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Master´s thesis
Licentiate’s thesis
Doctor´s thesis
Subject Virtual reality applications against obesity Date 31-May-2017
Author(s) Rutger Xaverius Smids
Student number 513812
Number of pages 106
Title Virtual reality, the last battle against obesity.
Supervisor(s) Dr. Kai K. Kimppa (1st), Prof. Dr. A.F. Rutkowski (2nd) & Prof. P.Rousseau (3rd)
Abstract
Obesity has become the number one disease in the world and many children suffer from the effects. This
thesis examines if virtual reality applications can help in the fight against obesity. The literature review
shows that virtual reality applications can be effective for treatment and the specialists interviewed agreed
with the potential of virtual reality usage in treatments. The biggest bottleneck would be the development
costs, but this issue can be solved in a variety of ways e.g. funding or commercial companies. The interviews
and literature review are used as a basis for a low polygon game design. The game is a combination between
a mobile application and the virtual reality game which teaches the child about nutrition while exercising.
The game is a motivational tool for the fight against obesity, since the game solely cannot tackle the whole
obesity problem due its complexity.
Key words Virtual Reality, Technology, Obesity, Overweight, Treatment, Game design, weight
control, diabetes prevention. VR game.
Further
information
This thesis is submitted for the IMMIT program and is written while doing an internship at
MediaMonks and consists of a qualitative analysis and a constructive game design.
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VIRTUAL REALITY, THE LAST
BATTLE AGAINST OBESITY
Master´s Thesis
Information Systems Science
Author (s)/Laatija(t):
Rutger Smids
Supervisors/Ohjaajat:
Dr. Kai K. Kimppa (1st)
Prof. Dr. A.F. Rutkowski (2nd)
Prof. P.Rousseau (3rd)
31.05.2017
Turku
3
Turun yliopiston laatujärjestelmän mukaisesti tämän julkaisun alkuperäisyys on
tarkastettu Turnitin OriginalityCheck -järjestelmällä.
The originality of this thesis has been checked in accordance with the University of Turku quality
assurance system using the Turnitin OriginalityCheck service.
4
ACKNOWLEDGEMENTS
I would first like to thank my thesis supervisor Kai K. Kimppa of the University of Turku. He has been of
immense value during my thesis and I could bother him any time with questions. During our meetings it
was not purely academically but we had some good laughs as well. He is an awesome person to have as a
supervisor and as a person in general. He helped me shaping this thesis into the right direction when needed
and we discussed which roads to take and prioritize before going into the constructive analysis, even though
we both would enjoy that part the most. The thesis structure is unusual and innovative, since it combines
qualitative analysis with a constructive approach. Since the topic is also innovative, an innovative approach
has been conducted on top of a normal qualitative thesis framework.
I would also thank my internship company, MediaMonks, which provided me with all the practical
knowledge and taught me the business side of virtual reality and what it means to be a virtual reality
producer. A tremendous shout-out for my mentor during my internship, Robert-Jan, with whom I have been
working daily and he taught me almost everything about virtual reality, film, producing in general and
everything that is relevant of production and project management. He is one of the smartest people I have
met and is always thinking about every possible solution or aspect before deciding what would be the best
approach. I am proud to have had him as my mentor and I am amazed how he deals with the workload while
being a family-man.
I would also like to thank Victor Knaap, the boss monk, who granted me the opportunity of doing my
internship at MediaMonks and providing housing the first two months. As would I like to thank all the
experts that participated in the interviews and provided me with all the data needed for this research, my
family & friends for the unfailing support and everyone else that has been involved in the process.
Also a shout-out to my second and third corrector; Prof. Dr A.Rutkowski and Prof. P.Rousseau for taking
their time to read this master thesis and to all my professors in IAE, University of Turku and Tilburg
university which lectured me during IMMIT.
I wish every reader a pleasant time reading and hopefully this thesis will be an inspiration.
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TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................................................................................................................... 4
1 INTRODUCTION ........................................................................................................................... 9
2 LITERATURE REVIEW ............................................................................................................. 12
2.1 HISTORY OF VIRTUAL REALITY .................................................................................... 12 2.2 BRIEF OVERVIEW OF CURRENT USAGE OF VIRTUAL REALITY ................................... 16 2.3 THE FUTURE OF VIRTUAL REALITY .............................................................................. 25 2.4 VIRTUAL REALITY DRAWBACKS ................................................................................... 27
2.4.1 TECHNOLOGICAL AND FUNCTIONAL DRAWBACKS.................................................. 27
2.4.2 SOCIAL, HEALTH AND PSYCHOLOGICAL DRAWBACKS ............................................ 29
2.5 THE OBESITY COMPLEX ................................................................................................. 32 2.6 DIFFERENCES BETWEEN CHILDREN AND ADULTS IN TREATMENTS .......................... 38 2.7 CURRENT STUDIES OF VIRTUAL REALITY AND OBESITY TREATMENTS .................... 40 2.8 CALORIE USAGE ............................................................................................................. 43
2.8.1 KCAL INTAKE ................................................................................................................. 44
2.8.2 KCAL BURNED IN VR ..................................................................................................... 44
3 RESEARCH METHODOLOGY ................................................................................................. 47
3.1 CHOOSING A RESEARCH METHODOLOGY .................................................................... 47 3.1.1 QUALITATIVE VERSUS QUANTITATIVE METHODOLOGY ......................................... 47
3.1.2 QUALITATIVE RESEARCH VERIFICATION................................................................... 48
3.2 INTERVIEW PREPARATION ............................................................................................ 48 3.3 DATA GATHERING .......................................................................................................... 49 3.4 INTERVIEW ANALYSIS .................................................................................................... 50
3.4.1 ANALYSIS APPROACH ................................................................................................... 50
3.4.2 METHOD DISCUSSION ................................................................................................... 51
3.5 CONSTRUCTIVE METHODOLOGY .................................................................................. 52
4 INTERVIEW ANALYSIS ............................................................................................................ 53
5 CONSTRUCTIVE GAME DESIGN: HEROES VS FAT ......................................................... 59
5.1 GAME MECHANICS ......................................................................................................... 65 5.1.1 GAME ELEMENTS .......................................................................................................... 66
5.1.2 CONCEPT ART AND DESIGN ......................................................................................... 66
5.1.3 RULES ............................................................................................................................. 67
5.1.4 MECHANICS .................................................................................................................... 69
5.1.5 GOALS ............................................................................................................................. 70
5.1.6 OPTIONAL GAME FEATURES ........................................................................................ 70
6 DISCUSSION ................................................................................................................................. 71
7 CONCLUSION .............................................................................................................................. 79
6
REFERENCES ..................................................................................................................................... 81
APPENDIX I: QUALITATIVE ANALYSIS TABLES .................................................................... 88
APPENDIX II: INTERVIEW QUESTIONS: .................................................................................... 92
VR RESEARCHERS ........................................................................................................................ 92
VR SPECIALISTS ............................................................................................................................ 93
CHILD OBESITY SPECIALISTS ...................................................................................................... 94
APPENDIX IIIA: LANDSCAPE DESIGN ........................................................................................ 95
APPENDIX IIIB: DESIGN STYLE ................................................................................................... 98
TABLE OF FIGURES
Figure 1: VR Landscape ......................................................................................................................... 14
Figure 2: Omni treadmill ........................................................................................................................ 17
Figure 3: VR surgery practise ................................................................................................................. 18
Figure 4: VR as educational tool ............................................................................................................ 19
Figure 5: Discovering Indonesia ............................................................................................................ 22
Figure 6: VR 3D model capture man...................................................................................................... 23
Figure 7: VR 3D model capture woman ................................................................................................. 24
Figure 8: Google trends VR porn search ................................................................................................ 24
Figure 9: MSI's VR backpack ................................................................................................................ 25
Figure 10: Microsoft Hololens ............................................................................................................... 26
Figure 11: Google Glass ......................................................................................................................... 27
Figure 12: Eyestrain: comparison real - and virtual world ..................................................................... 31
Figure 13: Division obesity over the world per men and women........................................................... 35
Figure 14: Percentage of obese people per country (BMI > 30) ............................................................ 36
Figure 15: Obesity US children .............................................................................................................. 36
Figure 16: Child playing with his virtual pet .......................................................................................... 42
Figure 17: Kcals burned per game .......................................................................................................... 45
Figure 18: Head mask HTC Vive ........................................................................................................... 46
Figure 19: Public opinion of VR ............................................................................................................ 55
Figure 20: Children's review of VR ........................................................................................................ 58
Figure 21: Production stages .................................................................................................................. 59
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Figure 22: User flow A: Mobile application .......................................................................................... 63
Figure 23: User flow B: HTC Vive ........................................................................................................ 64
Figure 24: Mountain example ................................................................................................................ 95
Figure 25: Map overview example ......................................................................................................... 95
Figure 26: Village overview example 1 ................................................................................................. 96
Figure 27: Village overview example 2. ................................................................................................ 96
Figure 28: HTC Vive "The Lab" parabolic point teleport function ........................................................ 97
Figure 29: Clash of Clans example ........................................................................................................ 97
Figure 30: First person view of enemy ................................................................................................... 98
Figure 31: "Cool" carrot archer .............................................................................................................. 98
Figure 32: Carrot arrows ........................................................................................................................ 99
Figure 33: Beetroot reindeer rider soldier .............................................................................................. 99
Figure 34: Hero example models ......................................................................................................... 100
Figure 35: Battle reindeer. .................................................................................................................... 101
Figure 36: Avocado shield of the broccoli soldier ............................................................................... 101
Figure 37: Broccoli soldier ................................................................................................................... 102
Figure 38: Evil burger example ............................................................................................................ 102
Figure 39: Burger example ................................................................................................................... 103
Figure 40: Evil French fry archer ......................................................................................................... 103
Figure 41: Evil pizza boss .................................................................................................................... 104
Figure 42: Pizza boss texture example ................................................................................................. 104
Figure 43: Weapon examples ............................................................................................................... 105
Figure 44: Building example 1 ............................................................................................................. 105
Figure 45: Building example 2 ............................................................................................................. 106
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TABLE OF TABLES
Table 1: Daily calorie need ..................................................................................................................... 43
Table 2: Kcal burned per sport ............................................................................................................... 45
Table 3: Assumptions game concept ...................................................................................................... 60
Table 4: Side notes user flow A: Mobile application. ............................................................................ 63
Table 5: Side notes user flow B: HTC Vive. .......................................................................................... 64
Table 6: Character & attribute overview ................................................................................................ 66
Table 7: Unlockable mechanics .............................................................................................................. 67
Table 8: Analysis categorisation............................................................................................................. 88
Table 9: Attachment Table 8. ................................................................................................................. 91
TABLE OF ABBREVIATIONS
AR Augmented reality
ED Eating disorders
FPS Framerate per second
GS Goldman Sachs
HDM Head-mounted display
MR Mixed reality
PA Physical activity
TMV Total market value
VE Virtual environment
VR Virtual reality
WWW World Wide Web
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1 INTRODUCTION
Standing on top of the mount Everest or on the floor of the Mariana Trench is something people can dream
off but most likely will never achieve in their life. This does not reduce the curiosity how it will look like
and people keep dreaming of being there. Virtual reality (VR) provides opportunities to ease this curiosity
by bringing the people to the desired destination. The possibilities of VR are growing every day and the
possibilities are endless.
VR programs are currently getting or already developed in the military, medical or rehabilitation field. But
what if you can prevent certain diseases and keep people out of rehabilitation instead of curing them? The
most common disease in first world countries is obesity and is often referred to as “the disease of the twenty-
first century” (Rössner, 2002). The cause of obesity is very complex and can be influenced by many factors.
This makes the cure or prevention of this disease complicated since multiple factors have to be targeted.
The disease and the current treatments are further explained in chapter one.
Modern technologies provide innovative ways of curing or preventing diseases and the question arose what
could be the impact of VR in the fight against obesity1? The need of finding an adequate cure has become
urgent since in 2014 in the USA 36.5% of the adults were obese (Ogden, Carroll, Fryar, & Flegal, 2015).
This thesis focuses on the target group of people with a BMI > 30, which is the benchmark of obesity and
not solely focuses on the morbidly obese.
VR is not exclusively used for military and medical purposes anymore since it is also widely used in
production processes, marketing and gaming. With the current VR trend people can use VR headsets to
enhance their daily life in a variety of ways. The definition of “enhanced” is used in the most extensive way,
following: “to intensify or increase in quality, value, power, etc.; improve; augment” (Oxford Dictionary,
2010). Someone can enhance his or her life in many ways, not only by improving certain experiences, but
also a reduction or complete annihilation of pain improves the quality of life. This can also be split up in
multiple factors, from physical to mental suffering, which will be elaborated in the literature review.
VR technology combined with the increasing obesity problem is the foundation for this thesis and resulted
in the following main question: “can VR applications help to cure or prevent obesity for the new
generation?” This research question is specified on children in the age-group of 5-9 and will make use of
the concept of gamification2. The target group of 5-9 was chosen since if children would get overweight at
1 If other external factors are not changing, ceteris paribus. 2 ““Gamification” is an informal umbrella term for the use of video game elements in non-gaming systems to improve
user experience (UX) and user engagement” (Deterding, Sicart, Nacke, O'Hara, & Dixon, 2011).
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this point, the chance of being obese as a teenager (age > 14) was 4 times higher. This longitudinal research
initially followed 9358 children with 6807 children in the follow-up data and had statistically significant
results. (Cunningham, Kramer & Narayan, 2014.)
Treating, curing or preventing the disease can be done in a variety of ways and is depending on the stage of
the disease is. VR applications are defined in this thesis as an application specifically designed to be used
in VR. The device on which this application should run is yet undefined and can vary from low- to high-
end devices. The final decision should be carefully researched. The application can be targeted to a specific
problem “causer” of obesity or towards obesity as one problem. This will be further elaborated in the
constructive part of this thesis.
Research has already been conducted in this field of how VR applications can help in treating obesity, but
only with adults as a target group. There is a lack of research on how it could (not) work for children and
this is an important gap in the current available literature. This is especially important since for this target
group obesity can be prevented instead of cured before other diseases are developed. This could potentially
not only bring less suffering, physically and mentally, but also reduces the amount of operations or
medicines needed caused by obesity.
Besides of the lack of research in this field, this needs to be researched because a lot is currently changing
in the field of VR due innovations. VR is already being used for children regarding educational purposes,
but is currently still in the development stage. A variety of research papers have been written of the potential
usage of VR, but the first devices for public usage have been launched in 2014 while most research papers
are dated before this time. The availability of VR devices provides researches with the possibility to test the
theory instead of just speculations. This thesis starts to explore the field of VR usage for treatment related
cures for obesity and could be used for further studies towards treatments.
The thesis itself will start off with a clear definition of VR and continues with an extended literature review
of the currently available literature in the field of VR, VR applications, obesity and psychology. Since this
study is multidisciplinary, the scope of the research is broad. Thus, the research will not only focus on the
technical possibilities of VR or VR as a medium but also the psychological impact of VR applications on
the behaviour of children and if this can be used in preventing or treating obesity regarding the causes and
results.
After the current literature of the different disciplines has been reviewed, it is explained why the qualitative
research approach is used in this thesis followed by the analysis of the interviews with different professionals
in the specified fields of: VR, obesity treatment and child psychology. The literature review combined with
the qualitative analysis provides a foundation of the constructional methodology as an addition of this thesis.
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Developing a game conceptually that could be used, based on the research and interviews is an interesting
challenge and combines skills learned during my studies, specifically my masters, and internships.
The thesis progresses with the discussion and the limitations of this research. This focuses on what could
have been done better in this research, which factors should be kept in mind for further research and
suggestions for future research in the field of VR. The concluding chapter will consist of the conclusion and
provides insights in the effectiveness and potential of VR and if so, how it can be used to fight welfare
diseases as obesity in the first world or how it could benefit in different ways the current treatments.
As Pearls S. Buck said: “If you want to understand today, you have to search yesterday”, thus this thesis
starts off with the first real example of VR in 1962 after defining VR.
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2 LITERATURE REVIEW
2.1 HISTORY OF VIRTUAL REALITY
Before the history of VR can be reviewed, the definition of VR needs to be clarified since it is a widely used
term and used in a variety of different contexts, and consequently often misused. This thesis will use the
following definition of VR in line with Margaret Rouse (2015): “Virtual reality is an artificial environment
that is created with software and presented to the user in such a way that the user suspends belief and
accepts it as a real environment”. Suspending the belief of being in the virtual world is with the current
technology hard to achieve. But the moment someone is acting and walking in a virtual world and
recognising the user is “really” in the world, shows enough belief in this virtual world3 to perceive it as real
(Rouse, 2015). This can vary from very simplistic 3-D worlds to immersive photorealistic VR experiences
that includes sound, smell, vibration and heat. Other definitions mainly involve goggles and gloves, but this
would abandon the earliest invention of VR since the term “goggles” is not covering all different kind of
machines.
Because of the hype, everything that falls partly in the boundaries of the definition it is called “VR”.
Therefore, researchers are more commonly using the term “Virtual Environments” (VE). A VE is a three-
dimensional representation, generated by a computer, of a setting where the user is enabled to interact with
the VE (Thesaurus, 2014; Mazuryk & Gervautz, 1996). Two important terms must be kept in mind regarding
VR and are often used in the same context since they are tightly coupled, but have some slight differences
with VR: Telepresence and Cyberspace.
• Telepresence - is referred to as a specific kind of VR that simulates a real but remote environment
(in terms of scale or distance). Another more accurate description would describe telepresence as
that the actor receives adequate quality and quantity of sensory feedback and thus has the feeling
that he or she is actual present in the VE. (Held & Durlach, 1992.)
• Cyberspace – this term was invented by the writer Gibson as: “a consensual hallucination,
experienced daily by billions of legitimate operators, in every nation, by children being taught
mathematical concepts… A graphic representation of data abstracted from the banks of every
computer in the human system. Unthinkable complexity. Lines of light ranged in the nonspace of
the mind, clusters and constellations of data. Like city lights receding...” (Gibson, 1984).
3 Many games are not close to our reality, but HTC Vive game “Job simulator” is perceived as “real” and people “feel”
they are in the game while it is a low graphic quality game (Interview R.Blonk, 2017).
13
Telepresence is based on the idea of our current presence or potentially occurring presence, but then
simulated or altered. Since presence can be seen as the experiences of someone’s physical environment,
telepresence is a simulation or perception of those surroundings. Thus, presence can be defined as “the
sense of being in an environment” with as condition is being in a “natural” non-fictional environment.
(Gibson, 1979.)
The confusion of what falls within the boundaries of VR and what not, has to be reviewed per different case.
But besides of VR, 360 film and augmented reality (AR) are often used as synonyms, while there is a
substantial difference which should be kept in mind and plays an important role in this thesis.
The difference between 360 film and VR is that in VR the user controls the experience while in 360 film
the user is simply joining the predetermined “rollercoaster ride”. The headsets used in the experiences are
both the same, but the production process and the features are different, which causes often confusion.
(Adams, 2016.)
The difference between VR and AR is based on the amount of virtual world the user sees. In VR the user is
completely in the virtual world, while in AR the real world is blending together with the virtual world. E.g.
the Microsoft HoloLens scans the environment around the user, and projects designs or models in the actual
environment. Thus users are able to interact with both the real and the virtual world. At this moment users
are able to make a distinguishing between the two due to technical restrictions, but this could be an
interesting research topic in the future. (McKalin, 2014.) The game “Pokémon go” was the first application
that was widely used by the public and often got confused with a VR game, while it was an AR application
since it projected Pokémon in the real world.
The hype of VR started around 2014, when people got more often in touch with VR through VR headsets.
Those were and are gaining high popularity and multiple developers established their name in the VR
business, e.g. Oculus Rift, PlayStation VR, Samsung Gear VR and the HTC Vive. (Lamkin, 2016.)
The VR landscape of Q1 2017 can be found in Figure 1. The VR landscape in Figure 1 shows all the
investors and big companies that are supporting or funding the VR market.
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Figure 1: VR Landscape (VRVCA, 2017).
15
The developers and companies shown in Figure 1 were not the first ones experimenting with VR headsets,
the first concept of an electronical VR “headset” goes back to the 20th century. The official starting point of
VR is discussable, but this thesis takes the Sensorama developed by Mortan Heilig in the 1950’s as the
beginning. (Mazuryk & Gervautz, 1996.)
Before the 1950s there were speculations- and ideas about VR and descriptions of goggle-based VR systems
were found, but this stayed in the theoretical field and was never developed. The same accounts for the
written literature, writers have been writing about VR as early as in the 1930’s by American science-fiction
writer Stanley G. Weinbaum, but this was still fantasy.
The real empirical example of a VR device taken as starting point is in line with Earnshaw, Gigante & Jones
(1993), Mazuryk & Gervautz (1996) and Burdea & Coiffet (2003) and provides the beginning for a journey
through history. The Sensorama was revolutionary at the time of development and was a multi-sensory
simulator which prototype was finalised in 1962. The machine was not only showing a pre-recorded film in
stereo and colour, but the experience was extended with elements as wind, smell and vibrations during the
movie. Three years later, in 1965, Ivan Sutherland published a paper which was called: “The Ultimate
Display”, in which he was describing that one day computers could provide a gateway into virtual worlds.
In 1968 Sutherland realised his idea and he build a head-mounted display, called the Sword of Damocles,
that presented the user left and right views of a 3D scene. This was the first “headset”, since the device was
head-mounted but attached to the ceiling due to the weight. (Adams, 2016.)
The system was able, in contrast to the Sensorama, to track the person’s head movement (Gutierrez, Vexo,
& Thalmann, 2008). In the 1980s commercial VR companies started to appear and Jaron Lanier’s company,
VPL, invented and promoted their VR goggles combined with touch gloves (LaValle, 2016). At the same
time, NASA was working on flight simulators for pilot training to get future astronauts ready for space. But
the headsets were heavy, the computers did not have enough processing power and the feedback systems
attached to the gloves were unreliable. Even though gaining more popularity by the bigger public because
of movies as “Tron” in 1982 and Star trek in 1979 with sequential movies in ’82, ’84, ’86 and ’89, it never
took off due to the excessive costs and low graphic quality (Nelson, 2014). In the 1990s VR-based arcade
video games gained popularity, but were mainly found in arcade halls since the experience was not
compelling or comfortable enough. During these years SEGA, Atari, Nintendo and Sony started to launch
VR and AR headsets, but after this initial launch the hype was quickly over because other innovations drew
the attention of the public, e.g. internet, DVD’s and “high” quality televisions. (The Nunatak Group, 2014.)
16
In 2010 the rumours about the Oculus Rift (VR) and Google Glass (AR) started to come up. In April 2013
Google Glass and in March 2014 the Oculus Rift got launched and both set a benchmark for the new VR &
AR technology. Both were a breakthrough in the VR or AR scene and they were relatively affordable for
the public. In the years after; Samsung GearVR (VR), Google Cardboard (VR), Microsoft Hololens (AR),
HTC Vive (VR) and Playstation VR (VR) were launched as the most important competitors on the market
(Lamkin, 2016). New models are projected for the upcoming years and every month new announcements
of VR devices are made on tech-websites e.g. “The Wire”.
2.2 BRIEF OVERVIEW OF CURRENT USAGE OF VIRTUAL REALITY
With the invention of the Sensorama, the first applications for VR were also developed. In this case a very
simplified space where the user could look around inside the virtual world and move around. (Mazuryk &
Gervautz, 1996.)
Once the first VR device was developed, development quickly took off and the possibilities of VR were
extended in many different fields and became a practical tool. The different applications are outlined in the
following paragraphs.
Entertainment
VR got known by the big crowd through games and movies, which are more related to 360 film, but many
people cannot exactly tell the difference and perceive 360 film and VR as synonyms. To enhance the user
experience while playing games external devices such as the Omni treadmill, which is a 360 degrees’
treadmill enabling the user to walk all directions, can be linked to a VR headset. This creates the feeling of
being in VR and makes the experience more engaging. The actual movement of the user is displayed in the
game and can bring shooter games to “a next level immersive experience” of reality for the player
(Earnshaw, Gigante, & Jones, 1993). As shown in Figure 2, the treadmill has a 360-degree radius and with
the special shoes the user has the feeling of really being able to move in the game, since the person is
physically walking (Virtuix Omni, 2016). Because of this actual movement, the body and mind are aligned
since what the body does is in line with what your eyes see. You feel you walk around while you move in
virtual space as can be seen in Figure 2. This creates less distortion in the body and can prevent motion
sickness, which is discuss in the drawbacks of VR.
17
Marketing
The purpose of marketing is attracting the attention of potential clients and move them from just having
interest for a product to making people buy it. Marketing can be done in many ways from simple
advertisements next to highways, to very targeted customer marketing by segmenting your target group.
Social media is more often used for marketing and the many advertisements shown on Facebook use
complex algorithms to track your internet behaviour for optimizing the advertisements the user is seeing.
One of the innovations that changed the whole concept and strategy in marketing is “big data” and VR is
could potentially do the same. (Erevelles, Fukawa, & Swayne, 2015.)
The concept of marketing changed from simply promoting, promising and bragging about a product to tell
a story about the product and attach people emotionally with this. Storytelling is planting an idea in a
potential customer their head and move them to buy the product, sometimes even without notice of the
customers. VR is providing the means for marketers to intensify the experience their customers go through.
Seeing or hearing a story can grab someone’s attention, but being in the story itself as a viewer or even as
the main character is next level engagement of the customer in the story. (Simmons, 2016.)
Figure 2: Omni treadmill (Virtuix Omni, 2016).
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As example, the results, because of the increase in involvement and engagement, can be seen in the
percentages of people donating to UNICEF. On average 8.3% of the people donate to UNICEF before
having the VR experience. After having the experience this percentage increased to 16.6% of the people
donating. This is caused by moving people closer to the story, having a first-person view is completely
different from seeing it in a third-person perspective and this increases the amount of emotions and feelings.
(Jones, Hah, & Shekhtman, 2016.)
Medical usage
In the medical field, VR can be used for everyone from regular nurses to a specialist in e.g. brain surgery.
VR programs enables the user, in this case the medical staff, to practise, rehearse and learn (new) situations
that can occur. With devices as the HTC Vive the surgeons can very precisely practise complicated surgeries
in realistic simulations before actual performing them on a patient. Besides of practising VR, it gives the
possibility to enlarge certain body parts and “tear” them apart and turn them inside out to see the structure
of all the muscles, tendons and cartilage (Glatter, 2015). Figure 3 shows a student practising a surgery in
VR. VR and AR enable the students to follow in-depth physician training programs and allows them to
prepare for real surgeries and with the increased experience will reduce the risk of failure. (UTHealth, 2016.)
Figure 3: VR surgery practise (UTHealth, 2016).
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Education
VR was originally used in the military field and the aviation business but is currently gaining popularity in
the educational field. With all the new applications developed to enhance the learning experience for
children or (young) adults, VR is more extensively used. The usage of VR in the educational system varies
from elementary school to university level, so is not only limited for young children. Examples of
applications used for the educational system are: virtual field trips, a tour through the body (biology),
walking on other planets (astronomy), going through historic events (history), games for children to improve
their counting, math or language. Besides of just educational purpose it enables people to make use of a
virtual environment so everyone can be present and interact in the virtual world. (Reede, 2016.)
Figure 4 shows children in-class discovering other planets and how the universe works on itself. This is
changing the educational field since children can be in the experience instead of learning by heart (Ali,
2016).
Figure 4: VR as educational tool (Ali, 2016).
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Military
As explained in the history of VR, one of the first applications of VR was NASA working on flight
simulators, to train and prepare the astronauts to go into space. The aviation industry was also making use
of those simulators to train their pilots and the military did not stay behind. They used VR to train their
fighter pilots not only for controlling the aircraft itself, but also what to do in emergency situations in case
of a technological failure or an enemy threat.
The military did not keep the training limited to pilots only. Soldiers are also trained in VR since very
realistic situations can be simulated and the supervisors can evaluate how the soldier is reacting and adapting
to a new situation. This is especially useful since commanders with a lot of experience can watch “over the
shoulder” of new recruits and give them tips and insights how they could better respond. Because everything
in the virtual world can be changed, a lot of costs can be saved for actual trainings missions in rough terrains,
since this can be simulated in a hall in a military facility and no actual ammunition is needed for shooting
practise. (Earnshaw, Gigante, & Jones, 1993.)
Therapy
After the initial usage of VR in the military and medical field, psychologists also started to use VR to treat
their patients with different methods. VR has been used for treating e.g. work or relationship issues, phobias
and fears, depressions and post-traumatic stress disorder for soldiers. One of the big advantages of using
VR treatment is a reduction of drugs prescribed for the patient. By being able to treat patients in a virtual
world, they can be distracted from their day-to-day fears or anxieties. The whole setup will be different
which gives therapy a whole new dimension. The initial investment of using VR as a treatment is one of the
reasons together with the small availability of applications and technological limitations that this treatment
is not widely implemented yet. The key challenge is to gain enough data to provide up-to-date results that
VR can be used in many ways to cure mental health diseases. This is the main topic of this research and the
therapy regarding obesity will be further elaborated 2.5. (Senson, 2016.).
Design
Many design programs enable the user to program, draw and develop 3D pictures or environments to be
able to see constructions from all angles. VR offers the possibility to walk around and in programmed
structures to see what should be improved. (Earnshaw, Gigante, & Jones, 1993.)
Besides of being able to see and walk around the constructions or 3D models, artists can make 3D drawings
in the virtual world. Instead of painting on canvas, the artist can paint in the air and walk around their
creation, e.g. using Tilt Brush, a HTC Vive application. IKEA launched in 2016 a prototype that enables
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the client to walk around different types of kitchen, while being in an empty space. So people all over the
world can “try” different kitchens before ordering them. (IKEA, 2016.)
Architects can walk through or around their sketches of buildings to see what is incorrectly implemented,
what would cause disturbance or future problems. Besides of walking through their sketches, designers can
quickly produce prototypes and more efficiently review flaws in those sketches than without this VR
visualisation. Visualisation is also a key component in selling houses that still must be built since this can
be more difficult because people do not know what they are buying. With the VR applications potential
buyers can already walk through their apartment and even decorate it in their own way to see if the house
exceeds up to their expectations. (Brouchoud, 2016.)
Tourism
The tourism industry also tapped into the VR world to attract more customers. Travel agencies and hotel
chains are offering a VR experience for the customer before they book the holiday or hotel accommodation.
Beforehand the “tourist” can review the hotel rooms and facilities and then whether decide to book or not.
Travel agencies are providing a preview of your travel destination and you can see spectacular activities as
the pyramids of Gyza, but up to a certain part, which is comparable with the trailer of a movie. The potential
customer is getting a sneak-preview of their trip, but to experience the whole trip and get the real feeling,
the customer should do the actual booking. (Butler, 2016.)
Figure 5 shows potential clients already a part of Indonesia to seduce them in booking a trip and experience
it in real-life. A VR experience can be a good teaser before going on an actual holiday (Jacobius, 2016).
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Porn
One of the industries that is worth mentioning because of the huge amount of investment, is the porn
industry. Pornography has been with humanity for a long time and the “Venus of Willendorf” is one of the
earliest created naked bodies, which dates back over 25.000 years. In this thesis porn will be restricted to
production side of pornographic visual material. Porn existed of drawings and paintings until magazines
and later video and films became available. With the birth of the world wide web (WWW), the world of
porn changed and became widely available to the whole public. From playboys being sold in the 90s, it
evolved to websites as Xvideos who had in 2012 4.4 billion page views per month and was in 2015 the 43th
most popular website in the world. (Weisman, 2015.)
The porn industry made around USD 97 billion in 2015-2016 and thus a lot of money is in this industry.
With the current available technology, many companies are starting to shoot their videos in 360 degrees. A
remark must be made that this is according to the definition not VR since there is no interaction and the user
is a passive viewer. Shooting these porn movies in 360 also brings a whole new dimension of costs along
since the equipment is a lot more expensive. This implies that only big companies can make this investment,
and the whole setup for the actors is different. Figure 6 & Figure 7 show the number of cameras needed to
capture a 3D model of an actor. The following paragraph solely focuses on the impact VR has and can have
in the future on the porn industry. (Stone, 2016.)
Figure 5: Discovering Indonesia (Jacobius, 2016).
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The term “porn sells” is often used in commercials and advertisement, but instead of watching porn on a
screen, being in the scene itself is a whole new experience. Figure 8 shows the interest over time from
Google search. The spikes indicate launches of new devices and the overall trend can be explained due to
the increase in VR adoption and adaptation (Google, 2017). The only thing required is a google cardboard,
which is distributed for free in many events or can be bought for prices starting from 3 euro. The interest of
the people in VR is there and the industry is investing, but the question arises how this would affect to social
relations between people. Since porn is moving to VR where the user can interact with the different “game
mechanics”, this can potentially influence the way people are looking at sexual intercourse. For instance,
“Realdoll” is a company investing in high-end artificial intelligence (AI) development which they would
include in their sex dolls. Thus, instead of just experiencing intercourse through a VR headset with your
eye-sight, those smart “dolls” can extend the experience with actual body interaction. (VRS, 2017.)
How the industry is going to develop depends on several factors, e.g. the interest of people, the business
models of companies and the initial investments, the development of headsets and the willingness to pay for
the content.
Figure 6: VR 3D model capture man (Stone, 2016).
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Figure 7: VR 3D model capture woman (Stone, 2016).
Figure 8: Google trends VR porn search (Google, 2017).
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2.3 THE FUTURE OF VIRTUAL REALITY
VR is used in many ways and the scenarios and options that can be designed in a “virtual world” are endless
and offers a lot of possibilities. The gaming industry will continue to develop better (in terms of graphics)
and different games for the VR headsets, since this gets the big public more interested (Dredge, 2016). One
of the potential flaws of increasing the VR sales is the need for an attachment to a strong computer. The
better VR devices as the HTC Vive and the Oculus Rift are in need of such a computer. A lot of processing
power is needed and the devices are attached to a computer with cables what hinders the movement of the
user. MSI teamed up with HTC Vive and build a VR backpack which enables the user to walk around
without being attached to a power source, since this is included in the backpack as can be seen in Figure 9.
The battery lasts for approximately 90 minutes, which is more than recommended playing time. (Heater,
2016.)
In the military, medical and therapy field the innovations and developments will continue and the usage of
VR will increase due to the increase in applications and technical improvements. The more data is gathered,
Figure 9: MSI's VR backpack (Heater, 2016).
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the more effectively VR can be used in training situations and better understanding of the possible potential
possibilities will be gained. Currently in the military field, more weapons are modified to be used in VR
training scenarios by companies as VirTra located in Arizona, USA. The weapons need to give the real
feeling in weight, recoil and precision in the VR experience compared with the real world to provide
adequate training. Similar with the military field, the medical field will have extension of the available
applications and currently the development of additional tools e.g. precise equipment for brain-surgeon
practise. (VRS,2017.)
In the education or psychological field, VR is still in the first stages of development, but is quickly evolving
and VR is introduced on all levels of education. The target-group of this thesis is children between 5-9 years
old, the younger end of this target group is mostly learning by gaming in the virtual world (Deterding, Sicart,
Nacke, O'Hara, & Dixon, 2011). Gamification is used as a basis since this can enhance the learning
experience and is a good motivation tool. It can additionally motivate students if they are competing against
fellow students. The effectiveness of gamification is highly dependable on the situation and the desired
result. (Hamari, Koivisto, & Sarsa, 2014.)
Besides of the potential of VR, less development is currently published about the AR technology but
together the projected revenues are expected to hit USD 162 billion US in 2020 according to Business
Insider. Expected is that AR will take over the leading position of VR, but AR is less far in the production
stage and the Microsoft Hololens (Figure 10) and the Google Glass (Figure 11) are the only available
headsets yet and only available for developers. (BI Intelligence, 2016.)
AR can be used during the user’s daily life since it only projects images in your real-time situation, while
with VR the user is “restricted or limited” to the virtual world and has no idea what is going on in the real
surrounding area.
Figure 10: Microsoft Hololens (BI Intelligence, 2016).
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Figure 11: Google Glass (BI Intelligence, 2016).
The current state of VR and AR brings some challenges along which should be solved in the future to
enhance the experience in all different field. The relatively high price compared with other devices, the not
up-to-date technology standards and the unknown health effects are still a challenge. Recommended is to
take at least a 10 to 15 minute break after being in the virtual world for a maximum time of 30 minutes since
some users experience symptoms as disorientation and nausea. The drawbacks will be more extendedly
explained in chapter 2.4. (Matthews, 2016.)
2.4 VIRTUAL REALITY DRAWBACKS
2.4.1 TECHNOLOGICAL AND FUNCTIONAL DRAWBACKS
Every product that contains hardware or graphics there is a trade-off between quality and costs, the same
applies to VR. The prices vary from USD 3 for the most simplistic cardboards to USD 900 for the more
advanced headsets. This price only includes the headset and not the computer the user needs next to it, which
drives the price for the advanced headsets between USD 1500 and USD 3000. (BI Intelligence, 2016.)
Simplistic cardboards are making use of the user’s smartphone and if the people that buy the cardboard are
in possession of such a device capable of enough computing power to handle VR applications, an additional
investment is not required. To maximize the VR experience the company Virtuix Omni designed weapons
and a 360 degrees treadmill so the players movement is based on the actual steps of the person and if the
user is running or walking and their shooting feels real. For instance, the weapon functions as joystick if the
user is playing a first-person shooter game which provides a very realistic game experience for the player
(Techopedia, 2017). This enhancement of the experience also increases the costs significantly up from
another USD 1000. (Virtuix Omni, 2016.)
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But even though all that additional equipment for the VR headsets enhances the players experience, the
hardware and graphics are lacking behind on the current standard. Since the first experience of a VR headset
is crucial to keep a new user interested the experience needs to be amazing. Even when the quality is high
but the framerate per second (FPS) is low, the user experiences a blurry and shocking view. (Jamie, 2016.)
Combined with the current lack of games and applications, VR is having a tough time to get known and
adopted by the public. But because of the endless possibilities and upcoming games, Goldman Sachs (GS)
projected an enormous growth the upcoming years. They projected three different scenarios: “base case”,
“accelerated uptake” and “delayed uptake” according to Bellini, et all. (2016):
• The “base case”: GS assumed that head-mounted displays (HMDs) gain popularity due to the
higher quality since the technology improves and because of expected price reductions, but is
still limited by battery life and mobility. The total market value (TMV) would be USD 80 bn.
• The “accelerated uptake”: GS expects a TMV of USD 182 bn. HMD evolves from a niche market
to a generic computing platform before 2025 combined with an enhanced user experience in both
AR and VR with breakthroughs in battery and cellular technologies.
• The “delayed uptake”: GS expects that the improvements of VR and AR are being developed at
a slower pace due to hindrance in adoption from safety, privacy, latency, display and other
occurring issues before it can be widely adopted. The TMV will be USD 23bn, in this case in
2025.
As GS states in the report, quality, battery life and mobility are key-factors for VR to be a success and thus
should be extensively researched. The VR market can be compared in the “base case” with the tablet
hardware market (USD 65bn), while the “accelerated uptake” can be compared with notebooks (~ USD
111bn) and the television (~ USD 99bn) while the “delayed uptake” is comparable with the current game
console hardware market (~ USD 14bn) today. (Bellini, et al., 2016.)
But once acquired, a VR headset brings along some practical disadvantages as well. Even though MSI is
working on the backpacks that include batteries, most VR headsets are still work with long wires and the
user easily trips over or get stuck in it. This can cause physical harm if the user would trip over and e.g.
knocks the head on a table (Heater, 2016). The wires also limit the movement of the user and if the user is
not in possession of an Omni 360 treadmill, combined with the lack of visibility of the real world, an accident
can occur quickly. Since the user is not able to see the surrounding area, a change in the surroundings, e.g.
adults, pets or children walking around can be dangerous. Also, when an unexpected element in the VR
world suddenly appears which causes fear, panic or reaction this can lead to potential dangers (Stein, 2016).
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2.4.2 SOCIAL, HEALTH AND PSYCHOLOGICAL DRAWBACKS
Except for the costs and functional drawbacks, VR can also affect the social interpersonal relations. Brey
(1999) conducted research about the ethical aspects of “representation and action in virtual reality”, while
the VR technology was not properly developed yet, he already came up with theories about representation.
VR applications had the possibility, especially if the application was aimed at a realistic situation, to give a
wrong or biased representation of the real world which could lead to social disruptions. The developers
should have the responsibility to take precautions to avoid these situations and, if working on VR
applications, should realistically shape the virtual world (Brey, 1999). To nuance this statement, this would
apply to environments with the purpose of making it seem realistic. This is not applicable to fantasy worlds
or games with the purpose of not being realistic.
Social isolation is a risk that has been brought up since the rise of the internet, and VR can be a potential
factor which increases the possibility to end up in social isolation. Social isolation can occur if there is a
lack of communication between people in any way, either verbal or non-verbal. When completely immersed
in the virtual world, there is no need of other people being “around” and can on one hand increase the social
distance between people. On the other hand, the social context has been changing since the internet.
Currently many applications on mobile phones enable users to interact with each other, and VR can be the
next step, but the question arises if this is necessarily a bad change. VR can be used aside the actual reality,
the danger is that people prefer the virtual world over the real one and thus “escapes” to the virtual word.
Nowadays people can live the biggest part of their life “online” without having actual in-person
communication with others and VR applications have the possibility to increase this even more. On the
other hand, this can be countered by having social VR applications, where you can “meet” other users in a
virtual world and thus be, in the user’s perception, together in an artificial space. (Kim, 2015.)
Since VR applications are quite recent, case-studies can be conducted in the future about the actual influence
on social participation. Dissociation is another possible disadvantage of VR applications. Since normal VR
headsets make use of two human senses, sight and hearing, the experience is still far from the reality. But
with modern technologies as the Omni treadmill and other equipment that can create input for other human
senses, the experience will be hard to distinguish from the real-life. (Virtuix Omni., 2016; Stuart & Chris,
2015.)
A dissociative disorder, and regarding VR especially depersonalization disorder (DPD), is a disorder that
causes a sense of detachment towards oneself which includes unreality. Aardema et al. (2010) conducted a
study towards the effects of an immersive VR experience. The research was based on a questionnaire that
was conducted before and after the VR experience, which lasted for 15 minutes. The study found that people
that already suffered from higher degrees of dissociative symptoms, had an additional increase of these
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symptoms after the VR experience. The test-group had an overall increase of those symptoms and showed
that there was a feeling of presence within the VR world, which implies, according to that study, detachment
from the actual reality. (Aardema, O'connor, Cote, & Taillon, 2010.)
This is a possible danger since with the development of the technology which makes the experience more
realistic, the distinguishing between the virtual and the actual world can become vague.
Many studies have been conducted on the relation between violence and playing violent video games, and
there is not a unanimous conclusion. In the case of VR this could be different, since the player can get used
to very violent situations from a first-person perspective and actively participates in inflicting this violence.
This could give cause effects of desensitization4 and then reduce for instance the feeling of compassion of
fear of shooting someone. (Brey, 1999.) This desensitization, which is also used in VR applications to get
rid of traumas e.g. war, acrophobia, arachnophobia, etc. can be used as a treatment. On the other hand may
flatten emotions and should be researched when first-person shooters become more realistic to draw an
adequate conclusion. (Diemer, Alpers, Peperkorn, Shiban, & Muhlberger, 2015.) More research is needed
to draw adequate results and at this stage it will be speculations, but all effect should be examined and not
ignored.
Besides of the factors summed above, VR devices could cause physical negative side-effect as well. The
long-term effects are not measured since people are not making intensive usage of the HMDs yet (Davis,
2016). Cybersickness is one of the most important health and safety concerns that is important for the future
of VR. Cybersickness is a specific type of motion sickness that occurs in VR because the human senses are
tricked. In VR the character is moving by gestures of for instance the joysticks, but the player is standing
on the same spot in the actual world. This causes a conflict between the vestibular and visual systems in the
body and is believed to cause the sickness. (Hettinger, Berbaum, Kennedy, Dunlap, & Nolan, 1990.) This
can be treated with devices as the Omni treadmill, since the actual body is in movement and is synchronized
with the virtual world and thus will not cause a conflict between the visual and vestibular systems. The
effect of this conflict is different per person, but is also dependable on the latency speed of the HMDs as of
the FPS. With improving the FPS and developing higher resolution headsets, the problem can be partly
solved. This combined with motion-, head- and eyeball tracking can reduce the chance the user will suffer
of motion sickness. (Menon, 2016.)
Using a VR HMD can also cause damage to the eyes themselves. “Don’t sit too close to the television” is a
commonly heard phrase as a kid because the eyes would become “squared”, which is a fable, but the headset
4“Psychiatry. A behavior modification technique, used especially in treating phobias, in which panic or other undesirable emotional response to a
given stimulus is reduced or extinguished, especially by repeated exposure to that stimulus.” (Thesaurus, 2017).
31
can cause eyestrains. This is due to a phenomenon called vergence-accommodation conflict, which is an
eye-focusing problem that is caused by the VR HMD. The VR HMD shows both eyes images that are
slightly offset to create the 3D image and the condition is only temporarily in current cases. (Hoffman,
Girshick, Akeley, & Banks, 2008.)
Figure 12 shows the perception the user’s eyes have in the real and the virtual world (3D display). The
difference in (C) and (D) can be seen since in the real world the eyes focus on an object somewhere in space
and the sides of the user’s point of view are blurry where in the 3D display the sides are equally sharp as
the focus object. This phenomenon causes the eyes to permanently keep adjusting to the pictures which
results in a headache and visual fatigue for the user. (Hoffman, Girshick, Akeley, & Banks, 2008.)
Specific risks for children are unknown since it seems there are no studies which have researched that area.
But several factors apply to children specifically. The weight and size of the headset could be a problem for
Figure 12: Eyestrain: comparison real - and virtual world (Hoffman, Girshick, Akeley, & Banks, 2008).
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children if they are wearing such a headset. But those are physical limitations, while the long-term effects
are unknown it would be speculating how children could be influenced. This can vary from a less or over
developed sense of balance to psychological effects or traumas that could be inflicted on children, this will
be more extensively discussed in the discussion. (Guarino, 2016.)
2.5 THE OBESITY COMPLEX
Before this thesis elaborates on the causes of obesity and how obesity evolved, an adequate definition of
obesity needs to be formed. People will be considered class 1 obese if their BMI is between 30-35, class 2
if their BMI 35-40 and class 3 if BMI >40, which is called “extreme” or “severe” obesity. A critical remark
on this measurement is that at any individual level BMI can only be used as a screening tool and a further
diagnostic is needed to measure the actual amount of fat in the body. People with excessive muscle, e.g.
bodybuilders, mostly have BMIs above 30 and would be according to the BMI-check considered obese,
while their body fat is typically under 10%. (CDC, 2016.) Bodybuilders on the other hand can suffer from
some of the same physical malfunctions as obesity patients, since the extra weight can cause for example
knee damage (Goertzen, Schoppe, Lange, & Schulitz, 1989). Another remark for this thesis is that
calculation the BMI for children is harder since they have an irregular growth pattern, but as mentioned, it
is a first estimation and a follow-up diagnostic is needed. The people that are “only” overweight are initially
not taken into account for the treatment applications, but should be considered since preferably people will
never end up in either class 1, 2 or 3 of obesity.
Since the different groups of obesity are defined, clarification is still needed regarding obesity itself. Thus,
this thesis will follow the following: “Obesity is defined as excess adipose tissue” (Obesity Society, 2016).
Adipose tissue, also called fatty tissue, is a connective tissue which mainly consists from fat cells. An excess
of this tissue is an excess in fat cells and this excess results in a weight increase if these kilocalories (kcal)
are not burned. (The Editors of Encyclopædia Britannica, 2016.)
This excessive adipose tissue has a variety of causes and the division is different for every individual. The
most influential factors are summed up underneath and are further explained in line with the study of Wright
& Aronne (2012).
1) Energy balance distortion. The most common cause of obesity. If the balance of calorie intake and
kcal burned is disrupted and the amount of calorie intake exceeds the kcal used, this is stored as
adipose tissue. This energy intake has multiple causes as well which are overlapping with other
causes of obesity.
2) The food environment. High calorie and foods full of fat are easily accessible all over the world in
forms of: fast-food restaurants, vending machines, food trucks, school restaurants etc. Besides of
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easily accessible, those foods are relatively cheap and requires no additional handling, e.g. cooking,
of the consumer. (Rolls, 2003.)
3) Decrease in physical activity (PA). PA levels have decreased drastically until 2005. From 2010 on
the change in physical activity levels is negligible. Less PA results in less kcal burned and without a
change in eating behaviour this will result in an increase of adipose tissue. School PA levels have
been dropping until 2010 and people in general are spending more time on sedentary behaviours as
surfing the internet and watching TV or playing video games. (Physical activity council report,
2016.)
4) Drug-induced weight gain. Some medical treatments including diabetic treatments, antihypertensive,
psychotropic medications, contraceptives and steroid hormones, protease inhibitors and
antihistamines can cause weight gain. While it is hard to estimate up to what extent these drugs cause
weight gain, there are significant correlations. (Aronne & Segal, 2003.)
5) Sleep debt. Having a lack of sleep decreases a person’s metabolism. Participants in the study that
had less than 7 hours of sleep had on average a higher BMI. A lack of sleep has a positive correlation
with an increase in hunger and appetite. (Gangwisch, Malaspina, Boden-Albala, & Heymsfield,
2005.)
6) Decline in cigarette smoking. Smoking cigarettes tend to reduce the appetite of a person and thus
reduces the calorie intake over the day. Quitting smoking triggers the appetite again to have another
habit.
7) Social networks. Quickly confused with social media, but a person’s network is an important “risk”
factor in becoming obese. Christakis and Fowler (2007) conducted a study over 30 years to research
the correlation of obesity and someone’s social circle. They found that a person has a 57% increased
chance of becoming obese, BMI > 30, if this person had a friend who became obese in a given
interval. Siblings had an increased 40% chance of becoming obese if the other sibling became obese.
In contrast to previous findings, they did not find any correlation among neighbours in the same
geographic location. The reason for this influence lays according to Christakis and Fowler (2007)
probably in the psychosocial means, in such a way that a person’s acceptability of obesity and being
overweight gets skewed and normalized. Hence as mentioned above, quitting smoking increases the
appetite but quitting smoking can be done together in a social network and thus in that way increases
the chance of obesity in that whole group.
All the above factors are plausible causes of obesity and has occurred across every sex, race, smoking status
and age. With a population in 2015 in the US and an obese rate of 36,5% there is a need to understand the
causes of this disease (Wright & Aronne, 2012).
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Besides of those effects, psychological factors as a trauma, low self-esteem or emotional concerns can
change the eating patterns of a specific person. This would result in factor 1, described by Christakis &
Fowler, since the calorie intake would increase compared with the kcal burned. A trauma can increase
overeating as a manner to “forget” what happened. A low self-esteem can lead to a downward spiral of
eating healthy since the person already feels uncomfortable. Other emotional concerns as stress, anxiety or
depression can all be potential causes of overeating, but that is person depended. (Balentine & Stöppler,
2015.)
Wright & Aronne mentioned factors that has changed over the years. Genetics were absent in their report
since genetic changes occur too slowly to have caused this sudden obesity “epidemic”. But genetics should
not be forgotten since they do play a part in which person is more responsive to store fat than others. People
with specific genetics are e.g. more responsive to weight increase after the use of particular drugs or already
at higher risk of developing diabetes. (CDC, 2016.)
Thus certain people have unfavourable genes and easier develop obesity, but as shown obesity can be caused
by a variety of reasons. To effectively define the target group this thesis will focus on, it is important to
examine at which age obesity is developed and evolves and who is more likely to suffer from obesity. As
shown the social network impacts the chance of being obese. But since preventing obesity is better than
curing, all the factors that can influence children need to be determined.
For children not all causes can be applied, e.g. quitting with smoking, but suggested child risk factors are:
physical activity, dietary intake and sedentary behaviour. The parenting style of families also play a role as
do environmental factors such as demographics, school policies, activity behaviour and parents’ work-
related demands which influence eating patterns. Genetics do play a part for children as well, but this factor
cannot be changed in a treatment. Children learn from their parents what to eat, what not to eat and what
should be eaten preferably. Parents can teach their children by repeated exposure in order to like healthy
foods that are disliked before. If they do not, the child will not learn how to eat healthy foods. This also
extends to what food is available in the household itself during the day, whether it is fruit, chips or candy.
(Davidson & Birch, 2001.) Physical activities are not only reduced because of the sedentary lifestyle, but
also through a lack of safe environment. In 2002 a study conducted by Anderson and Butcher showed that
parents in some states of the USA rather drive their children to school instead of letting them walk or bike
since they did not perceive the neighbourhood as safe. (Sahoo, et al., 2015.)
So, children are more likely to suffer from obesity if their parents follow bad eating behaviours, they are not
exercising enough and storing adipose tissue etc., but the question remains who are more likely to suffer
from obesity overall. Figure 13 shows the division of the overall population, which helps to identify the
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groups with a higher probability of obese children. As shown in the graph richer countries tend to have more
obese people than the lower income areas, but over the last 35 years there has been an increase on all levels.
The difference between obesity of men and women is highlighting an interesting dimension since more men
are overweight then women in the developed countries, while more women than men are obese in
developing countries. (Kanter & Caballero, 2012.)
Figure 13: Division obesity over the world per men and women5. (Kanter & Caballero, 2012) .6
5 Obese with a BMI > 30, severely obese BMI >35 6 The Lancet Publishing Group/Trends in adult body-mass index in 200 countries from 1975 to 2014
36
Those statistics apply to the entire world in general, Figure 14 shows the percentage of obese persons per
country. Mid-Africa and South-east Asia are the areas where the least people are obese, while in the USA,
Egypt and Saudi Arabia the most people are obese.
Figure 14: Percentage of obese people per country (BMI > 30) (guardian & Galka, 2017).7
Figure 15: Obesity US children (Linshi, 2015).
7 The Lancet Publishing Group/Trends in adult body-mass index in 200 countries from 1975 to 2014
0%
5%
10%
15%
20%
25%
1974 1980 1994 2000 2002 2004 2006 2008 2010 2012
Obesity statistics US children
Ages 2 to 5 Ages 6 to 11 Ages 12 to 19 Total
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Those statistics from Figure 14 can also be applied to children only, in Figure 15 the increase is shown in
obesity from 1974 to 2012 for children in three different age groups; 2-5, 6-11 and 12-19. The combined
group has the yellow bar as weighted average. As can be seen, the amount of obese children has more than
tripled the last three decades. Obesity is often forgotten since it is not a striking disease which suddenly has
a significant impact on someone’s life, but is slowly building up.
The obesity disease results in multiple possible forms of other diseases which are here further elaborated:
• Increases the chance on a heart disease or stroke. This is due to the increased likelihood of a
high blood pressure and high cholesterol which increase the chance of a stroke or heart disease.
• Diabetes type 2. This form of diabetes is developed instead of being a birth disease. Diabetes
affects the ability of the body to deal with the absorption and handling of glucose in the blood.
The body is not reacting sufficiently anymore on insulin and thus the glucose is not regulated.
• Increases the chance of some cancers: endometrial, breast, colon, kidney, gallbladder and liver
• Can cause breathing problems, asthma and sleep apnoea
• Osteoarthritis which is the breakdown of someone’s cartilage and bone within a joint due to the
high weight.
• Gout, which includes sudden intense joint pain, swollen joint and purple or red skin around
joints.
These diseases are all caused directly or have an increased chance of being caused by obesity.
(DerSarkissian, 2016). Except for just causing physical problems, the CDC (2016) also defined problems
outside this area:
• Low quality of life. Obesity does affect the person’s ability to perform certain tasks which
require any activity. People that struggle with this “handicap” rate their quality of life lower.
• Mental illness. This can take many forms as anxiety, depression, inferiority and other mental
illnesses.
These mental illnesses and feelings of not belonging or fitting in the group, can result again in an increase
of food consumption due to the sad feeling. Which will lead to a vicious circle. Mental illness not only
comes from a bad self-image, but a study conducted by Puhl and Brownell (2001) shows that there is
discrimination towards people with obesity. Stigmatization and discrimination occurred in the following
key areas of living: education, employment and health care. Being obese when entering an interview already
puts the applicant in a substantial disadvantage compared with equally good competitors who are not obese.
When hired, overweight managers were judged significantly more harshly for undesired outcomes
compared with their “slim” colleagues. This results in not only being judged more harshly, but also in
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inequity in wages, employment termination and promotions. According to the National Longitudinal Survey
Youth Cohor conducted in 1990 non-obese women would earn 12% more than obese women. (Puhl &
Brownell, 2001.)
Not being hired or getting a pay raise is not a concern for children. What does concern them is that while
there is not a noticeable difference in IQ, the test scores of children with obesity are lower than of their
fellow “normal” peers. The Avon Longitudinal Study of Parents and Children followed 6000 children’s
school performance and those who are classified as obese, tend to get awarded lower grades. This can be
explained by several reasons but the following two are the two main believes by the researchers: Obese
children set lower expectations and there is an anti-fat attitude among teachers. This results in both given
the “obese” a lower grade by unintentionally punishing them and following the expectation. This will
already give children a backlog compared with their fellow “fit” peers but also have a direct psychological
cost since this influences the child directly. This results in greater rates of depression and anxiety as
mentioned before, but also in higher suicide numbers among the heavier children. Besides of being
“punished” by the teacher, overweight children are a target of bullying by their classmates which again has
a psychological impact and often results in lower self-esteem. The results of being obese at an early age
follows the person through life if unchanged and should be avoided. (Meadows, 2015) Even though
prevention is better than curing, obese people still needs to be cured thus this thesis continues with the
treatments of obesity.
2.6 DIFFERENCES BETWEEN CHILDREN AND ADULTS IN
TREATMENTS
Since obesity is a disease which affects many people, it is a challenge to find an adequate and general cure.
But since obesity can be caused by several factors, it is one of the most challenging diseases and thus requires
a properly designed treatment. Since weight loss is the desired outcome a combination of addressing
physical activity, diet and the behavioural and mental issues is needed. Surgical approaches and medication
can be an option as well, but does not solve the entire problem since everything that is removed during
liposuction can be gained afterwards again if nothing has changed and thus would be considered out-of-
scope in this thesis.
Since the treatment of obesity consists of several components which all can result in weight loss, each one
of them will be discussed and elaborated. The treatment of obesity starts with the adjustment of the diet.
This thesis will not further elaborate in which diet is the most effective or dive into meal plans, but on
average a 500-kcal daily deficit is recommended to slowly lose weight in a responsible way. The diet can
be combined with drugs, but this is controversial and studies are not aligned on this topic. There are weight-
39
loss drugs which reduces the person’s appetite, but this is a temporarily effect and will come back when the
user stops using this medicine. As mentioned before, surgery, i.e. bariatric surgery, can be used to reduce
the appetite. This mostly results in a gastric band around the stomach to reduce its size or by removing a
part of the stomach. These surgeries result in a substantial 10-year weight loss, which was the duration of
the study. (Pories, et al., 1992.)
Getting a calorie deficit is simply caused by using more kcal than consuming. An increase in physical
activity increases the amount of kcal used and thus can be a crucial factor for weight loss. A higher PA
activity level, ideally with an increase in muscle, increases the amount of kcal burned even when in ”rest”
state. Only increasing physical activity will most likely not result in a weight loss since this also increases
the person’s appetite, thus this should be combined with a change in behaviour. The obese person ideally
monitors the eating pattern and this creates a better understanding of the own behaviour. (Thompson, Cook,
Clark, Bardia, & Levine, 2007.)
All those factors combined can, if the guidelines are followed, result in a weight loss. This is applicable to
almost every person that is suffering from obesity, leaving rare cases out-of-scope. The difference of the
treatment lays in the psychological problem, since this problem is not solved yet by simply adjusting the
lifestyle. Adjusting someone’s eating pattern is easy, but sustaining the new pattern and not indulge to treats
is the hard part. If this is caused by a deeper psychological problem, this problem must be identified to have
a long-term effect. This is hard to define in a general way, since the cause is different for every person and
can vary from having a passion for food to process a certain trauma. (Carter & Jansen, 2012.)
A lot of research has been done regarding obesity, especially to the causes and how to cure this disease for
adults. But less research has been done regarding children since the parents are often blamed for their
children’s “fatness”. Before VR applications can be added, the effective methods of fighting obesity have
to be determined and the treatment for children should be specified. Besides the different methods of fighting
obesity, the special conditions of obesity treatment for children should be researched. This will be done in
first determining the difference in psychological treatments.
The obesity treatment for children seems to have a lot of resemblance with the general treatment and is
perceived rather easy: Counsel the children, let them eat less and exercise more. But as Christakis and
Fowler (2007) mentioned, the direct social environment and the social environment of the patient’s social
environment play a big part as well. Thus, the parents of the children also need to be counselled since they
are the “food providers” for the household and do the grocery shopping. (Spear, et al., 2007.)
Important to deal with obesity is identifying young children who are already showing signs of obesity
development and how to react and help those potential obesity patients. Since obesity can lead to mental
40
and physical issues if developed in an early stage of life, it should be prevented as soon as possible signs
are shown. Any intervention got a low succeed rate if the child is not supported and actively pushed by
family members. An example is sitting down with the whole family together for meals. This makes it a
“real” event instead of eating in front of the television. Eating in front of the television got the disadvantage
that the person is eating faster and has a lowered awareness of the amount eaten, which can result in larger
portions. The portion size should be regulated during meals as well, since children need less food than an
adult. (Mayo Clinic Staff, 2016.)
Since in the age-group 5-9 obesity is most likely not caused by trauma handling or uncomfortable feelings,
a proper diet combined with exercise can rapidly drop the child’s weight. The parents and the child itself
should be properly informed of the dangers of obesity and how it will influence them in a later stage of life.
The treatment is in this case different from adults, since the psychological factor is absent or less important,
since at this early age those are not properly developed yet. Thus, regarding applications to help the obese
person to lose weight, the motivation shifts since the psychological problem is not the starting point. A low
self-esteem is often observed by people with obesity and the self-impression of the body is an important
factor of how to tackle the obesity problem, which is less present for children but can get developed.
(Franklin, Denyer, Steinbeck, Caterson, & Hill, 2006.) The relation with low self-esteem is working both
ways, people with a low self-esteem are more responsive to become obese, while obese people are more
vulnerable to develop a lowered self-esteem because of being obese (Connolly, 2010). The next chapter
focuses on how VR applications are currently used by treating obesity for adults and if those can be applied
for children as well with positive results.
2.7 CURRENT STUDIES OF VIRTUAL REALITY AND OBESITY
TREATMENTS
Currently there are already several treatments developed for obesity. This can vary from medical to
psychological treatments, but this thesis will leave out medical and psychological session or therapy details.
There have been tests with VR applications that are focused on weight loss for obese people but the target
group consisted of adults and even though this can potentially be used for children, the same aspects have
to apply. The research conducted by Giuseppe (2005) consisted of an overview of case studies and had as
conclusion that VR application can help to address two important features of eating disorders (ED). Those
two features include: self-efficacy and body experience disturbance. These are hard to target when making
use of traditional methods, but VR applications offer an innovative approach. Body experience disturbance
can start at an early age when children are getting bullied because they are obese, but self-efficacy will
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according to the interview with Giuseppe (2017) not be a significant issue since children are not busy with
losing weight and believing in themselves yet. (Giuseppe, 2005.)
Giuseppe (2017) has been one of the few researchers dedicating his career to VR, but many different
universities have been confirming his research regarding the two factors that can be influenced by VR.
People’s own impression of the body is a key factor in obesity for adults and thus changing the body
perspective is an important factor. (Derla, 2016.) Persky (2011) has done research about which methods of
obesity prevention could work by making use of VR applications and what the benefit would be compared
with existing methods. She concludes that big advantages of using those applications are the ability to create
adaptive virtual environments which can easily be adjusted. It provides the possibility to have a tight
experimental control group where all the factors could be controlled in the artificial environment. This
enables the therapist to tackle very specific issues of obesity. The study focuses on solely theoretical ideas
and was published in 2011, when VR devices were not available for the wider public yet, but already touches
upon the potential advantages and disadvantages. Some disadvantages are already outdated, e.g. the very
low quality of hardware and software. (Persky, 2011.)
Even though VR applications for obesity are not widely developed yet, they have been used for treating
anorexia (Giuseppe, 2005). Anorexia is an example of an addictive disorder that can be treated by making
use of VR applications. Bordnick, Carter & Traylor (2011) give as an example that if you put drug addicts
into a VR environment, the whole environment can be controlled and the researcher can take away all the
potential drug stimuli. This can be built up slowly by adding several factors e.g. liquor bottles, referring to
parties, or other drug craving stimuli. Many researchers are aligned with the research of Giuseppe (2005),
Bordnick, Carter & Traylor (2011), Persky (2011) etc. and are supporters of testing VR applications at
different levels to see how it can be used for treatments.
The research that is perceived as touching the closest upon the treatment of obesity for children makes use
of a mixed reality (MR) application. This application was tested and researched at a summer camp. Even
though the research was held at a summer camp which had the focus on a healthy lifestyle, remarkable
results were found in the behaviour of the children. The group was split in two to create a target and a control
group. Everyone got activity meters that were tracking their movement. But only one group would plug this
meter into a TV so they could see their virtual pet. If the child exercised more, the pet could learn different
tricks. The TV was connected to a Kinect device as can be seen in Figure 16. Even though the research
lasted for 72 hours, the group with the devices were significantly more active than the control group. The
researchers found that the game element was an important stimulant for the children, but they questioned
the long-term influence, since a game will not stay interesting for an extended period. Interactivity was
enjoyed by the children and could affect the design of the study if it was done again. (Johnsen, et al., 2014.)
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Figure 16: Child playing with his virtual pet (Johnsen, et al., 2014).
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2.8 CALORIE USAGE
This paragraph focuses solely on the amount of kcal needed by children and the amount of kcal current VR
games can burn. This will not be applicable directly to children since those applications are designed to be
a playful experience without any goals as weight reduction. The game designed in chapter 5 is partly based
on this since the constructed game will also involve intensive movements to make the player “workout”.
Table 1: Daily calorie need (Iannelli, 2016).
Age Active Boys Kcal needed per day
5 1,400
6 1,600
7 1,600
8 1,600
Age Active Girls
5 1,400
6 1,400
7 1,600
8 1,600
Age Inactive Boys
5 1,200
6 1,400
7 1,400
8 1,400
Age Inactive Girls
5 1,200
6 1,200
7 1,400
8 1,400
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2.8.1 KCAL INTAKE
The way children use kcals during the day has changed over time. Someone playing football outside burns
more kcal than someone watching a lot of television. In Table 1 the average daily kcal needed per child is
described per age-group. Here has been made a split between gender and activity level. This is the average
amount of kcal needed and can vary per individual. Iannelli (2016) took into account the difference in
activity and states that at least 60 minutes of physical activity is needed every day.
Encouraging your child to get a good night's sleep, keeping in mind that teens need about 9 hours of sleep.
Children between the ages of 6 and 12 need about 10 to 11 hours of sleep, and that pre-schoolers and toddlers
need even more. (Iannelli, 2016.)
Table 1 shows the kcal needed per age and sex group. If the child exceeds this number of kcal, the child
needs to burn more kcal to not gain weight. This can be done by increasing the physical activity level of the
child, for example by playing a VR game. Even though this is focused on adults, it can partly be applied to
children and the concept or thought of using VR applications in an active way can be discussed.
A non-academic study has been conducted by Donahey (2016), who monitored himself 50 days long
working out in VR by playing multiple games. He burned on average 796 kcal per session and lost 14.4 lbs
in those 50 days while only using his VR games as exercise tool (Durbin, 2016a). This was a home-
conducted study and there has been no track of change in diet or other behaviour, but monitoring someone’s
complete behaviour could be a suggestion for further research.
2.8.2 KCAL BURNED IN VR
This chapter compares the difference in kcal burned of playing certain VR games with old media as watching
television or playing traditional video games. This study has been conducted by a small group of game
fanatics to research if virtual exercising, in this case by making use of the HTC Vive, can be compared with
actual exercise. The kcal burned cannot directly be applied to children since this is not only based on the
type of exercise but also on body weight, age and heart rate. (Koning, 2012.)
Figure 17 shows the amount of kcal burned per activity for a 180-pound man (Durbin, 2016b). Similar to
previous research mentioned, this cannot be directly applied to children due to the difference in body weight,
age and heart rate. A correlation can be found between BPM and kcal burned per hour and can be seen in
Figure 17. This is in line with the research published in the journal of sports sciences. (Keytel, et al., 2005.)
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Figure 17: Kcals burned per game (Durbin, 2016b).
Table 2: Kcal burned per sport (USDA, 2015)
MODERATE physical activities: In 1 hour
Hiking 370
Light gardening/ yard work 330
Dancing 330
Golf (walking and carrying clubs) 330
Bicycling (less than 10 mph) 290
Walking (3.5 mph) 280
Weight training (general light workout) 220
Stretching 180
VIGOROUS physical activities: In 1 hour
Running/ jogging (5 mph) 590
Bicycling (more than 10 mph) 590
Swimming (slow freestyle laps) 510
Aerobics 480
Walking (4.5 mph) 460
Heavy yard work (chopping wood) 440
Weight lifting (vigorous effort) 440
Basketball (vigorous) 440
0 100 200 300 400 500 600 700 800 900
Thrill of the Fight w weights
Holopoint w/o weights
Audioshield w weights
Orc Hunter w/o weights
Hover Junkers w/o weights
Audioshield w/o weights
Quiver Aplha w/o weights
Spell Fighter w/o weights
Actively playing video games
Playing tarditional video games
Watching television
Calories burned
calories/hr BPM
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The kcal burned by playing VR games, especially with weights attached, are relatively high compared with
ordinary sports, which can be found in Table 2.
(USDA, 2015). These assumptions are made on a 154-pound male, which is less than the research conducted
by Durbin (2016b), but still implies that actively playing intense VR games burn at least an equal amount
of kcal compared with normal sports.
There are also other factors to keep in mind as social aspects, being outdoors (and absorbing vitamin D),
learning in a real-life environment instead of an artificial one etc. But those are out-of-scope of this thesis
since this is not relevant to the research question.
Problems also arise while playing those games in VR for children. As mentioned not only the weight and
size of the headset, but also the limited movement because of the cables are a problem. Besides, intense
exercises will make the user sweat which can cause the headset to become uncomfortable and the soft head
mask, as can be seen in Figure 18, will start to absorb the sweat. (Rainfold, 2016.)
Figure 18: Head mask HTC Vive (Rainfold, 2016).
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3 RESEARCH METHODOLOGY
The aim of this research is to examine if and if so, how VR application can help in treating or curing obesity
for children in the age group of 5-9. This chapter will elaborate in the setup of the research design, how the
research was executed and why qualitative is preferred over quantitative.
3.1 CHOOSING A RESEARCH METHODOLOGY
3.1.1 QUALITATIVE VERSUS QUANTITATIVE METHODOLOGY
The debate between which type of research is more valuable, qualitative or quantitative, still has not been
settled, but both approaches are applicable in different situations. Besides choosing which research approach
is the best, the approach should always be examined for validity.
The approach used as a foundation of this thesis is the qualitative research approach. Qualitative research
can be defined according to Strauss and Corbin as: “any kind of research that produces findings not arrived
at by means of statistical procedures or other means of quantification” (Strauss & Corbin, 1990). Since
qualitative research focuses more on the richness of the data instead of the amount of data points gathered,
which is the case with quantitative research, the approach is very different. Instead of looking only at data
points to draw statistical significant conclusions, this thesis started with a welfare disease; obesity. Since
this thesis researches the potential of VR applications to cure or prevent obesity, the qualitative approach
was a logical choice because:
1) There is no current available quantitative data yet on the impact of VR applications on children
regarding obesity.
2) Using qualitative research is a better use in a new field of study since it can be used in an exploratory
way.
3) Setting up a longitudinal study where test groups are followed for a longer period would not fit in
the time window.
4) VR applications for preventing or treating obesity are not created yet. By combining qualitative
analysis with a constructive design this research tries to partly fill the gap in the literature.
Thus the choice of research methodology is in this research the qualitative approach on one hand. As
addition on the qualitative research design, a constructive approach is used for a potential creation of a VR
application which could be used for preventing or curing obesity for children. The game will be designed
based on the findings of the qualitative research combined with the literature, author’s expertise and other
popular games. The constructive approach includes concept art, concept design, the UX of setting up the
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game, the game mechanics, characters and all other models in-game while keeping in mind the goal of the
game: getting the child “in shape”.
3.1.2 QUALITATIVE RESEARCH VERIFICATION
Regardless of the methodology chosen for a specific research, to have a valid and credible research the
concepts of reliability and validity should be checked. Reliability focuses on the aspect of when the study
is done again in a different place and time, whether it will yield the same results or not. Achieving reliability
is difficult, especially in the field examined in this thesis since it is an upcoming topic and undefined.
Reproducing interviews and achieving the same results will be difficult since it is person, professionality or
contextual dependent. This does not necessarily mean that qualitative interviews are unreliable, since this is
definition dependable. Interviews combined can yield to specific insights which could hold truth for the data
subset, but this cannot be generalised. (Silverman, 2006.)
Validity is another factor that should be checked after the initial analysis. Validity touches upon the point
that the researches actually examine what was initially supposed to be examined and accurately measures
the research (Silverman, 2006). Quantitative research is straight forward since quantitative data supports the
research (or not) and shows clear outcomes which are determined by the research setup. Qualitative research
is on the other hand less straight forward since it is based on observations and these can be interpreted in
diverse ways. The researcher should always strive to obtain objectivity. (Bryman, 2008.)
3.2 INTERVIEW PREPARATION
This thesis had to following setup: first an extensive literature review was conducted to test the existing
relation between technology and obesity prevention and treatments for children. This was targeted towards
all different factors that could explain obesity and factors that were used during the treatment. This will
result in making use of the inductive analysis theory since a new theory could emerge from the existing data
(Thomas, 2003). After the extensive literature review, the gaps in the existing literature were identified,
which was the basis of this thesis. The questions of the interviews were structured in such a way and setup
so that the information provided by the interviewees could potentially fill in some of the gaps in the existing
literature. Since there is a lack of knowledge in the current field of study, the interviews started off with
broad questions, before they were narrowed down to the detailed topic. This is due to that VR applications
are barely linked to obesity since VR is still in either year 0 or year 1 (Interview Öla, 2017). This thesis
moves into an undiscovered field of research and thus provides the option of except focusing on the
qualitative part, in terms of the interviews, combining the results with a creative constructive design.
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3.3 DATA GATHERING
To answer the research question, an adequate way of data collection had to be defined. This thesis is built
on semi-structured interviews in different target groups upon reaching the point of saturation. The research
was focused on different professions touching upon the field of VR applications or obesity. This includes
paediatricians, VR specialists and “thought leaders” who work daily with VR applications, professors and
experts with a combination of these professions.
The reasons of choosing those three different interview groups for the qualitative research interviews are
elaborated per group:
• VR specialists would increase the knowledge of VR, the current VR developments, possibilities
of VR applications, current usage of VR applications and how to immerse users in an
experience. The technical side of coding, shooting 360 movies or applications will not be taken
into account since this is not relevant for the research topic itself. But they would have a vision
of what can be done and how VR can be used for potential treatments.
• Paediatricians are interviewed to understand the social aspect of treating or curing obesity and
how they perceive the ongoing trend of obesity. Besides of their opinion this is useful to
understand the current procedures of treatments and measure the amount of technology
involvement in this process.
• VR obesity treatment application developers were identified as an initial target group, but this
group does not solely exist. VR fitness applications are not targeted towards obesity and see
them as a small part of their business and were thus also not suitable for this research. They
want to reach as many people as possible to sell their product. Instead of focusing on the
development side of the applications, this thesis targeted VR researchers since they are an
overlap between the technical and thought leaders in the field of VR and the psychological side
of this thesis.
The choice to use semi-structured interviews and not another structure has the following reasons:
1) A focus group would not payoff since there is such a diversion in knowledge about VR between
the different fields of interviewees. This could cause an information overflow for the less educated
in this field and steer them towards a biased specific opinion.
2) A structured interview would be too narrow, since the interview consisted of some “mind
stretching” questions and the imagination of the interviewee should not be limited by only the
research questions but should also leave room for side paths.
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3) A complete open interview would not provide any reliable or valid information, since this thesis
is focusing on one specific area instead of having an open conversation about VR in general.
The choice of a semi-structured interview seemed suitable in this case, to keep the interviewees within the
topic, but let them elaborate with their own ideas. Since this is an exploratory research instead of a
confirmatory research, the interviews could be less structured according to Silverman (2000).
The interview questions were categorised in such an order which provides flexibility during the interviews.
The interview started off with questions to measure the knowledge of the interviewee before going in-depth
and the questions could be adapted to the level of knowledge. If knowledge was absent about a core base of
the interview, e.g. VR possibilities, these would be explained to continue the discussion about the topic.
This provided a base for a multi-discipline discussion. Some questions could be skipped while other, side-
questions were introduced to get a broad picture of the interviewee’s ideas and insights.
All interviewees are experts in their field of work and the interviews can be categorised as “expert
interviews”. Some of the VR specialists had international recognition as had two professors since they were
working in inter-disciplinary fields, VR and treatments. They were approached by making use of the
network of MediaMonks and through other channels as universities, hospitals and internet. Most interviews
have been conducted in English, but not all the interviewees felt comfortable in being able to express
themselves in enough detail, thus then Dutch was used. The interviews lasted between 35 and 70 minutes,
depending on the knowledge, availability and time zone of the interviewee.
3.4 INTERVIEW ANALYSIS
When finalised, the interviews are all stored in the cloud which can be shared when requested. All interviews
were summarized to be able to process them in the analysis, the summaries can also be requested. The
method and exact type of analysis is described in the following paragraphs.
3.4.1 ANALYSIS APPROACH
The type of qualitative analysis used in the research is the content analysis by Mayring, which aims at
analysing the different interviews in a systematic way in order to compare them (Mayring, 2003). Since this
was an exploratory research and the knowledge and field of profession differed a lot, it seemed difficult to
make a suitable comparison between the interviews. Thus, the way to structure the analysis was to group
the interviews on the field of work of the interviewees and first compare the interviews within this group.
When an overall point of saturation was found within the groups, the groups were combined into one big
data set, to compare the correlation.
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The data has been summarized, structured and reduced until the point a comparison was possible to be made,
this breakdown is in line with the guidelines prescribed by Mayring (2003). Within the interview there could
be made a clear distinguishing between the questions and those could also be categorised in groups which
provided the possibility to test whether the interview was consistent in the answers.
The coding of the analysis itself was done by splitting their answers in three separate groups: positive,
negative and neutral reaction. This was applied to every sub-group of the question in the interview. Once
the reactions were measured, they were compared and linked to the other interviewees to measure if there
was a coherent line between the interviewees or not. This was done with a numerical system where positive
is 5, neutral is 3, neutral with potential negative aspects is 2, neutral with either better alternatives or positive
side-effects is 4 and negative is 1. This was done to simplify the thoughts of the interviewees. The outcome
would provide either a positive, negative or neutral outcome which were then split-up in different arguments.
The simplification at first provided a good overview which was the basis to go in-depth of the specific
arguments of the interviewees. Thus, the interviewees could agree with each other with the same or different
arguments which are then explained from a psychological point of view, taking into account their
background and forecasts.
3.4.2 METHOD DISCUSSION
The approach of doing a content analysis according to the guidelines of Mayring (2003) has been chosen
due to the richness of the data. This provided the possibility to categorise and simplify interviews initially
before breaking down into the reasons behind the answers. The strengths of this method are that the analysis
is most likely reliable and the results can be compared with each other. A requirement of this method is that
the questions had to be coherent between the interviews and cannot be used on a topic with only open
research questions, since this would most likely not provide answers that could be compared with each
other.
Simplifying the data in the first place would provide the possibility to group the interviews in different
categories in order to compare them. When comparing them with each other they can be clustered in fields
of profession, types of answers and personal point of view. After the initial categorisation within the groups
created, the different arguments can be compared if they are coherent or are different. This would provide
different insights of the interviewees which can be linked to their expertise. This could result in problems if
within the group of professionals there is no correlation at all. If this would occur, the simplification could
not work and the reasons behind the answers should be compared directly.
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3.5 CONSTRUCTIVE METHODOLOGY
After the interview analysis, found in chapter 4, this thesis proposes a game design in chapter 5. This is
specifically done after the interview analysis, since the interviews would provide information about the
potential flaws of a game design and which factors should be kept in mind.
The constructive methodology has been chosen because during the interviews a need for a game design has
been brought up. To the extent of the author’s knowledge, a VR game specifically targeted towards the
children’s obesity problem, does not exist. The goal of a constructive research is to solve a practical issue,
which is based on research and fulfils the academic requirements. The constructive methodology of this
thesis will follow the following 6 steps:
1) Selecting a relevant problem that can be practically solved.
2) Obtaining enough information from multiple sources in order to achieve understanding and
objective knowledge about the topic.
3) Designing one or multiple solutions that can be executed.
4) Examining the solution(‘s) feasibility, which can be limited due resources, hardware requirements
or a lack of knowledge.
5) Testing the results according to the theory in order to get the practical solution aligned with the
theoretical knowledge.
6) Researching the general feasibility and applicability of the results. If results are in scope of the
project boundaries, but are not feasible for being used in a general cause which was identified as
the initial issue, it cannot be applied and the constructive design should be revised.
The goal is to come up with a potential solution for the gap between the existing theory and the practical
problem itself. The constructive methodology is interested in the problem solving itself, which could have
an impact on the current theory and general opinion if executed correctly. (Pasian, 2015.)
Before one or multiple solutions can be constructed, research needs to be done as explained in step 2. This
overlaps with the research that needs to be done for the interviews. The interviews itself were another source
of additional information. The interviewees provided feedback about potential solutions and the feasibility
could be discussed in this matter.
The information gathered will be compared with popular game designs that are downloaded >1million
times. This will result in enough relevant information to start with the conceptual constructive game design.
This is further elaborated in chapter 5 and accompanied with examples in appendix IIIA & B.
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4 INTERVIEW ANALYSIS
According to the methodology explained in chapter 3, this chapter focuses on the execution of the
methodology and researches patterns between the answers given by the interviewees. These vary from
clustering the interviewees in groups, combining the knowledge level and answers of the interviewees.
Expected is that the group of VR specialists are the most up-to-date about new developments and thus know
what is feasible and what is not, while they would be less informed about child psychology and the different
factors that should be kept in mind while treating obesity. Since this thesis is exploratory research, the
analysis would focus on the difference opinions and bottlenecks identified by the participants which could
lay the foundation of an actual treatment. A game design setup is explained in chapter 5 which is based on
the literature review, interview analysis and author’s expertise. The game design functions as a bridge
between the theory and practical usage and proposes an idea to tackle issues that came up during the
interviews regarding the game design.
The findings of the interviews can be found in the appendix in which the interviews are rated accordingly
to the responses and explained in chapter 3. Table 9 (in the appendix) provides additional information about
Table 8. The fourteen interviewees are all numbered and the list of the exact names can be requested from
the author. Every interviewee’s profession is briefly explained and their relation with VR or to the topic.
This also provides a basis for their experience with and knowledge of VR, which is an important factor for
the analysis. The question categorisation is done in 4 different question types which are further evaluated
according to the Likert 5-point scale (Krosnick & Presser, 2010).
First the overall correlation between the experience and the responses has been measured to see whether
people with more knowledge about VR are more positive towards VR or that people with (almost) no
knowledge are seeing more opportunities due the lack of boundaries. According to the interviews conducted
there is a positive correlation between the experience and knowledge of VR which is reflected in the
positivity of the responses.
A critical remark must be made that if a person has more knowledge about the topic, the person scores easier
a 4 instead of a 3 in a response. A person without knowledge cannot come up with new ideas and in this
case would be neutral if this person is not enthusiastic about treatment opportunities for instance. Thus, a
conclusion that people with knowledge are directly more opportunistic or positive about VR in general or
regarding treatments cannot be drawn. Especially people that did not have a lot of knowledge were amazed
with the possibilities and would refer to ideas that exist from science fiction movies during the interviews.
54
Interesting , what is pointed out in the response grades, is that people with some knowledge that are lacking
the exact know-how were less positive regarding current treatments that exist. They were also less positive
about developing a potential VR application for an obesity treatment. This group was combined with the
group that had (almost) no knowledge because they were either simply not aware or never thought about
VR as a “tool” in the fight of obesity. The combined group has been compared with the group with a lot of
knowledge. This clustering was especially important due to the setup of the research, since only 3
participants had (almost) no knowledge and 2 an intermediate level, while the rest were categorised as
experts.
Everyone with some VR knowledge agreed that VR can be useful in many situations due its immersive
aspect. As Samual (2017) mentioned in the interview: “I have to set a timer when I put on Minecraft VR
because I lose track of time”. People are getting immersed in such a way they lose complete track of time.
The lack of knowledge about VR can also be caused by the fear of adopting a new medium which is not
fully researched yet and in the development stage, this combined with the lack of personal experience of the
participant can reduce the positive reaction. But overall most of the reactions towards VR as current or soon
to be developed treatment was positive among both the people with and without knowledge. The people
without knowledge needed some explanation and examples of what is possible, but then they were very
enthusiastic about the possibilities and opportunities. Important to note is that most thought VR applications
could be a useful tool but that it was just another tool as a part of the whole toolset to fight the problem.
Everyone, including the VR specialists, were aware of the complexity of the obesity problem and thus did
not think only VR could help solving the problem. The opinions were diverse between the level of
involvement of the human aspect in the treatment. The opinions also varied about the level of making use
of the VR applications. These varied from that the application could tackle a big part of the problem and it
needed to be developed correctly and then would, with some professional, help cure obesity. Or that a VR
session would last a maximum of 5 minutes and the human aspect was by far the most crucial factor. VR
specialist were more realistic in what was possible compared with the paediatricians due the lack of
knowledge. The difference was mostly on what was possible regarding graphics, movement and gameplay.
The VR specialist knew the boundaries that they needed to keep in mind while the paediatricians assumed
everything was possible.
Another difference was the scepticism of the paediatricians and researchers compared with the VR
specialists. The VR specialists were more welcoming a treatment if it could potentially help and would
support the “good cause” in any feasible way, while paediatricians and researchers were more thinking about
the negative aspects. Especially paediatricians had a strange “gut feeling” with putting children into a VR
game to get them to exercise more, since they were trying to get children away from computer games for
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years. “It doesn’t feel right to put a kid in a game for losing weight” (Interview M.Chegary, 2017). Since
they were not used to the idea of VR applications can be used as a “good cause” yet. The paediatricians and
interviewees with some knowledge were reflecting the public opinion as is shown in Figure 19 (Stevenson,
2016). Since only a small percentage of people have used VR headsets, especially the more high-end
devices, the lack of knowledge of the wider public can be justified. It is hard to judge something if you have
never heard of it since people first want to try it themselves. That was also something coming up during the
interviews, people that have not used it are excited to try it since they were either not aware of the existence
or simply did not have the opportunity to try it.
Figure 19: Public opinion of VR (Stevenson, 2016).
The way of thinking also had some differences between the groups. On average VR specialists would
directly jump into conclusions and in solutions. Most directly tried to figure out how this problem could be
tackled without fully being aware of all the various dimensions. Later in most interviews they took a step
back to first completely figure out the problem, while the paediatricians were directly thinking of the
bottlenecks of developing such a treatment.
The most crucial bottleneck directly pointed out by the paediatricians were the costs. Since they work in the
health care industry, they were all aware of the Dutch health system and the struggles of getting approval
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on payments. After the explanation of how the system worked, setting up a long-term project did not seem
feasible and since this is a long-term treatment, this was a problem. On the other hand, the VR specialists
were more thinking of technical limitations of the project and after having out-of-the-box ideas, limitations
were discussed regarding technical, graphical and design issues. The VR researchers were a bridge between
those two groups, since they would, as expected, in all cases stay in the middle and while keeping both
things in mind. Mostly because there were producing non-commercial content themselves, in contrary with
the VR producers. They were going through the entire process of getting funding which could only be
acquired with adequate research beforehand. The difference with VR specialists and especially VR
producers is that they could come up with their own projects, instead of getting requests of producing a
project with a budget.
VR specialists, VR researchers and paediatricians mentioned the problem of the initial setup costs of such
high-end VR devices. The VR specialists had besides of the hardware costs doubts about the development
costs. Since ideas that were discussed would require a large initial investment. All were thinking of solutions
in ways to find funding which had some interesting outcomes: they both had different ways of getting
funding. VR specialists would contact big companies, as HTC Vive or Oculus Rift, that would invest money
for social welfare projects, while the paediatricians would go through public funding channels from e.g.
hospitals, government or charity. The VR researchers discussed both options since they could go through
both channels.
To keep the development costs relatively low, the VR specialists were recommending using low polygon
models. Low polygon models are models that are less detailed and have a more playful look. This would be
more appealing to children and would reduce the development budget needed significantly. This will be
further elaborated in the game design chapter.
As mentioned by the paediatricians, getting funding for programs is very hard and is dependable on the
coalition ruling the Netherlands. Regional projects are funded by the municipality and can change every
year (Interview Sinette, 2017). Setting up a program is already difficult and using VR applications as a
treatment had some conditions. If it would be funded on municipality level, a contract need to be made to
setup and test the program before it can be shutdown. On the other hand, if it would be funded by insurance
companies for instance, the whole intention would change from simply getting people healthier to “how to
make money”. She believed that insurance companies could benefit in the long run of investing in such a
VR application now, but this will be elaborated in the discussion section of this thesis.
The goal of all the different groups was the same: getting children healthier by getting them on a healthy
weight. The way of targeting the problems had deviations across the different groups. VR specialist would
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mostly focus on the parents or develop a game involving the parents, because they thought children of the
age 5-9 were not independent enough to make their own decisions. But it must be mentioned that the VR
specialists wanted to gain more knowledge in this area before being able to make concluding statements.
On the other hand, the paediatricians always put the child as the focus point and the framework should be
built around them. Both agreed that the parents needed to be involved, but the focus area could differ.
Everyone was certain that children would highly enjoy VR experiences, which is in line with a study
conducted for children slightly older (age 10-17) with a test-group of N=500. The problems that could arise
during treatments were shared across the children participating in the research and the interviewees: health
issues, weight of the headset, getting hurt because of the surrounding area and addiction were potential
problems. The reaction of the children can be found in Figure 20 (Burch, 2015).
Since VR specialists and researchers were the only participants with enough knowledge to be able to come
up with innovative ideas, there was a big difference in ideas about the future of VR. The above mentioned
all thought that AR would become bigger than VR, but would get a different role. AR could be more useful
in someone’s daily life and some brought up ideas about headsets that could change from AR to VR, when
playing a game for instance. AR could also be useful of fighting obesity since in the corner of the user’s
field of view the amount of kcal burned or consumed can be shown in tables or a different kind of interface.
The possibilities are endless and this will be further discussed in the discussion part of this thesis.
Overall most of the participants were positive about the future of VR, and AR as additional element. They
were looking forward to the extra dimensions it could bring to our lives and how it could be integrated with
e.g. treatments, training sessions, educational purposes etc. Important factors to keep in mind are the
bottlenecks and thought leaders as Samual (2017) and Öla (2017) stated that developers have great
responsibility in developing harmless content. Everyone was aligned regarding the costs of VR; these need
to be brought down since the costs are high for setting up an installation, even when leaving the development
costs out-of-scope. The VR specialists all agreed that the VR hardware costs would go down over time and
that this could lower the setup costs significantly.
Due to the overall positivity of the interviews, chapter 5 proposes a conceptual framework of an actual game
design considering the recommendations of the interviews e.g. low polygon design, not too complicated
game mechanics and keeping the game fun. This will be supported by research on children’s interest within
the age group, current game designs of popular games while keeping in mind a feasible approach regarding
technical requirements and costs and the author’s expertise. The constructive chapter includes the game
design, concept art, user flows and game mechanics, attributes and models. The interview findings still have
58
to be discussed, but this is taken into consideration while developing the conceptual framework of the game
and is revised according the discussion of the interview analysis.
Figure 20: Children's review of VR (Burch, 2015).
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5 CONSTRUCTIVE GAME DESIGN: HEROES VS FAT
The literature and interview analysis combined, provided ideas and a start for a game design proposal, which
should be optimized to achieve the ideal result in the fight against obesity. The title of this game proposal
will be “Heroes vs Fat” and is derived from the popular games “Plants vs Zombies”. The title has been
carefully chosen in order to already describe what the game will roughly be. At the same time the term “Fat”
is used, but in a general way instead of stigmatising fat children, who are in this case the “heroes”. The title
can be seen as a metaphor, the child is in-game fighting enemies and at the same time being the hero in
fighting obesity.
Developing a game can be broken down into three basic steps, which can be broken down further: pre-
production, production and post-production, which is show in Figure 21. This thesis focuses on the pre-
production, since actual production and post-production is not feasible due time and resource constraints.
In the pre-production the concept, UX, UI, mechanical gameplay and designs will be created.
Figure 21: Production stages (Helppi, 2015).
While designing a game, especially for children, multiple factors should be taken into consideration. The
target and age group, what the intention of the game is, in which medium it should work and on which
devices the application will be running, the costs, the game design and how to gameplay works, how it can
be accessed, if the content is paid or free, who is responsible from a legal point of view, who is going to
design it, who will pay for the development etc. The combination of answers on those questions depend on
different factors, at the same time assumptions have be made before going into the constructional part.
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This section proposes a game design based on the previous findings and assumptions made regarding the
questions above and on child psychology. All the decisions will be explained and elaborated, as will the
assumptions.
Table 3: Assumptions game concept
Assumption Elaboration
1) All expenses are
covered
For the sake of the design, all costs made in the development process are covered.
Costs will be considered since there is no unlimited budget, but the budget is not
considered a bottleneck in this development process.
2) Accessibility Children who are participating in treatments and want to make use of the VR
application, have the resources and availability of the devices to play the game as
recommended in the treatment. This includes a mobile phone that can run the
application and has access to internet and access to a computer with a VR headset
attached.
3) Content
availability
The content is free for usage and will be available for every paediatrician that wants
to make use of the application.
4) Parents
cooperation
Parents of the child are agreeing with the treatment and that their child is playing a
VR game, even though the children are under the recommended age.
5) Legal
responsibility
The game is completely tested in order to prevent any negative impact it can have on
a child. Since children are very responsive to images, it will be developed in such a
way that the child will not get a negative feeling. Legal responsible is the
paediatrician using the application, but this is assumable used in a professional way.
The target group of this VR application are children in the age group of 5-9, both male and female. In these
years, the child is growing up and is developing interests, hobbies and skills. Using the child’s interests
could keep a child motivated and intrigued in the game. This can, and according to research should, be done
in a positive way, thus talking negatively about eating habits or the body can be avoided. Addressing it as
an improvement point instead of a negative issue could be more beneficial and that is the goal of this
treatment. (Stening, 2014.)
As discussed in the interviews, the parents are a very important factor of the treatment and thus should be
involved in the process as well. This can be done in a variety of ways, but in this design the game itself will
be developed for the children and parents will be educated through other mediums and encouraged to try
the game itself. Creating a game for the whole family will not the be the goal of this thesis, since the focus
point is the child itself. Creating content for adults requires a different approach since their interests are not
similar with their children’s, as is the level of development and understanding.
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The intention of the game is to get children healthier by creating an interactive game which makes the child
exercise, while providing information and education. The game will be developed for the HTC Vive, which
is a high-end device and thus will have higher costs, but offers a lot more possibilities. Especially since the
installation will be on a fixed spot, moving the device is not needed. This allows for the possibility of having
an empty room so the children could “exercise” by playing the game. The choice of the HTC Vive over the
Oculus Rift depends on the sensor tracking. The Oculus Rift has 1 or 2 sensors that need to be placed in
front of the user and when then user turns around, the device can lose tracking. The choice of a high-end
device over a middle- or-low end device is to create the optimal experience and provides more possibilities
regarding the movement and physical exercise. The mobile phone will upload all the data to e.g. a Gmail
account, which can be accessed in the computer. The requirements for the phone are: having enough
computing power to run the application and have access to internet. The type of phone, e.g. Samsung,
iPhone, Nokia etc., does not matter in this case. The mobile application developed for this project will be
customised for both IOS and Android, so it can run on all smart phones. An API will format the data into
the suitable format for the VR headset to be used and enables the child to play their own game.
The development of the game itself for the HTC Vive can be done in either Unreal or Unity. The game
engine preferred in this case would be Unity, because low polygon designs can be quicker developed and
thus will keep the costs lower. It can also be done in Unreal, but the development time is longer since Unreal
is mostly used for the high-end close to photorealistic games. So, both engines could develop it, but it
depends on the costs and profession or preferences of the company executing the game (VRstatus, 2016.)
The costs of developing the game are ideally all covered by funding, but as table 3 addresses, money is not
an issue in this development. Even though the costs are assumedly covered, they will be kept in mind during
the development and while making decisions on the game design. This is in order to keep the amount of
money needed to be raised for the game lower. This assumption is based on public or governmental funding
and it will not be a commercial game since the main goal is an educational purpose, the possibilities of a
commercial game will be discussed in chapter 6.
Every age group has different requirements for game designs, in this case the group of 5-9, which is in the
end of the early primary years to the middle of later primary years in the research of Gaffney and Hunter
(2011).
As mentioned children at this age are highly social, but dependent on peers for feedback and they are curious
and conscious of their relationship with the adult world since they are moving out of their “child world”.
Being highly social is reflected in their online behaviour, but this behaviour shows that they have rapid
responses instead of first absorbing all the information through reading. This suggest that the amount of text
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in the game should be limited and replaced by for instance a voice-over to still give them the required
information. Responding rapidly also corresponds with the children age since they are very active and like
to stay busy. Thus, based on the research an interactive and physical active game would presumably keep
the child’s attention the longest. (Gaffney & Hunter, 2011.)
The research of Gaffney and Hunter (2011) has some further recommendations when designing for children,
which is the bases of the user flow. Due the age of the children, straightforward text should be used instead
of focusing on the medical terms. The exact chemical reactions of the body on diverse types of fat is most
likely not adding extra benefits to the knowledge of the child and only increases the “educational part” of
the game. Instead this can be simplified and targeted with fun and interactive animations or voice-overs. To
reduce the amount of handlings that could distract the child, the game should not include explicit “save”
options, since the child can forget saving the game while playing. Instead an automatic save option every 5
minutes or by closure should be implemented. To keep the child focussed, the interface should be clear and
straight forward. A very complex or messy interface is only distracting for the child and gets their attention
of the game itself. (Gaffney and Hunter, 2011.)
Children should be able to personalise something in the game to feel more familiar, e.g. with the main
character. Applications that “engage” the child are more attractive for the children. This combined with
highly interactive game mechanics to keep to the child interested, can potentially result in enjoying the game
for the long term. To keep the child entertained the game should, as in any game, not contain any errors,
bugs or other game failure.
Those guidelines are implemented in the game concept in the user flows, which are show in Figure 22 and
23, and is further used in the game concept in chapter 5.1.
The process starts with installing the phone application. The HTC Vive application is already installed on
the computer by the supervisor or paediatrician. When the mobile application is downloaded, the user signs
up an account, so the data can be synchronized with the VR application. Figure 22 shows the flow from the
moment the user opens the game. The user flow is straight forward but side notes must be made for
additional clarification and are summarized in table 4 & 5.
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Figure 22: User flow A: Mobile application
Table 4: Side notes user flow A: Mobile application.
1 Login codes will be remembered per mobile phone, so the child does not need to login every time
since most likely the game is attached to one of the parents email accounts.
2 Per mobile phone ideally there is only one save game. Which can reduce the amount of user actions
needed to actually start the game.
3 The introduction explains the goal of the game, the controls and interactions and the mechanics.
This can be later accessed in-game as well through the menu if necessary.
4 The guidance is a tutorial after the introduction, to not only explain the interactions to the child,
but explain while playing, which provides more interactivity.
When the game is setup in the mobile application, the data will automatically be saved to the account which
is used to login on the computer with the HTC Vive. Now the actual gameplay starts, but first the user flow
of the HTC Vive will be further elaborated.
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Figure 23: User flow B: HTC Vive
Table 5: Side notes user flow B: HTC Vive.
5 Per account ideally there is only one save game. Which can reduce the amount of user actions
needed to actually start the game.
6 The user can customise their character in the following categories:
• Sex: Male or female
• Class: Knight or Warrior
• Facial expression: 4 different choices with options to add (sun)glasses
• Skin colour
• Hair style
7 The introduction in the virtual world that explains the goal (visually), the controls and interactions
buttons.
8 The guidance is a tutorial after the introduction, to not only explain the interactions to the child,
but explain while playing, which provides more interactivity. This is with a pre-created village
and fighting a wave with all options unlocked. This is in order to keep the child looking forward
to unlocking features in their own village.
Since rough user flows are now described in Figure 22 and 23, the game mechanics, designs and concept
art can now be further elaborated. The figures and concept art has, in contrast with the rest of this thesis, all
figures included in the appendix due the amount of examples.
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5.1 GAME MECHANICS
During the interviews and while working at MediaMonks, multiple game types were discussed, and this
thesis has chosen the following type of gameplay: “Tower defence”. This is a popular game and renewed
on regular basis by multiple developers as “Plant vs Zombies” from Popcap being one of the most famous
tower defence games. The first release was in 2012 and launched on the following platforms after success:
Xbox One, Xbox 360, Microsoft Windows and Playstation 3 & 4 (Popcap, 2017). The advantage of this
gameplay is that it is straight forward, relatively easy to develop and provides opportunities for interactions
(McAnlis, et al., 2014).
The following paragraphs will describe in detail the purpose, goals and other factors keeping in mind for
the game. Heroes vs Fat is a game where children have to protect their village against fast food. The user’s
army consists of healthy foods as vegetables & fruits. Besides of their eating pattern, as mentioned, sleep is
an important factor for children to have a normal functioning metabolism. The game should, because of this
sleep requirement, be limited in time playable without creating stress for the user. The experience in the
HTC Vive is limited per child since it will consist of sessions, but the mobile game option can result in long
playing times. This will be limited by putting a maximum of time a day that the user can play and giving
the user a bonus when not login in for 12 hours. On the other hand, users get a daily bonus when walking a
certain distance, which is further elaborated in the game mechanics part. With this construction the user is
playing the game every day, but will not play it all day due the bonus of not logging in.
The goal of the game is to survive through all the 10 levels and defeat the final boss and eliminate all the
“bad foods” from the world. The tower defence game normally has no fixed ending and is an endless
“runner”. This game design will have an end because the game will be used as a therapy. An unlimited game
should also be avoided because this can imply that the fight against obesity is senseless. It is possible though
to fail a level, but this can be restarted. It is up to the supervisor to postpone trying the level again or to give
it another try the following session.
In line with the Clash of Clans game setup, the town hall is in the middle of the map and the player builds
their city around it, which is shown in figure 29. An additional option would be that the player could move
the town hall to another location if defeated by a wave of enemies. But at first every player starts at the same
point and this is the starting point how the players can build their village. The player starts the game in front
of this town hall the first time the player goes into the VR application.
While being in the HTC Vive game, the player is seeing the hero from a first-person perspective. The hero
can walk and teleport around. The teleport option will use the same mechanics as the teleport option in the
HTC Vive game: “The Lab”. Figure 28 shows this from a first-person perspective.
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The following subchapter 5.1.1 sums up all the different buildings, characters and attributes that will be
used in this game design. The characters all have concept art examples added in the appendix. Appendix
IIIA shows a mood board of what the environment will look like and how game mechanics as teleportation
and full resources. Appendix IIIB shows the style how characters, attributes and buildings will be designed.
Appendix IIIA & B is accompanied with extended informative captions. The clothing should be customly
designed in line with the style of the characters. The range of options is limited due cost restrictions, but
also to not overwhelm the user by the “endless” options.
5.1.1 GAME ELEMENTS
To build a village, buildings and walls are needed in a tower defence game. Those should be limited to keep
the strategic level of the game minimal due the age group.
Buildings
• Town hall.
• Walls made from leaves to protect the city.
• Barracks to create the broccoli foot soldiers.
• Farms to grow the beetroot soldiers.
• Archery to create carrot archers.
• Training centre to train your hero.
• Stables to create reindeers who are being ridden by soldiers.
• Blacksmith for buying special weapons.
5.1.2 CONCEPT ART AND DESIGN
Table 6: Character & attribute overview
Good: Bad: Attributes
Customized hero Hamburger Customization for hero: clothes, armour, weapon,
equipment.
Carrot archers Giant hamburger Bow and arrow for archers.
Broccoli Fries (archers Weapons for warriors, both for enemies and fellow
soldiers.
Beetroot on a reindeer Pizza Buildings (see buildings paragraph)
All above mentioned characters and attributes have concept design images in the appendix, corresponding
with Figure 30-43.
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Table 7: Unlockable mechanics
Level Unlocked options per level Amount of waves per level
Level 1
hero, town hall (needed to be
place in beginning), houses
(population), farms
1 wave: hamburgers
Level 2 Warriors, walls, 2 waves: fries
hamburgers & fries
Level 3 Archers 3 waves hamburgers & fries (2x) + 1x mini boss
Level 4 training centre 3 waves, candy, candy, hamburger and fries (2x)
Level 5 Stables 4 waves candy, hamburger and fries (4x)
Level 6 4 waves, candy, hamburger and fries (2x), fries and mini-boss,
hamburger and mini-boss
Level 7 Blacksmith 4 waves, candy hamburger and fries (2x) fries, candy and mini-boss
(2x)
Level 8 6 waves candy hamburger and fries (6x)
Level 9 5 waves, candy hamburger and fries (2x), 2x mini boss, 1x all (2
mini bosses)
Level 10 2 waves, 2x mini boss + fries, final boss
Not all game elements will be available from the start of the game, but are unlocked when gaining levels.
Table 7 shows the difference levels, characters and buildings that are unlocked at the specific levels. The
amount and type of waves are also predetermined and can be found in the third column.
5.1.3 RULES
Every game functions according to rules which should carefully be determined. This game will have
physical laws as gravity, so the child will not be distracted. Weather conditions in the game are either day
or night, depending of the time zone the child is playing in. The actual live weather data will not be
implemented in the game, since this would increase the production costs and will not have a beneficial effect
on the purpose of the game.
In-game also certain rules apply and will be discussed in the following paragraphs. The player will have a
maximum amount of playing time on the mobile phone, which is limited to 60 minutes. The time in the VR
headset will be limited to a maximum of 30 minutes, or less if desired by the supervisor. The fight itself will
be limited to 15 minutes, due to the level of intensity of the game and taking into account the time limitation
of the game itself. The fight lasts in-game from the morning to the beginning of the afternoon, inside the
game. Outside fighting “minutes”, the player can prepare the troops and buildings, while in the afternoon
the actual fight is happening.
The game is not an endless open world game and within the game area there is a maximum space where
buildings can be build. This can be seen as example in Figure 25. In this case the green sidewalk is the out-
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of-bound area. The boundaries are predefined and the player is not able to change or manipulate these. An
open world game would be too advanced and would take too much time and is thus costlier in terms of
development. There are two different physical boundaries:
1) The edge of the game map, the player cannot move further than this area with their hero.
2) A virtual boundary which disables the user to build buildings in this restricted area.
The boundaries of this game are set by difference in grass colour and with environmental objects, e.g.
mountains, rivers, forests or cliffs. The user can still see the rest of the landscape fading away, but this area
is not accessible. The player can move through the game by actual walking, within the limited space of the
VR room. As mentioned before, the player can also move around in the environment by teleporting. Making
use of the mechanic used by HTC Vive game “The Lab”. An example can be found in figure 28. (Biagioli,
2017.)
On the map the enemies have two different spawn points. This is to introduce an element of tactics, while
keeping it in the range of difficulty. Between the spawn point and the zone where soldiers can be placed is
a part of “no man’s land” which can be classified as boundary. This in order to keep the player from
“ganking”, a game term to wait for the enemy to spawn and directly kill the enemy, which would make the
game too easy.
The overall goal of the player is to defeat all the waves and staying alive with the hero, while the enemy
tries to destroy your town hall. The player loses the game if either the town hall is destroyed or the hero
dies. If a player fails in a level it is possible to restart the level. The starting point is that of the same day
with the same amount of resources. If a level seems too hard, the supervisor can decide that the child can
try the level again next session, which enables the child of increasing the amount of resources by playing
the game on the phone. A child or supervisor can also decide to replay a former level to get more resources
if the game is too “challenging”. This enables the player to get resources if needed from lower levels and
“prepare” for the harder fight.
In-game exams or informative movies can unlock daily boost bonuses once completed and can yield e.g.
10% more vegetable health, 10% extra damage or 10% coin discount on soldiers created. Even though, as
discussed during the interviews, children will quickly learn how to give the right answers, it can still provide
information. If the question pool is large enough, children will not get the same question twice.
An additional option to increase the amount of resources will be by walking a certain distance a day.
Pokémon Go is the leading example that introduced this method in their game by rewarding the player with
a hatched egg if the user walked a certain distance. This was a great success and a lot more people were
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going by foot or were walking an extra distance just for the game. (Ritchie, 2017.) In this way players can
get additional resources and at the same time they are more active.
5.1.4 MECHANICS
Thus in order to teach the children knowledge, incentives had to be created for the player to finish
assignments, exams and getting them to walk daily. The preferred results is that this would enhance the
child’s knowledge and keeps the child moving while not being able to “fight” in VR. This is done by
rewarding the player with extra resources, which can be used for their “army” or for customisation of the
hero.
When fighting in VR, the health bar is the most important bar of the hero. The moment an enemy touches
the hero, the health bar of the hero decreases and when the bar hits zero, the hero dies. The enemies also
have health bars and they can be killed if their health bar is brought back to zero, the same way the player’s
hero can die.
Once a “wave” of enemies is conquered, the user has time to build up their city, strengthen their soldiers
and tactical (re)place buildings. This also allows the player to create more soldiers that might be lost in the
battle. Building up cities and strengthening the army can be done by spending resources.
The resources in this game used are golden coins and can thus be gained in the followed 4 ways, which are
briefly summarised:
1) By waiting, resources slowly load while offline and this goes faster per hour not logged in.
As explained before this motivates players to be active during the day and not play the game.
2) Doing in-game exams, every correct answer will yield coins and doing a test without any
mistake will result in a bonus.
3) By doing physical activities as walking. The phone application will track the distance covered
and resources will be send to the player.
4) By killing enemies. They can drop golden coins which can be collected when they are picked
up.
The golden coins cannot be bought with real money, which keeps the focus on the treatment. Thus the coins
can only be acquired by the above mentioned factors and not by other means. This is important to keep all
players equal, even though the game starts with only offline modus. Optional features are discussed in
chapter 5.1.6.
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5.1.5 GOALS
The goal of the game varies depending from which perspective it is reviewed, this paragraph discusses it
from a children’s, game’s and paediatrician’s point of view.
For children. It is an ending game, but the player needs to play the mobile game every day in order to get
the most resources in the VR game. This stimulates the player to do quizzes and walk a certain distance
daily. Since players can increase their level by defeating enemy waves. Players proceeding through all the
different waves can unlock achievements and the goal is to defeat the final boss. This game ideally creates
a feeling of victory when bosses are defeated as do games that are designed for fun.
Of the game. The goal of the game is to reduce the weight of children and get them healthier. This can be
accomplished by getting them to be more physically active. Physical activity combined with the knowledge
about nutrition taught to the children and how they can empower themselves to eat healthier, should ideally
result in a weight loss.
For paediatricians. The goal of the paediatricians is to reduce the weight of children, in this case similar
with the purpose of the game. But the paediatricians perceive and use the game as a tool instead of using it
as the whole treatment. The mean of the game would be to enhance the current treatment and increase the
effectiveness and efficiency of the treatment.
5.1.6 OPTIONAL GAME FEATURES
The current game proposal is targeted towards individuals and is a single-player game, but this can be
expanded in the future in a variety of ways. To extend the game itself, extra levels can be added if the
treatment is effective which enables the supervisor to use the game for a longer time than just the 10 levels.
As additional on extra levels the game can be enriched by adding extra characters. Some premises would be
that the game is a success and more funding is available. This will diversify the game and give it more depth.
Adding extra characters makes the game also more tactical, due the increase of possibilities. Since the
children are between 5-9 and the younger children might think the game is too difficult, extra characters can
be added in the form of more customisation possibilities (Gaffney & Hunter, 2011).
Adding a multiplayer version of the game can provide the game with an additional dimension. Players can
help each other defeating the enemy waves and there will be an online leader board at which players can
see their score compared with others. In this way players can support each other in the game itself, but also
during the treatment and a feeling of cohesion can be created.
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6 DISCUSSION
Since the qualitative analysis and the proposed constructive framework are finalised, this chapter discusses
the improvement points regarding this research. Besides discussing the flaws and shortcomings of this
thesis, this chapter will provide recommendations for future research in this topic and discusses the
feasibility of the proposed framework in chapter 5 after having discussed the framework itself. But before
the research itself will be discussed, this chapter starts off with the discussion about VR.
This master thesis started off with the research question: “can VR applications help to cure or prevent
obesity for the new generation?” and based on the research done, VR applications can be considered feasible
for curing or preventing obesity. But there are requirements that need to be fulfilled which are explained
underneath together with the potential drawbacks. As mentioned in the interview analysis, AR could also
be an option with tracking calories. This could be useful for a different target group, since showing raw
statistics to children will quickly get them bored. This has been discussed with the interviewees and they
agreed that VR would most likely have more positive effects than an AR application could achieve.
Even though VR has been researched for a long time, the research was based on speculations and on devices
not available for the public. Because of the significant increase of VR devices in 2014 the research could be
expanded as well due to the possibilities of testing devices instead of pure theoretical approaches. The use
cases of VR and the effects (both positive and negative) have been explained in the literature review, which
could be backed-up by research. A big part of the effects of VR applications are still undiscovered and this
was also reflected in the interviews. Participants of the interview brought up a variety of potential outcomes
that VR can cause and should those be examined. The doubts that were intensively discussed are listed
underneath.
Addiction: As mentioned by participants and blogs on the internet, there is a fear of getting people addicted.
Although one interviewee compared it with the current smartphone addiction and that is “normal”, some
people are little hesitant with adopting VR. Addiction can go as far as people not willing to leave the virtual
world since they prefer the virtual over the actual world. In VR the user can be and do everything that is
desired and if virtual jobs are taking off, there would not be a reason to leave the virtual world except for
eating, drinking and sleeping. There is no need of face-to-face social contact at all since this can take place
in the virtual world, so why would someone bother to leave their comfort zone? These cases are the most
extreme, but it should be examined how many people will behave like this. The interviewees suggested
adding time limits to the VR game against obesity for health reasons, but these can also be used for avoiding
addiction. Addiction can be linked with the following potential drawback; social changes.
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Social changes: Especially the paediatrician were slightly negatively biased on the impact VR can have on
social relations. As mentioned above, social interactions do not necessarily need to take place in the actual
world anymore, since people can meet in virtual spaces as for instance in “Facebook Social VR”. Facebook
creates a virtual room with open source data, which enables all the users to meet up in this room. Thus
everyone can just login and join and meet other people. This could affect the way children develop social
skills and how they would act in a later stage of life. This was perceived as negative and that topic was
discussed with VR specialists as well. Samual (2017) would expect a shift of social interactions and how
people interact with each other, but this is not necessarily a bad change, just different than what we are used
to. As it could be compared with chat mediums as MSN 10 years ago and WhatsApp or Snapchat are current
examples that changed the social interactions.
Another aspect that was brought up was that the concept of cyber-bullying would get a whole new dimension
if the VR application was an online game. This should be researched, but otherwise health games could stay
offline. A user could virtual intimidate another with body language since the users are able to see each other.
New guidelines, rules and security must be set to deal with these situations, but this can be a potential
drawback of the popularity of VR.
Psychopaths: as explained beforehand there is the ongoing discussion if videogames increase violence or
are a way to relieve violent tendencies. There are no significant statistically correct studies that show
videogames increase violence, but with VR booming some interviewees and blog posts were afraid of
encouraging violence. As Öla (2017) brought up during an interview: “Shooting people in the face is
different compared with gaming on a screen, because there is always space in between the player and the
screen, but in VR you are that person”, this can change the perception of people towards violence, since
they get used to first person violence, and potentially causes them to accept it. This is an interesting research
topic, but this will need to be examined in order to prevent “accidents” if it is proven that VR games increase
the violence level of a person. Prevention of massacres as the Columbine High School shootings by two
teenagers should be enacted, as the shooting was, according to the police encouraged by the videogame
“Doom”, although the police are hardly psychiatrists, which needs to be kept in mind when evaluating the
validity of the claim. (Harding, 2012.)
Adopting old mediums: This was especially a concern of the thought leaders of the participants since they
were afraid that people tend to use VR in a way we use currently television or computers. VR is a new
medium and new content should be developed in a creative way instead of making our current mediums
more immersive. On one hand, developers and other creative people should make use of the full potential
of VR and should discover new areas, but on the other hand the current mediums already set guidelines
which are easy to follow and if this kind of content is requested by the big audiences, companies want to
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produce that since it is profitable. Both are interesting views and this question can only be answered in the
future if VR evolves to a new medium or whether it stays in line with the existing standards.
Physical long-term effects: This was a point brought up by the paediatricians, since they did not know
what could be the long-term effects, especially on children that are still developing their body. As mentioned
before, it is suggested that it could change the growth of the balance system, but this cannot be concluded
as long there is no research done with control and test groups. A lot is yet unknown about how the body,
brain and nerves would react to a device so close to the eyes, especially of a growing child. Even though
the children are in the proposed game design relatively short per week in the virtual world, the effects should
be researched. Even if it would just be for knowledge enrichment, but since the VR applications are rapidly
increasing and the medium is, according to Bellini, et al. (2016), forecasted to grow quickly, it is useful to
know the drawbacks.
Psychological long-term effects: These effects can partly be linked to the social development, but also to
cases of violence in videogames. Öla (2017) was fighting VR experiences that includes “jump scares10”
since this could also inflict a trauma to a person. The VR specialists were anxious about the development of
VR and as Samual (2017) said: “I like to be a pioneer in the field of VR to choose what will be developed”.
Due to the immersive aspect of VR the effects should be carefully measured on the long-term and every
developed application should be carefully tested.
All the above-mentioned lead back to one concluding answer; more research will be needed to draw
adequate conclusions about drawbacks of using VR. This raises the question if the topic of this research was
not too progressive and should be researched in a few years. On one hand this would be the case, since there
would be a clearer outcome since more people have experienced virtual worlds and trial groups could be
setup. Then very specific designs of games could be tested on various groups and the most effective factors
could be combined which could lead to the best possible VR treatment for obesity. On the other hand this
research had the intention to be an exploratory research and focus on a topic with questions that are yet
unanswered. Making other researchers aware of potential beneficial use cases and the dangers of using VR
was an important factor of this thesis and can be a trigger for further research.
As mentioned by paediatricians the biggest issue of developing such an interactive game is the financial
problem. To develop a smoothly working game with a proper user experience, good designs, fun interactions
and a game that keeps the player intrigued, money is needed. This issue can be overcome by seeking
financial support from big VR companies or public funding, but even when the game is designed and
10 Shocking or scaring the user so the user “jumps away” when a certain animation is triggered (Gallager, 2015).
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development costs are covered, the financial issue is not solved. VR companies as HTC Vive offers funding
possibilities for projects with socially favourable intentions (Nafarrete, 2017). Setting up the installations
would also require additional money which cannot be afforded by everyone. After the initial design, the
question arises where the installations would be placed and who is financing this. When putting those in an
elementary school, the school could finance the headset, but one VR device per school would not allow all
the children to play the games. But if the VR headset is out of budget, the school needs another way to
obtain funding. Every case would require alteration and adaptation to the situation and thus developing
general guidelines will not help in this case.
Another way of funding the project could be if insurance companies would take the lead in developing such
applications. The general view of the interviews was that it would be costly upfront, but will pay-off over
time. A reduction in obesity cases would reduce the diseases that are caused by obesity, e.g. cardio-vascular
diseases, knee problems due the weight, diabetes etc. This led to the discussion of “why” would insurance
companies develop these applications since after the treatment people can switch to another insurance
company. The initial investment would, in this case, not be earned back. Assuming that the investment
would raise the monthly payment. (Obesity Society, 2016.) If the initial investment will not boost the
monthly payment, it could be beneficial for everyone, the participants and for the insurance company it
would be a long-term investment.
Still some questions remain: who is going to keep developing the application, who is responsible for hosting,
how is the content getting promotion, who got access and will it be a free application? According to the
paediatricians ideally it would be an open platform so everyone has access and ideally funded by social
welfare funds. In this case it does not matter if it is financed on municipality level or company funded, and
maintained by professionals. As discussed with the VR specialists, their opinion is more business related
since public funding can be cut and no one would have the responsibility. Out of experience most of them
argued that a project without a responsible party is doomed to fail.
Another option could be to lead this project by a research team and do the development at the university
itself. The issues arising here is the lack of experience and that the original intention of helping the children
could become of lesser importance. This is also a potential risk if it becomes a business model and the
executing company developing, launching and promoting the application wants to maximize their profit.
Many options and constructions of funding are possible, which is depending on the person, team or company
leading the developing process while keeping mind all the stakeholders.
Coming back to the research question, almost all the interviewees were coherent in their answer that VR
applications can be a useful tool, but a tool and not the whole treatment on its own. It could be a great
75
motivational tool and can be interesting for children to work with but, as mentioned above, there are a lot
of factors which should be solved before it could be useful. Especially the long-term effects, the added value
to current treatments and the financial aspect are bottlenecks.
All the above issues mentioned are applicable to the outcomes of this research and are comments on the
constructive framework, but another step back would provide a critical look towards the research itself
which always has room for improvement. The research itself could be improved on several aspects regarding
the design and execution. Every research conducted faces limitation due to the boundaries of time,
availability and financial resources. Ideally a target group of N>12 would be interviewed per discipline and
not in only 3 disciplines. Different groups of multi-disciplinary teams that are working with VR would be
ideal. This would provide a wider overview of all the different opinions. Even though this research reached
the point of saturation relatively quick, the participants could be considered biased. To reduce the clustering
of the participants, e.g. all being Dutch while VR is getting more popular worldwide, the participants came
from various countries in the world: USA, Netherlands, England, Italy and Japan. Even though this is a
mixed group, all these countries are first-world countries and score high on the welfare index, although
considering the price and the level of the technology, this is not surprising. On one hand it can be discussed
that obesity is a welfare disease and only the “richer” countries have access to VR devices. On the other
hand, children struggling with obesity in the industrialised countries tend to be from the poorer families.
Nevertheless, the more experts interviewed, the better and in this case, ideally around 12 specialist per area
and thus minimal 36 in total would provide more accurate data. Another drawback of the participant group
was the ratio VR specialists, VR researchers and child obesity doctors. On one hand this can be explained
due to the fact that multiple institutions contacted were either not open to talk about VR, since they had no
idea how it could be used, or they were interested but had no knowledge and wanted the interviewer to
inform them. Also, the ratio of men to women was not equal. The paediatricians were overly represented by
woman, while the VR specialists had the contrary. Even though the participant pool was not as diverse as it
would be in the ideal situation, enough information was provided to be able to conduct an analysis and
create a constructive framework.
But due to the time and resources constraint, it was not feasible to execute the game design and run trial
groups over a period of time to see noticeable differences (or not) and ideally follow the children until they
finish high school. Their statistics could be traced by making use of high school doctor measurements e.g.
height, weight and endurance levels. Running two trial groups with N>250 in each group, would provide
enough data to do meaningful quantitative analysis. Before running those groups, the game design should
be carefully mapped out by experts in the field of user experience and design, who will base their decision
on research conducted on various elements of what would be attractive for children and their previous
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experience. Again, a setup of the combination of qualitative research combined with a constructive approach
would suit this topic. Those two combined would eventually provide enough material to run the test groups
and gather quantitative data.
Doing research on topics with available data would provide insights on a topic, from a hindsight perspective.
If afterwards it is discovered that treatments have not been effective but rather caused damage to a child,
this can be measured, argued and proven. This research, as mentioned before, tries to avoid mistakes that
could be made in the future and is a set of guidelines for further research.
An aspect that could use improvement was the way of interviewing. The interview questions were asked in
the most neutral way, but if the interviewee had a lack of knowledge the interviewer unintendedly would
steer the participant. This was one of the reasons why the choice was made to conduct one-to-one interviews
instead of doing a panel interview. Because of the expected variety of knowledge about the topic. Since the
interviewer was excited about the topic, his enthusiasm could have jumped to the interviewees with less
knowledge. The questions themselves seemed obvious at first glance, but during the interviews many
drawbacks came up. This flow from positive to negative could have affected the answers of the interviewees
as well. Which should be kept in mind in further research designs.
All the above-mentioned factors also influenced the initial idea of a constructive framework of this thesis.
The biasedness and enthusiasm of the interviewees, could have let to overestimating the benefits of a VR
application in the first place. Assuming VR applications could work, there are limitations on the constructive
framework. As mentioned as a potential issue, getting the required money, decisions were made in order to
save money on certain costs. The decision of low polygon usage would most likely also have been made
even if there was unlimited amount of funding. This would have been chosen to keep the game on
imagination level and more playful. The budget has more restrictions on the amount of characters,
multiplayer mode and the customisation of the hero itself. As mentioned, adding more characters would
increase the difficulty of the game and could lose the initial purpose.
The game design itself could have been optimised by writing out all the complete scenes, but this should be
done by an experienced game designer that worked on children games before. The current design is based
on the interviews with VR experts, literature, popular mobile games and the author’s experience gained
during the internship. This is biased since every input factor, except for the outdated literature, is commercial
input. The experts are working with VR as their profession, as is the author, and the popular mobile games
all had a commercial purpose. Most educative games are not enjoyed by children as mentioned by the
paediatricians, thus the fun and enjoy factor needs to be in there, but could be over exaggerated in this case.
The purpose of the game is still to be educative, instead of only being a tower defence game that is enjoyable.
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Mentioned in the interviews was that children quickly realise how to give the “required” answers on for
instance the quizzes to gain resources instead of actually learning something. This could be avoided by
having a diverse set of questions which are dynamic in the sense of order. Adding animations in the VR
headset, which cannot be skipped, could also enhance the knowledge gain of the player. The specific goals
and information that have to be distributed is not defined in the design. This should be reviewed by
paediatricians together with an animation team to determine the most effective way to target obesity factors,
e.g. the child’s eating behaviour or daily exercise rhythm.
In the current game design there is no involvement of the parents, who are according to the literature and
interviews an important factor. The game design focussed on the child and that the game will be used as a
tool during the treatment. Educating the parents is not included in this process and the game should not be
used for this matter. It is arguable that, to have the full experience for the child, parental support is needed.
But assumed that the game is going to be used in a professional environment, the paediatrician involved can
educate the parents and provide them with information. A potential issue is the support of the parents of
letting the child carry a phone with them, to track the amount of distance walked. Data privacy could be an
issue since the parents have to agree with the terms of conditions for the child because the parents are
responsible at that age. If the child plays the game on the phone of one of the parents, the daily distance
walked cannot be tracked, assuming the parent is carrying the phone. This would imply the child needs an
own phone, but parents have to agree with a child (age 5-9) owning a phone.
Having additional hardware, e.g. a pedometer, that only tracks physical activity could solve the problem of
not having access to a phone all the time, but adds another device to the list and more actions have to be
done before being able to play VR game. This would increase the bar of adopting such a game and should
and can be solved in a variety of ways. A potential solution is lending the “patients” an older model of a
phone, which keeps track of their movement and at the same time grants them access to the mobile game.
This will increase the total costs of setting up the game and is thus depending on the budget. Parents still
have to agree that their child is carrying a phone, which is brings back the initial phone problem (Perle,
2011).
Since the children are under the age of 13, as mentioned in the literature review, HTC Vive is not
recommending VR headsets for people under that age. This due the unknown effects of VR on the child
physically and mentally, but also due the weight of the headset. The interviewees did not see problems in
the usage of VR headsets since the time spend in the virtual world would maximum be 30 minutes per week.
This also needs parental approval due the age restriction violation.
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The game needs to have a balance between being fun, providing exercise and learning about nutrition. This
can only be tested once the prototyping starts, which in this case was not feasible. As mentioned as
recommendation, a prototype should be developed and this should be tested with a control group of children
over a period of 2 years. Not being able to test the game combined with the funding and mobile accessibility
are the key issues that should be solved in further research. Without prototype discussing the constructive
design and approach can only be done in theory. If the game design is reviewed and worked out until the
smallest detail, a prototype is needed to test the theory. This could be a great start of future research and this
is an interesting field which offers a lot of potential.
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7 CONCLUSION
VR applications have been around for a long time, but in 2014 with the introduction of the Kickstart
campaign of the Oculus Rift and the launch of the GearVR, it became available for the wider public. VR
can be used for a variety of purposes, some examples are; usage in education, military and medical training,
travel previews, porn, design and therapy sessions. While next to VR, AR is growing rapidly, VR is still
bigger in terms of revenue, sales and media attention, but it is forecasted that AR will eventually grow bigger
or that VR and AR will be merged into one headset. AR has issues due technical limitations, but this field
is intensively researched.
The research question, “can VR applications help to cure or prevent obesity for the new generation?”, can
be answered with “yes” based on this dataset, but a lot of conditions and premises have to be fulfilled before
an actual game design could be executed. The interviewees were overall positive about treatment usage,
although the VR experts disagreed with the paediatricians about how it could work exactly. On one hand it
could be a great motivational tool and on the other hand have a deeper impact on children than a simple
video or book. The problems brought up by VR experts focused mostly on the technical and distribution
side in combination with the carefulness VR applications should be developed. While the paediatricians
were anxious about the long-term effects, both physically and mentally, they also expected problems to get
the required funding, which was their main concern of the execution. More research will be needed and this
thesis provided a foundation.
The constructive framework was designed according to the literature review and interview analysis and
focuses on the various aspects to keep a child entertained while providing physical activity and education.
This should be combined with involving the parents in the process who are, according to the literature and
interviews, very important in the potential development of obesity for a child, what should be avoided.
Before launching the game certain issues should be solved. The problem with getting the required funding,
a test with the prototype of the game and the accessibility for children to a mobile phone need to be solved
before going further in the process. The balance between being educative and fun should closely be
examined and the specific goals of the game should be identified before acquiring the funding, since this
has mostly likely to be included in presentations of the funding requests.
As next steps for further research, interviewing more VR experts and paediatricians could be useful while
developing an actual game which can be shown to these two groups. Test groups should be monitored to
measure the effects of the VR application while also tracking the change in behaviour of the child. The
development of the game itself would consume the most time due to the different steps that should be
following. First the required funding should be gathered and a division of who or which party is responsible
80
for what should be determined. All the stakeholders should be aligned and this is very dependable on the
different parties involved and the intention of developing the project which can be (non)profit based. Before
starting the actual development, after having obtained the funding, the UX, concept art must be determined
before going into the choice of designs and gameplay. Afterwards development can start to program the
game and testing should be done. Ideally children are used during those testing review moments, to measure
what they like and do not like. The long-term effects should be measured while closely monitoring the
development of the VR market and the companies investing in this new medium. The literature review of
this thesis should be updated when necessary, especially with innovative technologies regarding tracking,
graphical performance improvements and new headset releases. The latter is especially important since a
high quality headset with a price undercutting the market can boost the adoption of VR significantly. When
a new release is adopted by the wider public, there is more demand for content and more research can be
conducted on all different applications. This field has a lot of potential but also some drawbacks and it is
thus important that it is closely researched.
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APPENDIX I: QUALITATIVE ANALYSIS TABLES
Table 8: Analysis categorisation
Interviewee* Profession** Experience*** Question type **** Response*****
1 2) VR producer. Has
knowledge of producing
VR campaigns, but no
technical knowledge.
1 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
3-1
Future of usage VR in
daily life
4
Future of VR
treatments
3
2 2) AR/VR creative
technologist. Knows
everything of
equipment,
development and
innovations in the field
of VR and AR.
2 General opinion about
VR
4
Effectiveness of VR
treatment for obesity
5
Future of usage VR in
daily life
4
Future of VR
treatments
5
3 1&2) CEO of VirZoom,
a company developing
VR fitness bikes.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
5
Future of usage VR in
daily life
5
Future of VR
treatments
4
4 1&2) Global head of
VR at MediaMonks.
Knows everything from
equipment, psychology,
developments in the
field of VR and AR.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
5
Future of usage VR in
daily life
4
Future of VR
treatments
5
5 2) VR producer. Has
knowledge of producing
VR campaigns and
technical knowledge.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
3-4
Future of usage VR in
daily life
4
Future of VR
treatments
3
89
6 1&2) Creative. Knows
everything,
development,
psychology and
innovations in the field
of VR and AR.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
4
Future of usage VR in
daily life
4
Future of VR
treatments
5
7 3) Child obesity
specialists working at
OLVG.
0 General opinion about
VR
3
Effectiveness of VR
treatment for obesity
2
Future of usage VR in
daily life
3
Future of VR
treatments
3
8 2) VR producers.
Knows everything of
equipment,
development and
innovations in the field
of VR and AR.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
4
Future of usage VR in
daily life
4
Future of VR
treatments
4
9 1) Italian professor
researching VR for over
10years.
2 General opinion about
VR
4
Effectiveness of VR
treatment for obesity
4
Future of usage VR in
daily life
4
Future of VR
treatments
4
10 1&2) CEO of
Coolminds. A company
producing VR content
for treatments and
campaigns.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
5
Future of usage VR in
daily life
4
Future of VR
treatments
5
90
11 3) Child obesity
specialists working at
Cool2BeFit
0 General opinion about
VR
3
Effectiveness of VR
treatment for obesity
3
Future of usage VR in
daily life
2
Future of VR treatments 4
12 3) Paediatrician and chief
information officer
1 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
3
Future of usage VR in
daily life
3
Future of VR treatments 5
13 1) Japanese professor
researching VR and
creating VR content.
2 General opinion about
VR
5
Effectiveness of VR
treatment for obesity
4
Future of usage VR in
daily life
4
Future of VR treatments 4
14 1&3) Program leader E-
Health. Developing E-
health content.
0 General opinion about
VR
3
Effectiveness of VR
treatment for obesity
3
Future of usage VR in
daily life
3
Future of VR treatments 3
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Table 9: Attachment Table 8.
* The interviewees are numbered anonymously, the list can be requested from the writer.
**
Profession is categorised in three different group as defined before:
VR researcher (academic research and measuring psychological effects)
VR specialists (working with VR on daily basis in their work)
Child obesity doctor
***
Experience is defined in three distinct levels:
0 = No experience with VR
1 = Some experience and knowledge of how it works
2 = Professional knowledge and experience.
This is accompanied with a little description of the knowledge of the interviewee
****
The questions are categorised in four categories:
General opinion about VR
Effectiveness VR treatment applications
Future of VR in daily life
Future of VR in treatments
The questions are defined in the appendix per profession.
*****
Response is categorised with the following numerical scale:
1 = Negative reaction
2 = Neutral reaction with potential negative aspects
3 = Neutral reaction (can be caused by either a lack of knowledge or interest)
4 = Neutral reaction with either better alternatives or positive with some
potential drawbacks. (this is either that VR also got negative effects, VR application can
help partly or that AR will change our life instead of VR)
5 = Positive reaction
If a score has 2 numbers, the interviewee developed an opinion during the conversation.
Which was the case with some VR specialists that did not think about the topic before.
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APPENDIX II: INTERVIEW QUESTIONS:
VR RESEARCHERS
1. How long have you been working in this field?
2. What is your specialism?
3. How long have you been in this job?
4. On average, how many patients do you treat a day?
5. How long do patients run with you during their treatment on average?
6. What is the percentage of obese patients?
7. What is your most common way to treat obesity patients?
8. What would you describe as main reason that your clients became obese?
9. How does an obesity curing plan look like?
10. What is your main audience group?
o Do/Did you work with children before?
o What are the difference between children and adults in treatment/?
11. What are motivations for children to keep joining?
12. Have you worked with younger children?
o What is specific to the child group 5-9 (tell about it)
13. Do you use VR applications, if yes: which ones, if not: are you knowledgeable on VR applications
and if, do you have ideas on how they could be used?
14. Did you see noticeable/potential differences with the VR treatment
o What was/could be the impact on physical progress
o What was/could be the impact on motivation
o What was/could be the impact on mental health
15. Were patients more enthusiastic with VR treatment? Do you see it as a motivational tool?
16. Did the time a patient was doing the treatment change? Was it longer/shorter/or neglect able
difference?
17. Do you see VR changing your field of work?
18. How do you see the future of VR in treatments? (motivational boosts vs efficiency?)
19. Would you embrace working with VR?
20. What would you love to see as VR development?
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VR SPECIALISTS
1. How long have you worked with VR?
2. What is your current position and how do you use VR in your work?
3. Do you use VR in your real-life and if, how?
4. How do you see VR developing in our daily life?
5. What advantages can VR bring to our life?
6. How do you see VR changing the future? (open minded question)
7. What potential disadvantages does it have?
8. What kind of applications do you develop normally?
9. Have you worked/are you working on applications specifically targeted towards children?
10. Have you worked with therapy treatments?
o If so, what was the impact/results
o If not, would you consider it
11. Do you think VR will change patient treatments and how?
12. What could be benefits by using a VR treatment?
13. What is a noticeable difference between VR for children and adults
14. What is specific to the child group 5-9 (tell about it)
15. Have you experience with VR treatments for children?
16. What do you know of obesity (tell about it)
17. What would be your first idea of treating this for children
18. How do you think this will impact children compared with original treatments?
19. What can be potential harms in treatment? If no ideas: elaborate on possibilities and ask their
opinion
20. Are VR treatments able to replace or augment existing therapies?
21. Do you see VR treatments happen more often and why (not)?
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CHILD OBESITY SPECIALISTS
1. What is your exact specialization?
2. Do you normally work with patients/what is your current research area?
o What kind of patients do you normally have?
o Do you also work with children?
3. How long have you worked with obesity/what do you know of it?
o Have you worked with obesity patients?
o How do you generally treat obesity patients?
4. What are the most common causes/most relevant causes of your obesity patients?
5. How long does an obese person stay in the treatment?’
6. What are your audience groups? (do you treat whole families?)
7. What is the difference in treating a child and an adult?
8. What is specific to the child group 5-9 (tell about it)
9. Have you worked with obese children before?
o If so, how do you treat them? If no, why not?
10. What are the trigger effects of obesity for children and how do they differ from adults?
11. What do you think/know of VR in general?
12. Have you worked with VR treatments before?
o If so, which one did you use and what was the outcome
o If no, explain
13. What do you think of VR treatments?
14. Would you use VR treatments and why?
15. Do, and if so how, you see VR change your field of work?
16. What would you see as positive effects of VR treatments?
17. What do you see as downsides?
18. Do you think VR treatments can help patients and how?
19. What would be the importance of VR in 5 years?
20. Would patients benefit from VR and in which way?
95
APPENDIX IIIA: LANDSCAPE DESIGN
Figure 24: Mountain example (Riyad, 2017).
Figure 25: Map overview example (NickKNumber1, 2014).
96
Figure 26: Village overview example 1 (Polysquid, 2015).
Figure 27: Village overview example 2 (Polysquid, 2015).
97
Figure 28: HTC Vive "The Lab" parabolic point teleport function (Serrano, 2016).
Figure 29: Clash of Clans example (Clash of clans, 2017).
1) The town hall located in the middle of the field.
2) The remaining time of the game. This will also be implemented in the VR game.
3) The amount of resources of the player. The layout will be roughly the same on the mobile application.
98
APPENDIX IIIB: DESIGN STYLE
Figure 30: First person view of enemy (Propagame, 2016).
Figure 31: "Cool" carrot archer (LebedevArtem, 2015A)
99
Figure 32: Carrot arrows (McGlinchey, 2015).
Figure 33: Beetroot reindeer rider soldier (Matheos-Fairey, 2015).
100
Figure 34: Hero example models (Dinges, 2017).
101
Figure 35: Battle reindeer (Reynolds, 2013).
Figure 36: Avocado shield of the broccoli soldier (Etsy, 2015).
102
Figure 37: Broccoli soldier (LebedevArtem, 2015C).
Figure 38: Evil burger example, too "scary" to use this image, but design should be in line with this hostility (Hawanja, 2009).
103
Figure 39: Burger example, needs to be customised to become "evil" (Mellinger, 2014).
Figure 40: Evil French fry archer (McCann, 2017).
104
Figure 41: Evil pizza boss (Red Nose Day, 2011).
Figure 42: Pizza boss texture example (HaHaHarls, 2015)
105
Figure 43: Weapon examples (Museblock, 2012).
Figure 44: Building example 1 (Bitgem, 2011).
106
Figure 45: Building example 2 (Bitgem, 2011).
