweight for 85th to less than 95th percentile and obese for 95th percentile or greater.
Global recommendation on physical activity
The WHO recommendation of physical activity for children aged 5-17 years is to accumulate at least
60 minutes of moderate to vigorous intensity level of physical activities daily (Physical Activity, 2018).
Most of the physical activity should be aerobic, and it can be achieved through a variety of forms such
as; playing, games, sports, recreation, chores, physical education and planned exercise.
Data Analysis
Bivariate analysis including chi-squared test and Mann-Whitney test was used to compare the two
study groups. Box plots were created to display the TV and total sitting hour distributions of the
exergamers and non-exergamers. Multiple linear regression analysis was used to evaluate the
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independent relationships of exergaming with other sedentary activities and BMI. All analyses were
conducted using SPSS (IBM SPSS, Inc., Ver. 25.0, Armonk, NY).
3. Results
The demographic characteristics of the participants are presented in Table 1. The key differences
between the two groups include that the fathers of the participants in the exergamer group had a
significantly higher education level in comparison to the fathers of the non-exergamer group (bachelor
degree 53% vs. 44%, graduate degree 23% vs. 17%, p=0.001). A significant shift towards a higher
socioeconomic level was determined among exergamers vs. non-exergamers (high SES=22% vs.
15% respectively, p=0.02). For the overweight/obesity status, there was a significant difference in BMI
among exergamers (overweight 7%, obesity 1%) and non-exergamers (overweight 53%, obesity 1%)
(p<0.01). There was no difference in sports participation outside of exergaming between both groups.
For the type of exergame, the majority of the exergamers played dance simulation games (66%)
followed by sport Kinect games (33%), and only one participant played scooter and bike exergames.
Table 1: Demographics of study participants
Exergamers Group
(%) n=100
Non-exergamers
Group (%) n=100
p-value
9
25
26
24
16
8
22
24
25
21
0.91
26
32
42
27
30
43
0.95
45
9
27
10
9
43
8
23
18
8
0.60
3
12
20
57
8
10
25
14
43
8
0.20
0
11
13
53
23
12
16
11
44
17
0.001
0
78
22
5
80
15
0.02
92
7
1
32
53
15
< 0.01
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57
43
57
43
1.00
Significant differences between the two groups were also observed for the dietary intake (Table 2).
Seventy-five percent of the exergamers reported eating vegetables three or more times per week
compared with 65% of the non-exergamers (p=0.03). For fruit intake, 89% of the exergamers
consumed fruit three or more times per week compared with only 66% of the non-exergamers
(p<0.01). Also, intake of snacks three or more times per week was lower among exergamers vs. non-
exergamers (52% vs. 67% respectively, p=0.04).
Table 2: Dietary intake
Variable
Exergamers
group (%) n=100
Non-Exergamers
group (%)
n=100
p-value
Home-cooked meals intake
Every day
Three times/week
Once/week
90
8
2
86
13
1
0.44
Fast Food intake
Every day
Three times/week
Once/week
Every two weeks
Once/month
Rarely/never
2
20
43
20
13
2
3
13
34
20
17
13
0.31
Fruit intake
Every day
Three times/week
Once/week
< Once/week
45
44
9
2
41
25
17
17
< 0.01
Vegetables intake
Every day
Three times/week
Once/week
1-3 times/month
Rarely/never
43
32
10
11
4
46
19
11
9
15
0.03
High sugar-sweetened beverages
intake
Every day
Three times/week
Once/week
Every two weeks
Once/month
Rarely/never
16
36
25
6
8
9
33
24
19
3
10
11
0.06
Milk intake
Every day
Three times/week
Once/week
1-3 times/month
Rarely/never
59
18
8
5
10
45
26
10
3
16
0.24
Snacks intake
Every day
Three times/week
Once/week
< Once/week
13
39
32
16
27
40
20
13
0.04
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Table 3 shows the descriptive data listing various activities between exergamers and non-
exergamers. A higher number of sitting hours (e.g., TV and computer) was found among the non-
exergamers vs. the exergamers (the median for watching TV =11.7 vs. 7.8 hours/day, sitting= 7 vs.
4.5 hours/day respectively). These differences between both groups for the same variables are
represented using box plots for total TV hours/week (Figure 1) and total sitting hours/week (Figure 2).
This was also supported by a statistically significant difference of the mean ranks among the same
sedentary activities (TV watching and sitting hours/day) (p<0.01). Aside from the active exergaming,
there was no statistical difference between the two groups regarding playing inactive video games
(p=0.29).
Table 3: Descriptives for various activities between exergamers and non-exergamers
Variable
(hours/week)
Exergamers
median (IQR) n= 100
Non-exergamers
median (IQR) n=100
Watch TV
7.8 (4.0-13.8)
11.7 (6.5-17.9)
Watch video
4.3 (0-10)
0.8 (0-7.9)
Play inactive videogames
7 (2.1-10)
6.5 (2-16)
Use computer
2.5 (0-7)
0.2 (0-5)
Doing crafts
5 (2-8)
2 (0-5.4)
Sitting
4.5 (1.5-8)
7 (2.5-14)
Exergaming
12 (10-14)
0 (0)
Sport hours/week
1 (0-3)
1 (0-2)
The results of the multiple linear regression model that predicts the association between the number
of hours of exergaming and BMI percentile (adjusted for age) after the adjustment for sedentary
behaviors is shown in Table 4. The number of hours of exergaming was a strong and significant
predictive of a lower BMI percentile (= -10.02, 95% CI: -12.4, -7.64, p<0.001). The adjusted R2 for
this model is 37%.
When comparing the percentage of meeting the WHO recommendation of 60 minutes/day physical
activity (i.e. sport + exergaming) among this age group between the exergamers and non-
exergamers, there was a significant difference between both groups with 98% of the exergamers
accumulating ≥60 minutes of physical activity daily vs. 0% among non-exergamers (p<0.001).
Table 4: Regression coefficients and p-values for exergaming and sedentary variables in a regression model
predicting BMI percentile adjusted for age (n=200)
Exposure average hour/day
Coefficient (95% CI) P value
Exergaming
-10.020 (-12.4, -7.641)
<0.001
Watching TV
2.360 (0.322, 4.397)
0.023
Watching video
1.51 (-.871, 3.892)
0.213
Inactive video games
2.376 (-0.689, 0.654)
0.032
Computer use
-2.395(-5.961, 1.17)
0.187
Crafts
0.374 (-3.196, 3.944)
0.837
Sitting
1.402 (-1.129, 3.934)
0.276
Sport
-0.805 (-9.933, 8.322)
0.862
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Figure 1: Total TV hours/week between non-exergamers and exergamers
Figure 2: Total sitting hours/week between non-exergamers and exergamers
4. Discussion
The present study suggests a significant association between the number of hours of exergaming and
a lower BMI among Saudi female adolescents. Childhood obesity has been increasing at an alarming
rate in Saudi Arabia with higher prevalence among girls than boys (34.3% vs. 17.3%, p<0.0001) (Al-
Mohaimeed et al., 2015; Alqarni, 2018). According to Al-Mohaimeed (Al-Mohaimeed et al., 2015) this
is due to the contribution of several factors including the inability associated with cultural norms of
girls to practice sports (Al-Hazzaa et al., 2011; Al-Kutbe et al., 2017). The findings from this study
show that exergaming may assist in meeting the daily physical activity recommendation among Saudi
girls and may contribute to reducing the risk of obesity.
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The WHO recommendation for children to accumulate at least 60 minutes of moderate to vigorous
daily activities among children is challenging among Saudi girls (Abalkhail, 2002). It was seen in this
study that the majority of girls who exergame (98%) not only significantly reached that
recommendation of physical activity, but also had a lower number of sedentary activities hours (e.g.,
TV watch and sitting) in comparison to non-exergamers. Being physically active is one of the keys to
obtaining high energy expenditure, and therefore lower BMI among children through the mechanism
of caloric balance (energy intake vs. energy expenditure) (Carlson et al., 2012; Hill, 2006). The
argument is whether exergaming alone can be sufficient to achieve an adequate energy expenditure
of moderate to vigorous intensity exercise levels. Several studies show that different forms of
exergaming are associated with the increase of energy expenditure (EE) at different levels. Bailey et
al. (2011) examined six different forms of exergaming systems among middle school-aged children.
They found a 4-8-fold increase on EE above resting level, and that corresponded to moderate-
vigorous intensity levels. Additionally, Haddock et al. (Haddock et al., 2012) measured a significant
increase in heart rate and EE associated with exergaming that was equivalent to moderate intensity
exercise. This was supported via a review of the literature on exergaming and EE conducted by
Sween et al. (Sween et al., 2014). Most of the studies showed a moderate to vigorous intensity
increase in EE associated with exergaming with the most significant increase associated with dance
stimulation games (increase in EE of 300% above resting level).
The literature has identified sedentary behaviors as one of the risky behaviors that increase the
likelihood of overweight and obesity among children (Alqarni, 2018; Anderson et al., 2008; Laurson et
al., 2008). Exergaming could assist in converting these sedentary behaviors into more active time
among children (Gao et al., 2014). In contrast to non-active video gaming, exergaming might provide
fewer opportunities for children to snack and drink high-sugar sweetened beverages while playing
since it keeps them in a physically active manner to interact with the game (Simons et al., 2015). This
could provide an additional aid in the prevention of childhood obesity.
To our knowledge, we are not aware of any long-term follow-up studies in exergaming. But several
studies have demonstrated that children who participated in exergaming interventions reported that
playing exergames is highly desirable, fun, enjoyable and increased their motivation to become more
active (Bailey & McInnis, 2011; Dos Santos et al., 2016; Graves et al., 2010; Witherspoon, 2013).
This is the first study that examined the association between exergaming hours and BMI among
Saudi female adolescents and explored exergaming as an alternative solution to meet the daily
physical activity recommendation among this population. The limitations of this study include: the
cross-sectional design inhibits making causal inferences, self-reporting questionnaires, and time
frame-limitation. The generalizability of our study findings may be limited due to the sample including
girls only from one city in Saudi Arabia.
5. Conclusion
The results of the current study show a significant association between exergaming hours and lower
BMI among Saudi female adolescents. Exergaming may contribute to reducing sedentary behaviors
and increasing physical activity levels and could be an alternative solution to aid in meeting the WHO
daily recommendation of physical activities for Saudi girls.
Acknowledgments
The authors would like to thank the participants in this study. This study was not funded.
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Few lifestyle factors have been simultaneously studied and reported for Saudi adolescents. Therefore, the purpose of the present study was to report on the prevalence of physical activity, sedentary behaviors and dietary habits among Saudi adolescents and to examine the interrelationships among these factors using representative samples drawn from three major cities in Saudi Arabia. This school-based cross-sectional study was conducted during the years 2009-2010 in three cities: Al-Khobar, Jeddah and Riyadh. The participants were 2908 secondary-school males (1401) and females (1507) aged 14-19 years, randomly selected using a multistage stratified sampling technique. Measurements included weight, height, sedentary behaviors (TV viewing, playing video games and computer use), physical activity using a validated questionnaire and dietary habits. A very high proportion (84% for males and 91.2% for females) of Saudi adolescents spent more than 2 hours on screen time daily and almost half of the males and three-quarters of the females did not meet daily physical activity guidelines. The majority of adolescents did not have a daily intake of breakfast, fruit, vegetables and milk. Females were significantly (p < 0.05) more sedentary, much less physically active, especially with vigorous physical activity, and there were fewer days per week when they consumed breakfast, fruit, milk and diary products, sugar-sweetened drinks, fast foods and energy drinks than did males. However, the females' intake of French fries and potato chips, cakes and donuts, and candy and chocolate was significantly (p < 0.05) higher than the males'. Screen time was significantly (p < 0.05) correlated inversely with the intake of breakfast, vegetables and fruit. Physical activity had a significant (p < 0.05) positive relationship with fruit and vegetable intake but not with sedentary behaviors. The high prevalence of sedentary behaviors, physical inactivity and unhealthy dietary habits among Saudi adolescents is a major public health concern. There is an urgent need for national policy promoting active living and healthy eating and reducing sedentary behaviors among children and adolescents in Saudi Arabia.
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