# Active Video Game Program for People with Type 2 Diabetes-a Pilot Study
## 1 Introduction  
Diabetes is an increasingly prevalent medical condition affecting 34.2 million people (10.5% of the population) in the United States [1]. Type 2 diabetes (T2D) accounts for approximately 90-95% of all diagnosed cases of diabetes. Diabetes is marked by high blood glucose levels with hemoglobin of A1C (HbA1c) 6.5% or higher. If individuals with T2D do not manage their glucose well, they may have a higher risk of developing progressive complications, such as heart disease, stroke, retinopathy, blindness, chronic kidney disease, neuropathy, amputation, and premature death [1]. Physical activity and exercise have been recommended to prevent and manage T2D [2]. Engaging in regular exercise has been demonstrated to improve blood glucose control, insulin sensitivity, lipids, and quality of life as well as reducing blood pressure (BP), risk of cardiovascular disease, and mortality [3]. One meta-analysis that looked at 42 randomized control trials (RCT) found similar results, including improved BP control, decreased low-density lipoprotein cholesterol (LDL-C), and elevated high-density lipoprotein cholesterol (HDL-C) levels among people with diabetes [4]. However, individuals with diabetes are much less likely to participate in regular physical activity. In the United States, olderadults with diabetes were reported to be 31-34% less likely to achieve the recommended physical activity guidelines and 13-19% less likely to achieve sufficient amounts of physical activity compared to adults without diabetes [5]. Several barriers to exercise exist among people with diabetes and have been identified through various studies. These barriers include poor health, lack of company, lack of interest, lack of time, lack of social support, cost, transportation, body image and embarrassment, access to facilities, and diabetes specific barriers, such as insufficient knowledge about managing diabetes and diabetic complications while exercising [3; 6]. One emerging form of physical activity is active video gaming (AVG). AVG, or exergaming, is a video game that requires physical movement to play. In the early years, AVG involved a wireless controller with motion sensing for upper extremity (UE) movement and/or dance pads on the ground to detect lower extremity (LE) movement. Subsequent gaming systems, such as the XBOX Kinect, are camera-based and capable of tracking the entire body movement. The wide variety of games available focus on many of the components of a traditional fitness program, such as strength, balance, coordination, flexibility, agility, and aerobic endurance. AVG can be tailored to an individual's interests and preferred exercise style through numerous gaming options. It can be an individual activity, where a person seeks to improve their own personal high score, or a group activity, where multiple individuals compete against one another [7]. Therefore, AVG might be suited to reduce many of the aforementioned barriers because of the following reasons: (1) it can be performed at home, (2) individuals can play against others, (3) there is no membership cost, and (4) it is designed to be a more enjoyable mode of exercise. Several studies have evaluated the effect of AVG as a method of exercise for children and adults. One systematic review suggested that AVG is capable of providing light-to-moderate intensity physical activity [8]. Another study found that energy expenditure, heart rate (HR), and oxygen consumption while playing AVG are significantly higher than resting values and these effect sizes were similar to traditional methods of physical exercise [9]. One study found that a healthy population that participated in a six-week AVG program showed improved flexibility, maximal oxygen consumption, and resting HR [7]. Another study found that a 12-week AVG program improved physical fitness, including diastolic BP, sit-up tests, and 3-min step tests [10]. On overweight and obese children, one RCT reported that AVG improved body mass index (BMI) and body composition [11].