This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.
The rising trend in obesity calls for innovative weight loss programs. While behavioral-based face-to-face programs have proven to be the most effective, they are expensive and often inaccessible. Internet or Web-based weight loss programs have expanded reach but may lack qualities critical to weight loss and maintenance such as human interaction, social support, and engagement. In contrast to Web technologies, virtual reality technologies offer unique affordances as a behavioral intervention by directly supporting engagement and active learning.
To explore the effectiveness of a virtual-world weight loss program relative to weight loss and behavior change.
We collected data from overweight people (N = 54) participating in a face-to-face or a virtual-world weight loss program. Weight, body mass index (BMI), percentage weight change, and health behaviors (ie, weight loss self-efficacy, physical activity self-efficacy, self-reported physical activity, and fruit and vegetable consumption) were assessed before and after the 12-week program. Repeated measures analysis was used to detect differences between groups and across time.
A total of 54 participants with a BMI of 32 (SD 6.05) kg/m2 enrolled in the study, with a 13% dropout rate for each group (virtual world group: 5/38; face-to-face group: 3/24). Both groups lost a significant amount of weight (virtual world: 3.9 kg,
Overall, these results offer positive early evidence that a virtual-world-based weight loss program can be as effective as a face-to-face one relative to biometric changes. In addition, our results suggest that a virtual world may be a
Recent national survey data indicate that 35.7% of the US population is obese and 68.8% overweight [
Over the last decade or so, Internet or Web-based programming has emerged [
The importance of behavioral change in face-to-face interventions is well established [
Given all this, behavioral change may be advanced by integrating an increased understanding of behavioral learning with innovative technologies. However, despite helping to overcome face-to-face challenges, current Web-based interventions are typically missing some important aspect of human (social) interaction
Virtual worlds share many of the strengths of virtual reality technologies, particularly the rendering of 3D spaces. However, they are more accessible to users (via an Internet-connected personal computer) and thus may offer a way to extend the reach of programs to obese and overweight individuals. Virtual worlds also possess affordances that differentiate them (to varying degrees) from virtual reality and Web technologies. Specifically, virtual worlds are
Importantly, the ability to customize one’s avatar self and use it to interact with others allows for a new way to assert one’s embodied subjectivity. Early research suggests that it is avatar identification that matters so significantly for identity and behavior modification. The effect of one’s experience in a virtual world on one’s being in the physical world has been termed the Proteus effect [
Based on these ideas, the purpose of the present study was to examine the effectiveness of a virtual-world-based weight loss intervention program in achieving weight loss, behavioral change, and self-efficacy.
Club One Island is an interactive weight loss community delivered via Linden Lab’s Second Life [
First, Club One Island was designed to be visually and functionally engaging. It offers highly interactive 3D spaces (eg, a restaurant, a Mini-Mart convenience store, and an encouragement room), creative educational tools (eg, a nutritional jeopardy game and a fire pit illustrating how the body uses food as fuel), over 30 movement activities (eg, bikes and bike paths, surfing, exercise balls, lap swim, basketball, weight lifting, yoga, dancing, and rock climbing), and numerous healthy habits tools (eg, tracking charts). All elements are intended to engage participants in social networking, play, and learning. For example, the restaurant area was designed for use as a practice area for nutrition planning. It has an interactive menu that displays a full selection of items that a participant might encounter during a restaurant outing. The menu works on a stoplight (red, yellow, green) model, and participants are asked to choose what they believe are the healthiest choices. The menu responds to their selection with the color appropriate to their selection and an explanation as to why this menu item was ranked at that particular color, as well as ways to make the item healthier. Topics discussed are hidden calories, eating out, and portion control. The restaurant area also includes an ice cream counter, dining tables, a dessert bar, and a bar area. In addition, the social support classes were designed to provide an environment within which the participant could reflect on the past week’s activities and social bonds. To this end, social support classes took place in the pool, at the camp fire on the beach at sunset, and while performing yoga poses. Overall, Club One Island was designed to provide an environment that closely mirrors the physical world. By setting up learning situations that incorporate practicing new behaviors (eg, throwing away 3D food, addressing the “food pushers” and nonsupportive people in their lives, and doing any physical activity in public), Club One Island is intended to help participants overcome their fears related to weight loss.
Second, the weight loss program itself was designed to move participants from a diet and exercise cycle of weight loss and gain to a view that they are on a
In the program, participants chose how their avatar looked (actual or desired) and made modifications over time, as wanted. In addition, the Nutrition, Movement, and Healthy Habits classes were all designed in such a way that participants were always moving. For example, participants (ie, their avatars) in Movement sessions engaged in 1 to 4 different activities, ranging from roller skating to surf boarding to riding bicycles, to swimming and more. Similarly, during the Nutrition and Healthy Habits classes, participants spent 90% of their class time in (virtual) standing and moving positions. When proceeding from one activity to the next, they would run, bike, roller skate, etc, to get there. These program design elements were intended to encourage avatar identification, leading to the transfer of virtual behaviors to the physical world.
Examples of program activities in Club One Island.
Design of the Club One Island virtual weight loss community.
We conducted a study of Club One Island’s weight loss program, comparing it with a face-to-face program similar in structure and content offered in a commercial setting (owned by Club One Inc., San Francisco, CA, USA). Specifically, this program included instructor-led weekly educational sessions on nutrition, movement, and habit change, as well as a social support group meeting. Program participants were also able to use club equipment and facilities during normal business hours.
Club One Island’s virtual-world program involved 38 participants recruited via print and online media. Participants had to be over the age of 18 years, with a body mass index (BMI) of 25 kg/m2 or greater, and have access to an Internet-connected computer. They were told they were helping to assess a new program and, as such, it was free. Of the 38 enrollees, 1 was a current Club One member, 9 were members of competing clubs, and 28 did not belong to any health club. Since the comparison face-to-face group had to attend a real facility, we recruited a convenience sample (via email and newsletters) from Club One’s member base. Enrollees had similar age and BMI requirements, leading to a 24-person face-to-face cohort. Across all enrollees, they had on average previously tried 2 other weight loss programs. Prior to the start of the virtual-world program, participants received technical training and support (eg, computer setup and navigating the island).
Data were collected by trained professionals at a Club One facility and provided to the researcher in de-identified form. Both objective and self-report measures were captured at baseline (preprogram) and within 1 week of program completion. Objective data (height, weight, and BMI) were recorded using standard techniques. We calculated the percentage change in baseline weight; a reduction of 5% or more of baseline weight results in clinically significant health benefits [
Descriptive statistics were used to describe baseline characteristics of groups. The analyses tested for group (virtual world and face-to-face) differences in baseline characteristics using a multivariate analysis of variance. We used repeated-measures multivariate analysis to detect group differences, within-participant differences (time), and interactions (group × time) in measured outcomes from baseline to postintervention. Paired
Full data sets were available for 33 virtual world and 21 face-to-face participants. Virtual-world participants (n = 5) dropped out in the first 2 weeks due to technical difficulties and personal reasons. Face-to-face participants (n = 3) dropped out midprogram, citing disinterest and personal reasons. Demographically, the virtual-world group was 76% female (25/33), with a mean age of 46.3 (SD 9.6) years; 73% (24/33) held college or advanced degrees; and 76% (25/33) had annual incomes exceeding US $75,000. All 33 reported they were novice users of Second Life (0–3 months). The face-to-face group was 95% (20/21) female, with a mean age of 37.5 (SD 10.6) years; 90% (19/21) held college or advanced degrees; and 71% (15/21) reported incomes over US $75,000. Across these data, there were no significant differences. However, regarding attitudes toward exercising at a real club, virtual-world participants reported a statistically significant (
The mean BMI of the overall sample was 32.0 (SD 6.05) kg/m2 (virtual world: 33.13, SD 6.13; face-to-face: 30.21, SD 5.62). No significant baseline differences were noted between groups for weight, BMI, general health, fruit and vegetable consumption, breakfast frequency, and physical activity self-efficacy. However, significant baseline differences were observed for moderate physical activity (
Changes in body weight from baseline to postintervention.
Outcome variable, |
Virtual world | Face-to-face |
|
|||
Pre | Post | Pre | Post | Group × time |
Time main |
|
Weight (kg) | 92.1 (23.2) | 88.2 (21.6) | 83.9 (16.1) | 81.1 (14.5) | .29 | .001 |
Body mass index (kg/m2) | 33.13 (6.13) | 31.71 (5.51) | 30.21 (5.6) | 29.13 (4.96) | .39 | .001 |
Changes in health behaviors and self-efficacy from baseline to postintervention.
Outcome variable, mean (SD) | Virtual-world group | Face-to-face group |
|
|||
Pre | Post | Pre | Post | Group × time |
Time |
|
Health (1 = poor to 5 = excellent) | 3.0 (1.1) | 3.5 (1.0) | 3.2 (0.7) | 3.4 (0.9) | .12 | .001 |
Sleep (1 = <6 hours to 5 = ≥9 hours) | 2.82 (0.88) | 2.87 (0.78) | 3.38 (0.81) | 3.23 (0.89) | .30 | .62 |
Moderate PAa (no. days/week) | 2.8 (2.2) | 4.2 (1.7) | 4.2 (2.1) | 3.9 (1.9) | .006 | .08 |
Vigorous PA (no. days/week) | 1.4 (1.8) | 2.5 (2.0) | 3.2 (1.9) | 3.0 (1.8) | .008 | .04 |
PA self-efficacy (1 = not to 5 = extremely confident) | 2.92 (0.80) | 3.42 (0.80) | 3.39 (0.92) | 3.41 (0.80) | .04 | .02 |
Fruit and vegetables (1 = 0 to 5 = >5/day) | 2.79 (0.93) | 3.37 (0.89) | 2.81 (0.81) | 2.90 (0.77) | .007 | <.001 |
Breakfast (no. days/week) | 6.15 (1.48) | 6.78 (0.60) | 6.52 (0.98) | 6.67 (0.66) | .13 | .02 |
Weight efficacy (scale 19 to 133) | 80.70 (20.1) | 108.7 (16.7) | 92.0 (17.2) | 97.3 (16.7) | <.001 | <.001 |
a Physical activity.
The purpose of this study was to explore the potential of a virtual-world-based weight loss program relative to weight loss, behavioral change, and self-efficacy. We used a face-to-face program that was similar in structure and content for comparative purposes. We found both groups significantly benefitted from their respective interventions in terms of weight loss and BMI reduction (see
As we consider these results, it is important to emphasize the tight integration of the Club One Island program and island designs. The design of both aspects allowed for motivational reinforcement, practice-oriented instruction and active learning, and social support, collectively serving to create a learning environment that fostered desired outcomes. In contrast, physical environmental limitations experienced by face-to-face participants seemed to have been less supportive of behavioral change. For example, the dynamic 3D spaces allowed virtual-world participants opportunities to test both positive and negative behaviors like navigating complex food situations, such as at a party. Our results suggest that behavioral change and increased self-efficacy were likely influenced by virtual-world participants observing their avatars engage in healthy behaviors. Virtual-world participants overwhelmingly created avatars that reflected real depictions of themselves. As they lost weight in the real world, they made changes to their avatar’s appearance to reflect this. Through this environment, participants were able—many for the first time in their lives—to have a positive experience related to physical activity, and to test both positive and negative behaviors such as navigating complex food situations. Sample comments by virtual-world participants provide evidence of avatar identification and the transfer of virtual-world behaviors to the real world, as well as the development of self-efficacy and the role of social support (for additional comments from participant interviews, see
During the workday, I remember my avatar sipping from a (3D) water bottle and I’d grab my own (real) bottle. Having the bottle and drinking animation has led directly to a change in my behavior.
Usually when I’m on the treadmill at the gym, I walk for 5 minutes and run 1 minute, which is really challenging. This last time, I pictured my avatar running and I felt like my avatar and it made me feel stonger. I ran for 2 minutes easily.
I’m integrating skills I didn’t know how to use. I usually read nutritional labels but didn’t really know what to do with the information. Now I have more confidence and know how to maintain my weight loss.
This was the best part of any class, when the other members talked about their experiences. It was just good to know other people out there are struggling with the same issues.
Overall, our results offer positive early evidence that a virtual-world-based weight loss program can be as effective as a face-to-face one relative to biometric changes. Our results also suggest that a virtual world may be a
While we do not direct compare them here, our results are also promising relative to those of prior studies of Web-based interventions. One indicator is that, despite the weekly time commitment, the dropout rate within the virtual-world program was low (15%) compared with other Web-based programs [
The sample in this study provided both strengths and weaknesses. Given our research focus and the interests of our industry partner, the demographics of our sample were appropriate. However, this is a possibility of a self-selection bias, as participants in both groups volunteered to participant in the study in response to a recruitment advertisement. Thus, their motivation and other possible variables may not be representative of the general population. Future research should involve a broader recruitment strategy and controlled assignment to an intervention. While our study followed past practice by using a face-to-face group for comparative purposes, the next step would also be to compare a virtual-world versus a Web-based intervention. This may allow, for example, deeper analysis of the relationship between avatar identification and outcomes.
We also focused our attention largely on outcomes to compare the effectiveness of the virtual-world and face-to-face weight loss programs. While we found positive benefits immediately following program completion, a longitudinal assessment is needed to determine whether behavioral changes are sustained over time for virtual-world participants. We have some evidence that avatar identification, virtual- to real-world behavior transfer, and social support components relate to outcomes. Yet, as with earlier studies [
Lastly, from a human–computer interaction design perspective, a deeper understanding of how design elements (eg, environmental or avatar realism) interact with individual characteristics (eg, a preferred representational system) is essential to advancing the adoption of virtual worlds. Moreover, while a virtual presence is considered central to the utility of a virtual world, attempts to design spaces to maximize presence are premature without solid evidence that it relates to desired outcomes. In this study, we also explored the efficacy of a specific virtual-world platform (Second Life). Further work should examine alternative platforms possessing varied sociotechnical capabilities.
In sum, further empirical testing in both controlled experiments and field studies would help to develop a richer understanding of the value of virtual-world-based interventions to address obesity and overcome the challenges of existing approaches.
The rising rates, high prevalence, and adverse consequences of obesity call for the development and testing of innovative approaches that address the cited barriers and bring needed help to those most affected. While more research is needed into their use in medical and health contexts [
Club One Island Virtual Spaces and Activities.
Participant Interview.
3-dimensional
body mass index
Weight Efficacy Lifestyle Questionnaire
J. Johnston and A. Massey have no conflicts of interest to declare. C. DeVaneaux is an industry partner who was blind to the analysis and the results prior to the completion of the paper.