Active Video Game Program for People with Type 2 Diabetes- a Pilot Study

Round 1

Reviewer 1 Report

This manuscript presents the importance of regular exercise for adults with type 2 diabetes for optimal disease management. The use of exergaming for adults is innovative and has been used in a younger cohort. 

There are several key suggestions that should be addressed to improve the contribution of this study. First, there is no mention of human subjects protection other than informed consent. Institutional review board procedure needs to be addressed. Second, there are no details on the recruitment of study participants. Inclusion and exclusion criteria are included, but no information is provided regarding how participants were identified and recruited or the study setting. Be sure to include the duration of diabetes when describing the sample. Third, the description of the exergaming intervention is limited and the frequency of the exercise sessions are not provided until the discussion section. Rationale is needed for the use of an 8-week intervention since other interventions are 12 to 16 weeks. The intervention needs to be described as occurring in a central location and not in the participant's home to minimize confusion. The number of sessions that individual subjects participated in over the duration of the intervention were not included in the analysis and may have affected the outcomes. There was a wide age range for the participants and this needs to be addressed as a potential limitation to the study results. 

Although the follow-up questionnaire include the average minutes of exercise after completing the intervention, there is no mention of this information in the manuscript. 

A few editorial suggestions include the following:

In the introduction, paragraph 1, Lines 33 -34, use active voice and present tense, "If people with diabetes do not..."

On page 2, Lines 66-73, indicate if these studies included adults with type 2 diabetes. On Line 74, there is a typo, change "obsess" to "obese."

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Abstract: the prior condition of fitness of patients should be described, this situation could be trascendental for results. It is assumed that, if they found a moderate intensity in the game, these patients start from a low fitness level? Can the intensity be changed in the games? Does it has different level of intensity?

Introduction: Maybe authors should show the prevalence of D2 in Americans (where the study is made).

In lines 44-47, references 5, maybe a bit more information of these adults should be shown (mean age or context).

Also introduction should show more information about fitness of D2T people. The introduction only shows prevalence and the benefits of physical activity, and that people with D2T are less likely to participate, but probably they have a lower fitness condition? 

Methods, subjects: There is a lack of information about subjects (it appears in results). It should be shown age, gender, physical activity participation regularly or not, how active they are, IMC,... etc.

Methods, psychological assessment: More information about each questionnaire is required, for example, number of items, example of an item, response scale, etc. whatever the authors consider that gives the reader more information about the type of scale used. 

Results are not good enough but it is a good start for a pilot study. Maybe this suggestions could take into account in Conclusions.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

This short report aimed at studying the effects of active video gaming on fitness, psychological and glucose-related parameters. While the study is well-conducted, the low number of subjects limits the reach of the conclusions. This work would make a good pilot study but at least one RCT has already been published with similar design, outcomes and population, which limits as well the novelty and interest of this work.

Minor concerns:

• An explanation should be provided as for the estimation of maximum HR (formula, measures?)
• Figure(s) illustrating the sentences " Subjects’ exercise intensity ranged between 61% and 83% of their max HR and the average was 71 ± 8% max HR" and  "Subjects’ average RPE throughout each session was 11.9 ± 0.8 and the max RPE was 14.4 ± 0.9" would be nice, including the levels of intensity, since the authors mentioned in the conclusion that some participants were able to reach vigorous intensity, at times.
• The authors state that no changes were significant because of the low number of subjects. The p-values could be easily added in the tables (1 and 2), for each line, to give the readers an idea of it.
• The authors use several times the wording "moderate intensity", this concept should be clarified (in term of max HR? RPE?) and the authors should be more specific.
• There seems to be grammar/syntax mistakes at lines 225-226 "On the same manner, although not statistically significant, the flexibility were increased. " and "It might be due to the movements in the games included kicking and punching"
• Line 232, this statement is obscur "Another participant showed the attempt but failed to complete one full sit up. A similar challenge was discovered on the sit up test in another study". What do the authors mean?
• This sentence is very vague, to say the least, line 257-258 "At  one-month  follow-up  via  phone  interviews, most participants reported better behavior and attitudes toward their health and physical activity. Some carried on playing AVG at home while one joined a gym". Please avoid using "some" or "most". If the number is known, it would be helpful to provide it.

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

The authors present a pilot study assessing the impact of active video games in people with type 2 diabetes. Despite the significance of this work, I suggest some improvements.

Major concerns:

• The number of participants is too low, only eight. Moreover, some of them don't participate in all experiments. So, as recognized by the authors, the results don't have statistical significance. The authors must include more patients in the study.
• The authors must improve the characterization of the patients included in the study.
• The contribution of this work is not clear. Please, include a review of the impacts of AVG on people with T2D and identify the contribution of this work.

Minor concerns:

• Please avoid the use of acronyms in the abstract.

Author Response

The authors present a pilot study assessing the impact of active video games in people with type 2 diabetes. Despite the significance of this work, I suggest some improvements.

Major concerns:
The number of participants is too low, only eight. Moreover, some of them don't participate in all experiments. So, as recognized by the authors, the results don't have statistical significance. The authors must include more patients in the study.

The authors must improve the characterization of the patients included in the study.

A: We appreciate your feedback and suggestions. We agree that small samples size is the limitation of this study. We also have recognized the wide variation on subjects’ characteristics as another limitation in the revised discussion.

The contribution of this work is not clear. Please, include a review of the impacts of AVG on people with T2D and identify the contribution of this work.

A: Thank you for your feedback. As described in our literature review, exercise is beneficial for people with T2D, but lot of people with T2D do not exercise. While AVG has been shown an effective way to exercise for general populations, we hypothesized AVG will be a good alternative of exercise and helpful for this specific population. While prior AVG study for people with T2D were unsupervised at home, our study was a supervised AVG program. Although one subject was not able to complete the study due to schedule conflict, this pilot study demonstrated the feasibility of a supervised AVG program in a central location for the T2D population. In addition, 5 of 7 (71%) subjects improved their glucose in HbA1c in only 8 weeks, which is clinically significant to people with T2D. We have addressed the contribution of this study in the revision. Thank you.

Minor concerns:
Please avoid the use of acronyms in the abstract.

A: Thank you for your feedback. Since there is a word limit for the abstract per journal requirement, we think that was the most effective way we can manage the wording in the abstract.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

The authors have been responsive to the earlier review and addressed concerned in this revised version of the manuscript. 

Careful review of verb tense usage and grammar is suggested. For example, see the Results section. Sentence should state "Eight subjects participated in the program..."

Discussion, line 235, "Although the decrease was (not were)..."

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

The authors have considered all suggestions and explained every question. Thanks.

Author Response

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Author Response File: Author Response.pdf

Reviewer 4 Report

I appreciate the author's reply. However, my concerns remain the same. The number of participants in this study doesn't allow to support the conclusions. The authors must add more participants to the study.

Author Response

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Author Response File: Author Response.pdf

Round 3

Reviewer 4 Report

Dear authors,

I appreciate your reply.

Please, make sure that the conclusion dos't make a recommendation.Make sure that the conclusion doesn't make a recommendation, sing the number of participants does not support it.