Save the Nobbies!

Save The Nobbies! Mapping Obesity Behavioral Risk Factors
as Children Play an Avatar-based Smartphone Game

Summary Statement

We propose an avatar-based smartphone game that can be used to assess obesity behavioral
risk factors in children and can be deployed in the healthcare or community setting.

Prologue for Avatar

A long time ago, before cars and skyscrapers, the land of lakes was filled with small elf-like
creatures known as The Nobbies. The Nobbies lived in trees and spent their days carving
fruits and vegetables for the woodland creatures. You may have never heard of The Nobbies
before, but there are three things about them you may need to know: (1) The Nobbies look a
lot like you and me, but their eyes are huge, their ears are pointy and they are barely bigger
than your pinky finger, (2) they require healthy behaviors to survive, and, (3) they need your
help before they disappear forever.

Scientific Background

In 2007, the American Academy of Pediatrics (AAP) published recommendations that
pediatricians assess all children for behavioral risk factors that have been associated with
childhood obesity and unhealthy weight gain into adulthood.1 These risk factors are
summarized below:
3 Avoid skipping meals, eat 3 meals a day (breakfast, lunch, dinner)
and up to 3 snacks a day. Eat family meals prepared at home.
2 No more than 2 hours of screen time per day
and no TV in the bedroom.
1 At least 1 hour of moderate to vigorous physical activity
0 Zero sugar-sweetened beverages. Drink un-flavored milk or water.

In 2011, following the publication of the 2007 AAP Recommendations, the USDA (United States
Department of Agriculture) published the dietary guidelines of ChooseMyPlate.gov,
recommending that half of the diet should consist of fruits or vegetables.<sup>2</sup>
Combining the AAP and USDA recommendations could theoretically create a campaign such
as the following: For a healthy weight…3-2-1-0 and half a plate!

Childhood rates of overweight and obesity remain high.3 Few studies exist examining how
many pediatricians in the U.S. are screening for the behavioral risk factors related to obesity or
how many providers are using that information to provide customized anticipatory guidance in
regards to nutrition, physical activity, and sedentary behavior.4 Often, studies rely on self-
report,5–7 which can misestimate screening practices.8 Previous studies have shown that early
identification of risk is the key to providing adequate and timely behavioral therapy.9 Treatment
efficacy is highest under the age of 10 and success rates of weight and behavioral change drop
precipitously as children approach puberty.10 Children under the age of ten are developmentally
very receptive to messages delivered through stories and cartoon characters. Therefore, this
may prove an effective strategy for assessing health information at this developmental age.11,12

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Software Description

We propose an avatar-based game aimed at children under the age of 10 and their parents, to
be launched on smartphone platforms using adorable cartoon characters known as The
Nobbies. The Nobbies are loosely based upon The Little People of Wisconsin Native American
Folklore and were created and tested for likability in pilot studies by Dr. Tracy Flood MD, PhD of
PlayingDoctor, LLC (unpublished data). These avatars simultaneously engage users (children
and parent dyads) and collect data on key obesity behavioral risk factors by creating an avatar
environment and then conducting a series of five mini-games that can be completed by children
alongside of parents. The smartphone-based platform was chosen because 1 in every 2
parents owns a smartphone device and users span all ethnicities and sociodemographics.13

The design of the software includes orientation and five mini-games. During orientation, users
choose an avatar and design an environment. Players can then give their avatar health points
via mini-games. Mini-games are designed to be brief and fun assessments (lasting less than 2
minutes each) of the child’s obesity behavioral risk factors. After the completion of a mini-game,
users receive immediate feedback from the avatar and a conglomerate score of the avatar’s
“health and happiness”. Avatar health is able to change over time, as mini-games are repeated
and behavioral risk factors change. These scores are compared to the scores and trends of
other users in the region.

Orientation

It is important to give users (i.e. the child) a strong sense of avatar in order to create a greater
sense of immersion within the game space. Upon opening the game, users create a Nobbie
that resembles their own likeness using a system similar to that seen in the Wii Mii system.
After the child has created their own avatar, they are prompted to create an immediate family,
reflective of their own family, within the Nobbieworld. During this initial process, background
information can also be collected on covariates such as the child’s age, sex, and self- or parent-
reported height and weight, as well as placing a “pin” on the GPS coordinates of their home.

Once the user has been prompted to design an avatar, which will serve as their personal
analog within the game environment, they are encouraged to make a few choices that will
inform the basic layout of the living quarters of their Nobbie. While Nobbies live in trees rather
than houses and their “backyards” are on the limbs of trees, users will form the imaginary world
of their avatar to be modeled after their own home. Users populate the indoor and outdoor living
space with furniture, toys, and electronic devices. This step provides background data on the
number of electronic devices (i.e. television, gaming system) and their placement, such as a TV
placed in the child’s bedroom. It also provides information on their immediate recreational
space (i.e. backyards, playgrounds, adjacent parks).

The final step of orientation is to stock the root cellar of the Nobbie with a few select items seen
in the user’s kitchen. This includes drinks (e.g. milk, 100% juice, sugar-sweetened beverages)
and fruit and vegetable representations that include commonly consumed, non-name brand
representations of fresh, frozen, canned, and dried fruits and vegetables. This provides data on
home availability of foods that are related to the AAP recommendations.

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After completing orientation, users have created an avatar, a family, and a home environment
reflective of their own lives. Now, upon opening the application, users shall see the avatar
“living” in the space. The space can be updated by users at any time. The homescreen showing
the avatar also displays stats on Health and Happiness as well as highlighted navigation
buttons directing users to the mini-games. Mini-games are ways in which players can collect
points to increase their avatar’s health and happiness.

Mini-Games

Mini-Games that are age-appropriate are used to directly assess five behavioral risk factors
outlined by the campaign: For a healthy weight…3-2-1-0 and half a plate! Games are visual
representations of previously validated questionnaire measures. Players receive points for
scores of healthful behavior and those points contribute to the avatars Health and Happiness.
On their first entry, users are given no feedback as to what behaviors generate maximal points
so as not to bias the initial responses. After the user has completed all five games once, a
button is made available to suggest ways to improve the avatar’s health and happiness score.
Younger children need to complete mini-games accompanied by parents, preferably at the end
of the day to recall the events of the day. The game is programmed to automatically time-stamp
mini-game scores with a time, date, and day to give longitudinal data and the ability to
discriminate between weekdays and weekends.

Making the Games Age Appropriate

Age-data from the orientation input automatically initiates one of two different gaming “styles” in
order to create a game experience that is age-appropriate. One play style appeals more to the
"twitch" style of game, most often preferred by older children, while the second will appeal to
the "casual" style of game, which is appropriate for younger players. Users can also choose to
change this manually in Game Settings if they wish. Regardless of gaming “style”, data
collected will be same and scores will not be lost.

Mini-Game “Meals”

3 Avoid skipping meals, eat 3 meals a day (breakfast, lunch, dinner) and up to 3 snacks a day.
Eat family meals prepared at home.

In this mini-game, the avatar asks users recount the meals of the day (with the help of their
parents). Children are asked by the avatar when they ate their first meal of the day (i.e. did they
eat breakfast), where they ate lunch, where they ate (or will eat) dinner, was it at home or at a
restaurant, and if they had snacks. As they answer, the avatar draws a diagram of the day
outlining their responses. The diagram will look similar to a sticker-chart with color-codes and
icons.

Responses are scored and users receive points for eating breakfast, regular meals, and meals
at home.

3

Mini-Game “Screentime”

2 No more than 2 hours of screen time per day and no TV in the bedroom.

This mini-game assesses the number of hours a child watches TV in a day. The avatar asks the
question: What did you do today? Did you watch TV? If the child answers yes, they are
prompted to answer on a sliding scale including 30 minutes, 1 hour, 2 hours, and 3 or more
hours. As the child answers, the avatar points along sliding scale along a measuring tape to
assess the child’s response.

Points are given for not watching TV and any number less than 2 hours a day.

BONUS POINT: Whether or not there is a TV in the bedroom is assessed during orientation
when the user creates the avatar’s home environment. If there is no TV in the bedroom, users
receive a bonus point.

Mini-Game “Physical Activity”

1 At least 1 hour of moderate to vigorous physical activity

This mini-game uses a similar structure to the one outlined for “screentime”, but assesses
physical activity and active play. The avatar asks: What did you do today? Did you play? If the
child answers yes, they are prompted to answer on a sliding scale ranging from 30 minutes, to
3 or more hours.

Points are given for 60 or more minutes of physical activity.

Mini-Game “Sugar-Sweetened Beverages”

0 Zero sugar-sweetened beverages. Drink un-flavored milk or water.

During this game, users are asked to “feed” the avatar what they themselves had to drink that
day. Players “drag” the drinks over to the avatar who makes drinking noises. Options include
pictures of what is currently in the avatar’s root cellar as well as soda, sports drinks, skim milk,
whole milk, chocolate milk, strawberry milk, fruit cocktail, 100% fruit juice, and water. Players
can give avatars multiple drinks.

Points are given for feeding the avatar milk and water.

Mini-Game “Half a plate”

Half a plate of fruits and vegetables.

During this mini-game, users are asked a single question by the avatar: Today, how many fruit
and vegetables did you eat? Players are shown four plates to choose from containing differing

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amounts fruits and vegetables: A little (10% of the plate), a medium amount (25%), a lot (50%),
or mostly fruits and vegetables (90%).

Users get points for choosing “a lot” or “mostly”.

Health and Happiness Scores

After the completion of each mini-game, players receive points that affect the health of their
avatar in the game-environment. The avatar’s “mood” is reflected by the number of points they
have. If they have few points, the avatar looks sickly, sad, and grey. If they have a high number
of points, they are happy, spritely, and colorful. Each mini-game can be played only once daily
as games assess the events of that day. The next day, users have the opportunity to improve
the health of their avatar. Users can see trends of their own scores as well as the scores of
others by region. Thus neighborhoods are in competition for having the healthiest Nobbies. In
regards to confidentiality, user health scores and precise GPS locations are all de-identified and
remain confidential, but users may invite others with the game to see their changing scores.

Additional Software
Physicians, community workers, and other allied health professionals can be invited to see
scores and are provided software that gives a “dashboard” of the itemized scores of individual
users within their patient population. Healthcare providers can also track patient and regional
data over time by and may be granted to ability to input health information into individual
accounts (either manually or automatically via electronic medical records) in order to update
measures of height and weight for the purpose of tracking body mass index (BMI) percentile
charts. Healthcare providers can then see how their region and patient population compares to
others.

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Data Generation Description

Using an avatar-based gaming experience allows for data collection of both novel and
previously-used measures of obesity behavior risk factors. Table 1 outlines the data measures
that are collected during the gaming experience. While longitudinal data is available from users,
it is likely that the most accurate assessment will be the initial one that occurs prior to the user
receiving any avatar feedback or points. More data is needed to assess the reliability and
validity of using avatar-environments to reflect real-world environments and whether changes in
behavior are valid and reliable with real behaviors.

Table 1. Variables Collected During Gamification

AAP Recommendations Gamification Measures Related
(mapped geographically by GPS coordinates) Population
Measures
Covariates Age, sex
Height, weight, calculated BMI percentile
Parental height, weight, and BMI
Location of primary home

3 Avoid skipping meals, eat 3 Frequency of skipping breakfast AdHealth
meals a day (breakfast, lunch, Frequency of skipping lunch or dinner Survey
dinner) and up to 3 snacks a Snacking frequency
day. Eat family meals prepared Frequency of meals eaten outside of the home
at home. Frequency of family meals

2 No more than 2 hours of Daily television usage IPAQ14
screen time per day and no TV in TV in bedroom (via avatar environment)
the bedroom.

1 At least 1 hour of moderate to Daily physical activity IPAQ14
vigorous physical activity

0 Zero sugar-sweetened Sugar-sweetened beverage consumption FFQ15
beverages. Drink un-flavored Milk and water consumption
milk or water. “Other” beverage consumption

Half a plate of fruits and Proportion of fruits and vegetables eaten unknown
vegetables.

AAP: American Academy of Pediatrics
Adhealth: Adolescent Health Survey
FFQ: Food Frequency Questionnaire
BMI: Body mass index
IPAQ: Physical Activity Questionnaire
TV: Television

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Community-Deployment Approach

Deployment will first occur in the state of Wisconsin. There is a robust network of childhood
obesity coalitions within the state. Coalitions are present in 70 of the 72 Wisconsin communities
and include faculty and staff of University of Wisconsin Extension, community-based
organizations, childcare providers, educators in schools, government employees, and allied
health professionals (e.g. nurses, dieticians, physical therapists, physicians). Childhood obesity
coalitions in the state of Wisconsin are supported by the Wisconsin Community Transformation
Grant. The smartphone software will be available as a free download in respective online
stores. Coalitions will aid with the initial dissemination of the “dashboard” software within the
healthcare setting.

The Aligning Forces dataset includes 19 Health Systems in the state of Wisconsin. In order to
identify individual practitioners within each system, databases housed at the Wisconsin Medical
Society (which contains information on approximately 80% of all physicians statewide) will be
used to identify physicians in family medicine and pediatrics. If a practice adopts a tool, they will
be given handouts for patients with information on how to download the app and a QR code will
be on the handout so patients can scan it and be directed immediately to the download.

While the primary focus of the game is to provide healthcare providers with the behavioral
assessment recommended by the AAP, parents may also wish to use the app even if it has not
been recommended to them by an allied health professional. Childhood obesity coalitions may
aid with dissemination to schools and childcare settings. Parents may also be reached via
online advertising and the building of a social network by integrating it with networking platforms
like FaceBook, Google+ and Twitter. Users will be able to share their scores on these platforms
and track their improvement, if they desire. Peer feedback will in turn drive the motivation of
those peers with the game to do the same.

Future Directions

As technology is validated and made more readily available and affordable, self-assessments
can be replaced with direct assessments such as an accelerometer (e.g. Zamzee) or shoe-
based device (e.g. Nike+) to assess when a child is active during the day. There may also be a
device that is attachable to the TV to measure number of hours the television was on. Scores
from those measurements can be used to get points and, therefore, directly improve the health
of the avatar.

Overall, we recognize that more studies are needed to assess the validity and reliability of
game-based measures and game-measured behavioral change. Building the games is a
valuable first step.

Thank you so much for the opportunity.

Tracy Flood, MD, PhD, PlayingDoctor, LLC
Michael Diedrick, Byte Studios, Inc.

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