Digital Games for DM

(Type 1>Type 2 focus)

Nabiel Mir
UQ MBBS MSIV

Contents

What
What
What
What

are the current challenges with T1DM?

makes a good game?
kind of applications are out there for all ages?
is the current landscape of DM gaming?

YourWay Vanderbilt Diabetes Center

The Glucose Race
Bayer Didgets bG meter
Games for teaching compliance

Can Virtual Reality play a role?

What interactive games are being planned for the future?
French Study: What sort of success have these games
achieved?

Current challenges in T1DM Patients

Children have to monitor bG, Diet, Insulin and
participate in physical activity = Time
consuming and stigmatizing from non DM
Adolescents are growing
Insulin requirements change with age and hormones
Increased independence from parents
Social issues/Peer pressure/Risky behaviors
Avoid Hypoglycemia in social situations (run high)
Depression and low self esteem Eating d/o

MUST FIND WAY TO ENHANCE COMPLIANCE

Supportive, personalized, responsive to needs

Why Digital Games?

Internet and mobile access
give us tools to enhance self care via education and
information access and social support with other chronic
illness sufferers
available to a most consumers today

Gamifying disease has been shown in the literature to

transform bothersome tasks into rewarding experiences
to overcome disease burden
Can have social in game components to motivate
positive behavior change
XBOX Kinect and GPS functions of mobile phones are
being used as tools to help the obese lose weight as
part of VIDEO EXERGAMES

What makes a good

game?

Boulos, Maged N Kamel, Shauna Gammon, Mavis C. Dixon, Sandra M.

Macrury, Michael J. Fergusson, Francisco Miranda Rodrigues, Telmo
Mourinho Baptista, and Stephen P. Yang. "Digital Games for Type 1
and Type 2 Diabetes: Underpinning Theory With Three Illustrative
Examples." JMIR Serious Games 3.1 (2015)

Games to build self-efficacy via Design Thinking

rapid and empathic problem solving
Understands cognitive bias of users (want less
complex choices or default decision making)
3 main elements
NARRATIVE: reframe illness a challenge that can be
overcome with cultural references the app is FOR
you
PROGRESSION: Health goals divided into
steps/levels/XP with feedback/rewards as they go on
SOCIAL INTERACTION: inter-messaging between
players with the same illness

What kind of applications

are out there for all ages?

 Help T2DM habituate to a Dr prescribed program

of medication introduction and lifestyle change
Delivers educational content that connects with
real-world healthy activities
Breaks up health related information into small
steps/quizzes with feedback
Narrative used with stories to connect with the
gamer can be used over a period of months >
dumping information over a series of consults
Market research on women aged 35-60 with DM
showed increasing self efficacy and peer support

 Facebook-based to help DM improve their health

through lifestyle changes
Works on multiple devices
Supported by the Diabetes Hands Foundation and the
Joslin Diabetes Center at Harvard
Supportive social networking environment with
actionable missions and immediate positive feedback
Spanish translated as well for Hispanic patients
Helps patient work through the stages of change
model (contemplation action)
Qualitative eval showed players responded positively
and has been used by DM educators in the past

What is the current landscape of DM

gaming?

Lazem, S., M. Webster, W. Holmes, and M. Wolf. "Games and

Diabetes: A Review Investigating Theoretical Frameworks,
Evaluation Methodologies, and Opportunities for Design
Grounded in Learning Theories." Journal of Diabetes Science
and Technology (2015)

2010-2015 review of the current landscape

of digital games for children with DM
18 games
CONTENT
12 focused on self-management and factors that
change bG
4 focused on encouraging patient to increase their bG
checking behavior

7 focused on DM education of Sx, biology,

mechanics of inulin injection, estimating carb intake
and healthy lifestyle intervention

YourWay Vanderbilt Diabetes

Center
NIH funded website for teenagers with Diabetes (Type 1 & 2)
target PSYCHOSOCIAL HURDLES
Help resolve feelings of stigma/ embarrassment/lack of
planning/distraction.
Manage depression/burnout and inadequate situational decisionmaking
First-person accounts of situations that teenagers and their
parents encounter
Ex:
Jake, a soccer player who worries that his brother, a teammate, is embarrassed
by him.
Jake does not want to test his blood glucose in front of his teammates prior to a
soccer game and then experiences a severe hypoglycemic episode during the
game.
Model shows Jake learning how to resolve this problem, including a part where
he talks to his brother about the situation and another part where he learns
more about insulin dosing and sports from his nurse practitioner.

The Glucose Race

iOS platform using gestures to control a character
that uses a plane/car/bike in a race to see who wins
The game tricks the players into unknowingly using
their knowledge about insulin fuel is food, oil/air is
insulin and speed is exercise level.
The player should plan before the race; speed, fuel
and oil must be in balance
Races against recorded races of friends giving the
impression of live interaction.
Help from friends can be provided in form of prerecorded comments and tips from previous play

The Glucose Race

Bayer Didgets bG meter

Bayer Diabetes Care
an effective way of promoting good health practices
among children like checking their sugars
DIDGET is the first blood glucose monitor only for kids
which connects to Nintendo DS
Make sugar testing fun
Rewards kids for regular testing, meeting sugar goals by
collecting points
Study
DIDGET bG Monitoring vs regular analyzer
123 subjects aged 4-24 yo
no difference in the devices performance or accuracy across
age subsets.

Games for teaching compliance

Other games designed for traditional computers and a gaming

console (Nintendo Game Boy Advance) to educate patients
on diabetes management.

Tamagaya:
players feed insulin or food to an egg and get an egg to
exercise for a simulated week.
After a week, the egg hatches with a chicken whose
visual appearance and behavior is a result of the care
that the patient provided to the egg
Persuades the user toward appropriate behavior by
providing a visualization of effects of good/ bad
behavior practices

Tantei:
A virtual detective who has type 1 diabetes mellitus and is
chasing a criminal.
The detective has to stop during the chase to maintain plasma
glucose levels by consuming food or insulin.
Users have to answer a quiz centered on knowledge of
diabetes management.
Visualization of their behavior as effects on the virtual

Can Virtual Reality play a

role?

Ruggiero L, Moadsiri A, Quinn L., et al. Diabetes island:

preliminary impact of a virtual world self-care educational
intervention for African Americans with type 2 diabetes. JMIR
Serious Games. 2014;2(2):e10.
Diabetes Island
A game on second life which is a virtual world/computer simulated
environment that users inhabit and interact via an avatar
was designed to facilitate optimal diabetes self-management in lowincome African Americans with diabetes attending primary care clinics
Access to DM educational resources 24/7
Programmed scenarios
Nutrition labels and education centers
Formal presentations on good dietary choices, medication adherence,
physical activity, proper DM education and foot care all provided by
experts

Results of the study were positive

BMI level decreased over time
A1C decreases over 3-6 months
Increased healthy substitution and better dietary choices

Dietitian-led discussion of reading food labels

in the grocery store

What interactive games are being

planned for the future?

Integrative gaming
paradigm
Human Machine Symbiosis Laboratory
at the Center for Sustainable Health Arizona State University
A game-based storyline that links
various activities such as
measuring glucose levels
taking insulin
performing exercises
problems solving

Integrative gaming
paradigm
Central unit links to many different kinds of exercise
equipment
Move through various exercises or can compete with
multiple patients
Users get persuasive game scenario + visual feedback on
their performance
Can be done in a gym like setting or even at home
Every exercise could be visualized as a game level where
the story links all the activities
Sensors monitor movement, HR, SaO2 etc and drive the
game
Transition to cognitive exercises in the context of DM
management

Human Machine Symbiosis Laboratory, School of Biological and

Health Systems Engineering, Center for Sustainable Health,
BioDesign Institute, Arizona State University, Tempe, Arizona

What sort of success have

these games achieved?

Joubert, Michael, Coline Armand, Julia Morera, Leyla Tokayeva, Aurore

Guillaume, and Yves Reznik. "Impact of a Serious Videogame
Designed for Flexible Insulin Therapy on the Knowledge and
Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot
Study." Diabetes Technology & Therapeutics 18.2 (2016): 52-58.

French Health Ministry study

A serious/applied game called Mr Birmans File to
educate T1DM children on insulin injection therapy
Problem solving involving a narrative about Alex a T1DM
bG Simulator and patient adapts insulin dose for each meal
Free on www.gluciweb.com

Evaluated the effect of this videogame on the

therapeutic knowledge and behavior of children with
type 1 diabetes
38 children with mean age 13.7, mean DM duration for
6 years and mean A1C at 8.5%

Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge
and Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study Michael
Joubert, MD, Coline Armand, MD,2 Julia Morera, MD, Leyla Tokayeva, MD, Aurore
Guillaume, MD,3 and Yves Reznik, MD

Results
PCQ score
Explores carbohydrate recognition
Carbohydrate quantification
Ability to adjust insulin doses according to carbohydrate intake and
glycemic level
[T0 = before, T1 (immediately after) and T2 (6mo post)

Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge
and Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study Michael
Joubert, MD, Coline Armand, MD,2 Julia Morera, MD, Leyla Tokayeva, MD, Aurore
Guillaume, MD,3 and Yves Reznik, MD

Results
DSMP questionnaire quantifies
Adherence to the prescribed regimen
Self-management behaviors, such as remediation or prevention of
unwanted glucose excursions

The DSMP score was not different at T0, T1, and T2

Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge
and Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study Michael
Joubert, MD, Coline Armand, MD,2 Julia Morera, MD, Leyla Tokayeva, MD, Aurore
Guillaume, MD,3 and Yves Reznik, MD

Results
HbA1c levels also remained stable throughout
the study (8.4 1.3%, 8.4 1.2%, and 8.5 1.5%
at T0, T1, and T2, respectively; difference not
significant).
Severe hypoglycemia occurred in the past 6
months in 10.5% and 13.1% of subjects at T0 and
T2, respectively (difference not significant).
Hospitalizations in the past 6 months were also
stable, involving 15.8% and 13.1% of the
subjects at T0 and T2 (difference not significant).

Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge
and Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study Michael
Joubert, MD, Coline Armand, MD,2 Julia Morera, MD, Leyla Tokayeva, MD, Aurore
Guillaume, MD,3 and Yves Reznik, MD

Conclusions
SO Benefit of game was mainly observed on
carbohydrate counting and insulin dose
adaptation,
BUT Lack of a knowledge transfer towards DM
Self-management
Higher PCQ score improvement in children with:
Lower baseline knowledge about diabetes
More precarious family structure
Poorer metabolic control.
These findings suggest that this game is well
suited for beginners

Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge
and Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study Michael
Joubert, MD, Coline Armand, MD,2 Julia Morera, MD, Leyla Tokayeva, MD, Aurore
Guillaume, MD,3 and Yves Reznik, MD

Barriers to DM Games
Hard to integrate into Tx course
Balancing the game with the educational
content
education fun

Need to make a costly multiplatform

interoperable software since technology is
labile
Reluctance amongst HCW to use without
regulation
?try certifying programs

?Trying to use it to train PCPs to dose insulin

instead

References
Boulos, Maged N Kamel, Shauna Gammon, Mavis C. Dixon, Sandra M. Macrury, Michael J.
Fergusson, Francisco Miranda Rodrigues, Telmo Mourinho Baptista, and Stephen P. Yang. "Digital
Games for Type 1 and Type 2 Diabetes: Underpinning Theory With Three Illustrative Examples."
JMIR Serious Games 3.1 (2015)
J Diabetes Sci Technol. 2011 Sep; 5(5): 11641166. Published online 2011 Sep 1. PMCID:
PMC3208874 Analysis Article: Accuracy of the DIDGET Glucose Meter in Children and Young Adults
with Diabetes Sarah Kim, M.D.
Lazem, S., M. Webster, W. Holmes, and M. Wolf. "Games and Diabetes: A Review Investigating
Theoretical Frameworks, Evaluation Methodologies, and Opportunities for Design Grounded in
Learning Theories." Journal of Diabetes Science and Technology (2015)
Fuchslocher A, Niesenhaus J, Krmer N. Serious games for health: an empirical study of the game
Balance for teen- agers with diabetes mellitus. Entertainment Computing. 2011;2(2):97-101.
J Diabetes Sci Technol. 2011 Mar 1;5(2):293-300. Integrative gaming: a framework for sustainable
game-based diabetes management. Kahol K.
Ruggiero L, Moadsiri A, Quinn L., et al. Diabetes island: preliminary impact of a virtual world selfcare educational intervention for African Americans with type 2 diabetes. JMIR Serious Games.
2014;2(2):e10.
Joubert, Michael, Coline Armand, Julia Morera, Leyla Tokayeva, Aurore Guillaume, and Yves Reznik.
"Impact of a Serious Videogame Designed for Flexible Insulin Therapy on the Knowledge and
Behaviors of Children with Type 1 Diabetes: The LUDIDIAB Pilot Study." Diabetes Technology &
Therapeutics 18.2 (2016): 52-58.