Wii Fit may help people control diabetes

"Wii Fit games 'help control diabetes'," reports BBC News.

People with type 2 diabetes are usually advised to change their lifestyle – including taking more exercise – to help control their blood sugar levels.

In a novel randomised controlled trial, patients were given Nintendo Wit Fit Plus – an interactive console-based exercise game – to assist their efforts.

The researchers' main goal was to see if there was a change in people's blood sugar levels (HbA1c) after 12 weeks. They were also interested in their weight and quality of life.

After 12 weeks, the people who used Wii Fit Plus had significant improvements in blood sugar, but the researchers did not compare these results with people who received standard care. Reported quality of life was also significantly improved for people using Wii Fit Plus compared with people who received standard diabetes care.

The study's results are promising, especially as the game console is cheap and easy to use compared with other forms of diabetes care. However, the study does have limitations, including the fact that a relatively high number of people did not complete it.

Where did the story come from?

The study was carried out by researchers from the West German Centre for Diabetes and Health at Düsseldorf Catholic Hospital in Germany, and was funded by Novartis Pharmaceuticals. It was published in the peer-reviewed medical journal, BMC Endocrine Disorders.

The story was picked up by BBC News, which has not entirely accurately represented the study's findings. But to be fair to the BBC, these were not presented clearly by the study authors.

Although BBC News accurately reports that people who used Wii Fit Plus had improved body weight and HbA1c levels, these findings were also the case for people who received standard care.

What kind of research was this?

This was a randomised controlled trial (RCT) that looked at the health effects of a 12-week Wii Fit Plus intervention programme, comparing the results with standard diabetes care. 

An RCT is the best type of study design to determine whether a treatment is effective. It compares the effects of an intervention or treatment with another intervention or a control. Participants are randomly allocated to which of these they receive, which should balance out any other differences between the groups that could otherwise confound the results.

What did the research involve?

The study included 220 people with type 2 diabetes who were recruited throughout Germany through physician appointments or newspaper articles.

To be included in the study, participants had to meet the following criteria:

• have had type 2 diabetes for less than five years
• be between the ages of 50 and 75
• have a body mass index (BMI) of 27 kg/m2 or more (a BMI of 27 is considered overweight)
• be subscribed to the type 2 diabetes disease management programme

People who carried out regular physical activity or who were receiving particular diabetes drugs, such as metformin, were excluded.

The people with diabetes were then randomly allocated to one of two groups:

• An intervention group of 120 people was provided with a Nintendo Wii console, the exercise game Wii Fit Plus and a balance board, and were instructed to use these items for at least 30 minutes a day for 12 weeks.
• A control group of 100 people continued to have their usual care for 12 weeks, which consisted of visits to a physician for diabetes care. After 12 weeks, the control group then also received the Wii intervention.

The researchers carried out a series of measurements at the start of the study and again 12 weeks later. The control group also received assessments 12 weeks after they received the intervention.

Measurements included weight, blood pressure and blood tests to assess things such as HbA1c and cholesterol levels. Participants also completed a series of questionnaires on physical activity levels, quality of life and depression.

The main outcome that the researchers were interested in was whether there was an HbA1c reduction in the groups after 12 weeks. HbA1c is a measure of blood sugar levels and is used to monitor a person's diabetes.

Other outcomes they were interested in were weight change, possible risk factors that could affect the heart and metabolism, physical activity and quality of life. 

What were the basic results?

Of the 220 people included in the study, 176 people completed it (80%). Only about half of the control group who went on to have the intervention completed it.

The main finding was that after 12 weeks, there were no significant differences in HbA1c levels between people who received Wii Fit Plus compared with people who received their usual diabetes care.

However, people in the Wii Fit Plus group had significantly improved HbA1c levels after 12 weeks compared with the start of the study.

People who received their usual care did not have significantly improved HbA1c levels after 12 weeks compared with the start of the study.

Improvements in HbA1c were also seen when the people that initially received usual care later received the intervention.

Compared with the measurements taken at the start of the study, both the groups had significant reductions in weight and BMI after 12 weeks. However, the researchers did not compare BMI between the two groups.

Both groups had a significant improvement in self-reported physical activity, with the people in the Wii Fit Plus group showing more significant improvement. When the control group had the intervention, their physical activity levels also increased.

Diabetes-dependent impairment was significantly reduced in the Wii Fit Plus group compared with the usual diabetes care group. Quality of life also significantly improved in the Wii Fit Plus group

The presence of depression – assessed using three different questionnaires – provided mixed results, although at similar rates in each group. After 12 weeks, depressive symptoms reduced in the Wii Fit Plus group, but this was only found to be significantly reduced with one of the assessment tools. Depression was found not to change in the people who received usual care.

The study authors report that most of the participants did not make use of the exercise game alone, but played it with family members, which could be seen as a further beneficial effect of the intervention.

How did the researchers interpret the results?

The researchers report that the study demonstrates a significant reduction of HbA1c, weight and BMI during the 12-week intervention. They conclude that a low-threshold intervention with the interactive exercise game Wii Fit Plus was able to motivate people with type 2 diabetes to improve physical activity, metabolic control and quality of life.

One of the researchers, Professor Stephan Martin from the West German Centre for Diabetes and Health, is reported by the BBC as saying that exercise computer games offer an alternative way to get people physically active.

Conclusion

This study provides some evidence of the health effects of a 12-week Wii Fit Plus programme in older adults compared with standard diabetes care.

The study has many strengths, including its design: a randomised controlled trial, which is the gold standard in evidence-based medicine.

However, the people in the control group were most likely aware that they would be given the intervention 12 weeks later and that it was an exercise intervention. This may have increased the likelihood that they started other forms of exercise in the meantime, which was seen in the results. This makes it harder to see what the effects of the programme would have been compared with the status quo.

Despite the strengths, the study has some limitations. There was a relatively high level of drop-out from the study, which may have biased the results, but the researchers say the level of drop-out is similar to other studies of exercise interventions in older adults.

The authors also note that people who showed diabetic improvements may have been more strongly motivated to complete the study, which may not be representative of the general population with type 2 diabetes.

For some of the outcomes, no details are provided about whether there was an effect seen between the groups, so it is not possible to say that one had a better effect than the other. However, the researchers do provide information about whether there were any improvements within each group after 12 weeks compared with measurements taken at the start of the study.

Another limitation that the authors note is that the exercise game was used at home in an uncontrolled setting, so no objective information was obtained about whether or not the participants actually completed the recommended 30 minutes of Wii practice each day. Physical activity was also self-reported, so it may have been that the reported levels were not accurate, which may have biased the results.

Despite these limitations, the results are encouraging. A common complaint about exercise is that many people find it boring, so the "gamification" of exercise could make it more appealing to people. It would be interesting to see if an exercise game specifically designed for people with type 2 diabetes could lead to sustained improvements in outcomes.