Physical activity (PA) promotes cardiovascular (such as elevations on heart rate and blood pressure which stimulates post-exercise hypotension) and metabolic benefits (such as favorably change energy expenditure and oxygen uptake and improve energy intake of blood glucose) ¹ . However, people in general not take part in considerable amounts of PA to attain positive psychophysical outcomes. PA is still a relatively underutilized strategy for the prevention, care, and management of numerous illnesses ^2,3 . In general, an effective PA program must take into consideration a person’s interests, needs, environment, social contexts, and even the possibility of inclement weather.. Therefore, a successful intervention requires that the subject is motivated and quickly experiences a tangible effect on personal efforts ⁴ .

Although traditional aerobic and strength training has been recommended in exercise programs ¹ , active video games (AVG) are becoming a popular form of PA, and they have been used to treat a wide range of chronic diseases and clinical disorders in different age groups and special population.. AVG are a genre of serious games and games for health with a high level of enjoyment (LE) to play it that requires body movement to move the game forward, assisting to improve fitness levels and develop motivation and self-efficacy for PA ^6,7,8 . Despite AVG share common physiological responses with other forms of exercise ^6,9 , little attention is given to blood glucose (BG) and other cardiovascular parameters in response to AVG, which could be an alternative to analyzing the physical effort at home.

Acute effects of AVG on glycemic control are not well studied, although some variables of exercise prescription, such as intensity and duration, could change it ^{10, 11} . A single bout of traditional aerobic exercise (30-60 min up to 60-70% of maximal oxygen consumption) increases glucose transporters (GLUT-4) translocation to the sarcolemmal membrane and can significantly lower plasma glucose levels ¹² . However, a previous study with AVG did not show a significant acute reduction in BG levels, probably due to light intensity and short duration of the session (Wii Fit Running game), even when maximal oxygen uptake of healthy adults was controlled ¹¹ . Thereby, it also seems that game type and LE are potential variables that can influence metabolic responses to AVG ^{6, 13,14,15} .

Physical inactivity increases the risk of cardiovascular diseases such as diabetes and its comorbidities, such as metabolic changes related to hormones and glycemic control ² . Although PA is one of the principal therapies recommended for people with diabetes ² , it is not known if people with diabetes can use AVG safely. Some elevation in risk can occur with increased PA, and specific precautions need to be made to lower these risks, mainly if these persons are unaccustomed to exercise ¹⁷ . Thus, requirements for evidence-based medicine have indicated that each tool used in the therapeutic process should be assessed for safety in healthy volunteers before diabetics ¹⁸ .

The rationale of this study relies upon the fact that effective BG and blood pressure control prevents cardiovascular events and that AVG effects are still unclear as to type, duration, and intensity. This study aimed to analyze acute glycemic and cardiovascular responses of a 30-minute AVG session at moderate-intensity in healthy adults (before in diabetics) and their LE after the game. We hypothesized that an AVG session at a moderate- intensity promotes acute BG and blood pressure reduction post-session, increasing cardiovascular variables at safe levels, as well as high LE during the practice. The present investigation has the potential to elucidate the effects of AVG in relation to glycemic levels and post-exercise hypotension.

A single experienced physical trainer controlled all the sessions in order to provide standardized instructions on how to perform the game. Participants were encouraged to do their best in the AVG session, but no feedback was given during the assessment. All participants were instructed to wear minimal clothing and appropriate footwear for PA, to avoid moderate or vigorous exercise for 24 hours before testing, to feed 1-2 hours before the assessment, and to refrain from ingesting beverages containing caffeine, others substance stimulants or alcohol during the 24 hours preceding the tests.

Fourteen healthy adults, seven males [Mean (SD), age: 24 (6) years, mass: 69.3 (5) kg, height: 1.72 (0.03) m, body mass index: 23.3 (1.2) kg·m−²] and seven females [Mean (SD), age: 22 (4) years, mass: 59.3 (3) kg, height: 1.63 (0.02) m, body mass index: 22.4 (1.0) kg·m−²] participated in this study. Most of the participants reported a family history of diabetes (71.4%). They performed exergames at an intensity of 55.5% (SD= 8.5) HR reserve. Maximal and average HR were 169 bpm (SD= 21) and 130 bpm (SD= 18), respectively. LE and RPE were 8.6 (SD= 1.1) and 15 (SD= 2) at the end of the session, respectively.

Table 1 shows acute BG, SBP, DBP, and DP responses over time. BG changed over time (F1.4, 18.4= 5.1, P= 0.025). There was a statistical reduction in BG at POST-0 in comparison to the PRE (%Δ= −9.1, P= 0.001, d= 0.94). MDD for BG was equal to 15.1 mg·dL⁻¹.

Table 1

Data reported by mean (SD), except heart rate expressed by median (interquartile range).

This study analyzed acute glycemic and cardiovascular responses of 30-minute continuous AVG session with “Kinetic Adventures!” game in non-diabetic adults and yours LE after the game. Our findings confirmed partially the hypothesis an AVG session at moderate- intensity promotes BG reduction and cardiovascular increase (HR, SBP, and DP), as well as high LE, while DBP was unaltered. Previous studies with AVG have examined HR and/or blood pressure in several settings ^{7,8,9, 11, 14, 16} . However, this was the first investigation to explore BG responses while playing AVG commensurate with the moderate (by HR reserve) or vigorous (by RPE) intensity according to ACSM ¹ . This fact reinforces the need for using both subjective and objective measures when assessing neurophysiological responses ⁶ .

Although MDD for BG was about 15 mg·dL⁻¹, glycemic levels reduced about 10 mg·dL⁻¹ (large ES) immediately after the AVG session. This ES indicates 82% of the values at POST-0 will be above the mean of the PRE moment, and there is a 74% chance that a person picked at random from the POST-0 will have a higher score than a person picked at random from the PRE moment (probability of superiority) ²⁸ . It is known that an acute bout of exercise induces an insulin-independent translocation of glucose transporter type 4 (GLUT-4) to the cell surface and increases insulin-stimulated whole-body glucose uptake12. Thus, as with other forms of aerobic exercise, AVG at a moderate-intensity can act with synergistic action with insulin in insulin-sensitive tissues ² , although effect duration at POST-30 was not detected.

Soltani and Salesi ¹¹ observed the combination of music and an AVG (Wii Fit Running) as a video intervention have a significant change in the total time of running, however, they did not find any statistical effect on changing levels of BG compared with the control or other training groups. Our findings did not corroborate with these results, probably because their intervention intensity may have been light due to the use of Nintendo Wii, in which participants may underestimate body movements from the fact of his motion sensor is an accelerometer ²⁴ , using for example just the hands and wrists. Also, the longest Wii Fit Running session lasted only about 18 minutes ¹¹ . Thereby, BG reductions related to AVG sessions seem to depend on intensity and duration.

In general, there is a dose-dependent effect of intensity and duration on the cardiovascular changes following aerobic exercise ²⁹ . Our AVG session resulted in greater values immediately after the session, and, despite the nonsignificance, SBP presented the expected hypotensive effect after 30 minutes of passive recovery, while DBP showed an even slighter reduction. Once HR at the POST-30 was slightly higher than PRE values, it seems cardiac output remained high and, therefore, systolic hypotension was limited. Moreover, participants presented high levels of LE, which may have provided a greater release of catecholamines ⁶ and hence influenced the HR at POST-30.

DP values at POST-0 suggest the AVG session induced substantial stress on the heart with lower blood pressure overload. Thus, cardiac workload and myocardial oxygen demand were similar to an aerobic exercise bout. Such as exercise capacity (in metabolic equivalents - METs) for example, DP is an essential feature of exercise, and it can be measured as a useful hemodynamic predictor for cardiovascular mortality (DP reserve) and when evaluating the efficacy of therapy ³⁰ . Similarly to our findings, Neves et al. ¹⁶ showed an increase of about 97% on the DP of healthy adults after a 22-minute Zumba Fitness Core® game session. Nonetheless, further research should be conducted to investigate other cardiovascular changes for AVG at different intensities and durations.

Kinetic Adventures! game yielded LE levels closer to 100% “Very Enjoyable” by VAS. Mellecker et al. ⁶ highlight this game inspires triumphant affective expressions by offering opportunities to make one's trophies by striking a pose upon concluding a level. Therefore, these embodiment characteristics may contribute to feelings of fun during play and induce similar physiological effects to those of classical PA with the experience of enjoyment ⁶ . These results were analogous to other studies with young adults such as the analyses of two different AVG (Kinect Sports Boxing and Nike Kinect Fitness), which showed high LE levels over 6- week training ⁷ and another research with six different AVG found they were more enjoyable than traditional exercise (cycling) ¹³ .

Our data, obtained from healthy adults, demonstrate the relevant role of AVG to promote beneficial and safe cardiovascular changes by a very enjoyable form of exercise. Moreover, this study provides the first reference for acute reduction of BG in healthy individuals by AVG. High levels of sedentary behavior such as screen time may be partially modified using AVG, once Kinect Adventures! game session met the current recommendations for PA ³ . In addition, enjoyment exercise by AVG can remain high over the weeks, supporting the process of individual behavior change ⁷ . Thus, our findings have practical applications for improving PA from attractive exercise forms, and it seems reasonable to recommend that people with diabetes can use this form of PA ^10,11 . Even though AVG sessions can be performed at home, the authors genuinely recommend a professional prescription once there is AVG with numerous objectives ⁸ .

Although the participants were normoglycemic, a control session (passive rest/recovery) could better evidence of the individual BG control compared to AVG at the moderate/vigorous intensity. In our investigation, the sample size was restricted to detect only statistically large ES (d≥ 0.9), this could be a limitation of the study. It is known that minor cardiometabolic changes elicited by PA, such as blood pressure reduction, bring potential health benefits, especially for special populations (e.g., hypertensive or diabetic patients). Nevertheless, we calculated a priori power for BG as the primary outcome. Another limitation was that the participants' range of motion during gameplay was not evaluated, and although standardized instructions have been given, there was undoubtedly variation in exact movement among participants, which can affect physiological responses.

A 30-minute AVG session (Kinetic Adventures! game) at moderate-intensity was considered very enjoyable and effective in reducing blood glucose levels and promote safe cardiovascular acute changes in healthy adults.