Exercise as it relates to Disease/Is Pokemon Go-ing to increase exercise?

This is a critique of the article Influence of Pokémon Go on Physical Activity: Study and Implications, by Althoff T, White RW, Horvitz E (2016) published in the Journal of Medical Internet Research vol 18 issue 12

What is the background to this research?
A sedentary lifestyle has often been associated with increased risk of diabetes and cardiovascular diseases. Physical activity reduces the risk for disease and illness such as obesity, high blood pressure, depression, anxiety, as well as a lowered life expectancy. However it is a worldwide phenomenon that the recommended amount of daily physical activity is not reached by adults or children. Obesity is becoming a worldwide health epidemic, and while diet and exercise are imperative to its treatment and prevention, it is important to include physical activity as the main lifestyle change.

The research conducted by Althoff et al quantifies the impact of Pokémon Go on physical activity. No previous studies have been conducted with large-scale wearable sensors to study the effect of Pokemon Go. Although Pokémon Go was not created as an exercise intervention, the nature of the game results in incidental exercise. The game uses real-world maps to help players catch Pokemon, hatch Pokemon eggs after walking a specific distance, reach Pokestops for collecting items, and battle other players at Gyms. This research is important as physical activity and exercise are immensely critical for health, for the prevention and treatment of many chronic diseases. As Pokémon Go became a world phenomenon, it became an intervention for promoting healthy behaviour and implementing a lifestyle change.

Where is this research from?
This research was a joint study between the Computer Science Department at Stanford University and Microsoft Research, and published in the Journal of Medical Internet Research. There is no conflict of interest as Pokémon Go was not created by Microsoft nor Stanford University. Furthermore, the study was cleared by the Ethics Advisory Committee at Microsoft Research. The study population were users who had linked data from their Microsoft Band wearables and online activities to facilitate research and improvement of Microsoft products.

What kind of research was this?
This research was a longitudinal study conducted retrospectively. A longitudinal study involves observations over a period of time, allowing researchers to monitor developments of the target population. Physical activity levels of Pokémon Go users were compared to a control group of randomly selected Microsoft Band wearers.

What did the research involve?
Pokémon Go users were identified through Bing search queries that were Pokémon Go related. These search queries were manually executed by an author familiar with the game, and judged whether the query was evidence of someone playing the game. Examples of queries are Pokémon go guide', Pokémon go individual values', Pokémon go eevee evolution'. Users included in the data set had been using the Microsoft Band for a significant amount of time, median 433 days, such that there is already a pre-existing baseline of activity. The control group were randomly selected US population who had allowed Microsoft to see their data, and happened to be predominantly ale. Limitations of the study include that this study population was not taken at random, and it was highly likely that there were many Pokémon Go players that did not have, or could afford, a Microsoft Band. This restriction may have reduced the socioeconomic status of the users and narrowed the scope of participants. Participant recruitment was not an active process, but users who had allowed access to data from their Microsoft Band wearable device for activity tracking and had allowed data sharing for research purposes. Users were separated into groups based on the average number of searches. It can be extrapolated that one query less engaged users spend less time playing Pokémon Go when compared to ten query heavily engaged users. Lastly, the research follow-up period was limited to 30 days, restricting the long term longitudinal aspect of the study. Future research, for example in a cohort study, should have a longer research period to maximise the understanding of Pokémon Go on physical activity.

What were the basic results?
Initially, Pokémon go users had less activity than the control group, the average Microsoft band user. Following the start of Pokémon Go play, activity increased to a level larger than the control group, at an increased 192 steps per day for a less engaged user. Activity increases were larger for engaged users with at least ten queries, to an average of 7229 daily steps which was 1473 steps more than the control population.

Physical activity levels for both user groups decreased after 3 to 4 weeks. However, the activity for the strongly engaged ten query user group dropped to a higher level than the original baseline level. This suggests that there could be long term behaviour change.

What conclusions can we take from this research?
At the time of publication, this study found that Pokémon Go led to larger increases in physical activity than other mobile health apps, and further attracts more users who are not yet very active. Pokémon Go has the ability to reach low activity populations whereas activity and health apps largely draw from an already active population. Thus, game based approaches are promising as a global intervention when traditional approaches are often ineffective at reaching the sedentary population.

Potential benefits of Pokémon Go include increased physical activity, spending more time outside, exploring the neighbourhood and city, social interactions, and mastering game challenges. Therefore Pokémon Go has benefits for physical and mental health. In recent publications this has also been coined the ‘Pikachu effect’.

More recent publications have found that participants overall physical activity behaviour is positively associated with frequency of app usage, attitudes towards exercise, and Pokémon Go related exercise. Sadly, impact of the app on exercise is only moderate, lasting for as long as the user continues playing. . Only small associations have been found between increased physical activity and playing time However, there are challenges in realising the potential of activity-encouraging games. These games need to sustain long-term engagement and lead to sustained behaviour and lifestyle change. As games such as Pokémon Go are observed to be more appealing to males, it may be difficult to increase levels of gaming in females. Finally, these games do not replace existing physical activity programs, but are merely complementary in contributing to exercise. Therefore playing augmented reality games such as Pokémon Go can kickstart a lifestyle change.

Practical advice
A beginner's guide can be found here. Tips and tricks are available here. It is not recommended to play Pokémon Go whilst driving, as a safety precaution, as well as negating the effect of physical activity occurring as incidental exercise.

Further information/Resources
Other augmented reality apps
 * Ingress
 * Zombies, Run!
 * Zombies Everywhere
 * The walk
 * Superhero workout
 * Clandestine anomaly
 * Temple treasure hunt game
 * Parallel kingdom MMO