A Preliminary Randomized Crossover Trial Comparing Acute Glucose and Physiological Responses to Active Video Gaming and Traditional Exercise in Sedentary Office Workers

#

Reviewer comment

Response to the reviewer

1

General assessment: The study presents a crossover design, rigorous experimental control, well-demonstrated physiological equivalence between AVG and MICT, and practical relevance for a sedentary population.

Thank you very much for your comment.

2

Title: The title is well-described and engaging.

Thank you very much for your comment.

3

Abstract: The abstract is well-structured. However, I suggest stating the study objective more clearly. It would also be important to better detail in the methods section how and where the study was conducted, as well as to address ethical considerations. The conclusion should directly respond to the objective. The objective should be consistent with the one presented in the introduction.

We appreciate the reviewer’s valuable observation. The abstract was revised to improve consistency with the Introduction by clarifying the main study objective and ensuring that the conclusions directly address the stated objective. In addition, the Methods section of the abstract was expanded to better describe the study design, participant characteristics, and study setting.

4

Introduction: The introduction is well-written. I believe additional studies that have addressed the same topic could be included, both nationally and internationally. The introduction presented the objective, but I felt the lack of a more explicit and clear hypothesis. Additionally, the rationale for the study could be stronger: why compare with treadmill exercise? Is there evidence supporting this choice?

Thank you very much for your observation. A paragraph summarizing studies similar to the present investigation was added; however, these studies did not use active video games (AVG) as a variable. There are currently very few studies comparing glucose responses across exercise modalities involving AVGs. Furthermore, to justify the inclusion of the MICT session, it was noted that moderate-intensity continuous exercise is among the most commonly performed forms of exercise worldwide.

5

Methods: The study design is a strength. It is well-written and detailed. I suggest adding: why was the sample size 17 participants? Was there a sample size calculation?

Thank you very much for your comment. The sample size was calculated a priori and reported in the first paragraph of the Results section.

6

Inclusion and exclusion criteria could be more detailed.

We appreciate your comment. A paragraph was added providing more detailed information on the study's inclusion criteria.

7

The text mentions "overweight/obese" and "sedentary" without specifying objective instruments such as IPAQ or accelerometry to define sedentary behavior. Visual BMI classification (greater than or equal to 25) is used, but there is no mention of body fat percentage or waist circumference.

Are there other studies that used these criteria? It should also be clarified whether blood glucose is the primary outcome of the study.

Thank you very much for your comment. Additional information was included specifying that physical activity level and sedentary time were assessed using the IPAQ-SF. Considering that the study sample was physically inactive and spent prolonged time in sedentary behaviors, overweight (25–29.9 kg/m²) and obesity (≥30 kg/m²) classifications were assigned based on BMI.

8

Results: The tables and figures are well organized. A table presenting the sociodemographic data of participants separated by group would be interesting, since the control condition showed results with little difference. It would be important to detail whether all participants completed all conditions.

Thank you very much for your comment. Sociodemographic information was not presented separately by sex (male and female) to avoid suggesting sex-based comparisons, as the primary objective of the study focused on the acute response to exercise rather than sex differences. Additionally, the sample size was insufficient for stratified analyses, and the study was designed as a preliminary investigation. Nevertheless, the data for each condition and variable are presented within their corresponding sections. Furthermore, the first paragraph of the Results section states that there was no participant attrition and that all participants completed the three study conditions within the established timeframe.

9

Normality and sphericity tests such as Shapiro-Wilk and Mauchly are not mentioned, although they are prerequisites for repeated measures ANOVA. Regarding the figures, they were not included in the fragment available for analysis, making it impossible to assess the quality of the graphical presentation.

Thank you very much for your comment. Although some measurements showed a non-normal distribution, ANOVA is considered relatively robust to moderate deviations from normality.

10

Discussion: The discussion is well-described. Here are some suggestions. The differential glycemic reduction (AVG greater than MICT) is underdiscussed. This is the most innovative finding of the study, but the discussion does not offer convincing physiological or metabolic mechanisms. Why would boxing as AVG reduce blood glucose more than treadmill as MICT, even with comparable intensity? Unexplored possibilities include greater total muscle activation, type II fiber recruitment, the eccentric component of punches, catecholamine release, or the effect of pleasure and enjoyment on glucose metabolism.

We appreciate this insightful observation. The Discussion section was expanded to further explore potential physiological and metabolic mechanisms underlying the capillary glucose reductions observed after the AVG condition. Specifically, we added information on whole-body muscular involvement associated with boxing-based AVG, the potential influence of movement characteristics, and eccentric muscular components related to punching actions.

We also acknowledged that these mechanisms remain speculative, as they were not directly measured in the present study, and current evidence regarding eccentric exercise and glycemic regulation remains limited and inconsistent. In addition, most of the literature focuses on running.

Additionally, we briefly discussed the possible contribution of greater enjoyment and exercise engagement during AVG participation to psychophysiological responses to exercise.

11

The sample size is not discussed as a limitation. The discussion acknowledges that the effects are acute, but does not mention that 17 participants is a small sample, even for a crossover design. Null findings, such as differences in blood glucose between conditions immediately post-exercise, may reflect lack of statistical power.

We appreciate the highlighting of this point. A statement acknowledging the relatively small sample size has now been added to the Discussion section’s limitations and future studies.

12

There is a lack of comparison with the existing literature on AVG versus traditional exercise. How many studies have compared AVG and MICT? Are the heart rate and energy expenditure findings consistent? The discussion could better situate the results within the context of the published literature. Selection bias is not addressed.

We appreciate the reviewer’s comment. We expanded the Discussion section to better contextualize our findings within the existing literature comparing AVG and MICT. Previous studies, primarily in individuals with type 1 diabetes or healthy adults, have reported similar physiological and glycemic responses between AVG and traditional exercise when intensity is matched. We also addressed potential selection bias by acknowledging that participants may have had a positive predisposition toward AVG participation, which could have influenced enjoyment responses. This limitation was added to the Discussion, and future studies were encouraged to assess participants’ prior attitudes toward AVG before enrollment.

13

Participants who volunteer for a study on active video games may have a priori greater interest or positive predisposition toward AVG, which could inflate enjoyment measures.

We appreciate this observation. Although participants had no prior experience with active video games, volunteers in this study may have had a greater interest or a positive predisposition toward AVG participation, which could have influenced enjoyment responses. A note on this consideration for future studies was included.

14

The practical application for office workers is discussed, but without considering logistical limitations such as space, noise, privacy, and equipment required to implement AVG in the office environment.

We appreciate this important observation. The practical implications section was revised to acknowledge potential logistical barriers to implementing AVG interventions in workplace environments, including considerations of space, noise, privacy, scheduling, and equipment availability.

15

Conclusion: The conclusion is succinct and aligned with the presented results.

Thank you very much for your comment.

#

Reviewer comment

Response to the reviewer

1

Title: Change to, “A pilot randomized…”. here and in other relevant locations of the paper. Given sample size, recruitment, design, etc. The study is pilot-level.

Thank you very much for your observation. We used the term “preliminary” because the aim of the study was to evaluate exercise conditions; therefore, we considered this term to be more appropriate.

2

Lines 122-123: List how people were recruited in the text.

We greatly appreciate the reviewer’s comment. In response, we added a paragraph describing the participant recruitment process, including how the study invitation was distributed, the eligibility criteria, the number of individuals who expressed interest, and the final number of participants who completed the study.

3

Lines 122-127: This information seems out of place because we don’t yet know how these data were collected. Consider a re-org or even delete given this is in the results.

Thank you very much for your observation. Part of the text was relocated, specifically to the Procedures section, to improve clarity and comprehension.

4

Section 2.1: How many participants expressed interested, were screened, excluded after screening, etc. These details are absent.

Thank you very much for the comment. This point was also addressed in our response to the previous observation, where we added a detailed description of the participant recruitment and screening process.

5

Lines 147-158: Bullet points should be avoided. Repurpose to paragraph format for maybe create a study schematic to couple with Figure 1 (which is good). Can more details also be included here?

Thank you very much for your comment. We removed the bullet points and revised the paragraphs so that they followed the same format as the remaining sections of the manuscript. Additionally, more details regarding the AVG session procedure were included, specifically a table describing the exercises performed by the participants.

6

Line 147: Completely at random or block randomization?

We appreciate your observation. A completely randomized allocation was performed; therefore, the term “completely randomized” was added to the manuscript.

7

Lines 303-307: There were more limitations that what was included here.

This section was expanded. Thanks for the observation.

8

Discussion: How do these findings inform interventions, worksite health promotion, and clinical practice? There will be costs and regulation for gaming at the workplace and role of implementation should be considered. This warrants further discussion.

We appreciate the reviewer’s comment. We expanded the Discussion section to address the implications of AVG for worksite health promotion and clinical practice. We highlighted that AVG may be a feasible and engaging strategy to increase physical activity among sedentary workers. We also acknowledged potential implementation challenges, including equipment costs, space availability, institutional policies, and access to technology. Finally, we suggested that future studies should evaluate the long-term feasibility and cost-effectiveness of AVG interventions in real-world workplace settings.

9

Line 324: Be sure abbreviations are used consistently.

The abbreviations were reviewed to ensure consistency throughout the manuscript.

10

Make any changes to the abstract that align with those in the text.

Changes to the abstract have been made to align more precisely with the objective, analysis, and conclusion

#

Reviewer comment

Response to reviewer

1

The manuscript investigates the acute effects of active video gaming (AVG) versus moderate-intensity continuous training (MICT) on capillary blood glucose and perceptual responses in sedentary office workers with obesity. While the randomized crossover design is a strength and the research topic is timely, there are several methodological, statistical, and formatting issues that should be addressed before the manuscript can be considered for publication. My detailed comments are as follows:

Thank you very much for your time and careful review of the manuscript. We truly appreciate all your observations and valuable feedback.

2

The two-way repeated measures ANOVA revealed no significant main effect of condition (p = 0.840) and no significant time × condition interaction (p = 0.084). However, the authors proceeded to perform simple effects analyses and concluded that AVG significantly reduced blood glucose. Performing post hoc pairwise comparisons in the absence of a significant interaction effect increases the risk of Type I error. It is recommended that the authors revise their interpretation to more accurately reflect the overall ANOVA results.

We appreciate your comment. We revised the definitive tone of the conclusion to a more cautious interpretation. Additionally, greater emphasis was placed in both the Results and Conclusion sections on the absence of a significant interaction effect, and the findings are now discussed more carefully. Finally, the effect size (Cohen’s d) for the pairwise comparisons was added.

3

Both the Abstract and the Conclusions sections definitively claim that AVG promoted acute reductions in capillary blood glucose. Given that the overall statistical model did not show a significant difference between the exercise modalities and the control condition, these statements appear somewhat overstated and could be misinterpreted. The conclusions should be toned down to align strictly with the statistical findings.

Thank you very much for your comment. The conclusions in both the abstract and the manuscript were revised and tempered to ensure consistency with the statistical analysis.

4

In Section 3.1, the 95% CI [3.288, 11.751] is incorrectly reported alongside the main effect of time. Please clarify what this CI represents and move it to the appropriate context (e.g., post hoc comparisons).

Thank you very much for your observation. We removed the 95% CI because it had been inadvertently included in that section.

5

The baseline capillary blood glucose for the AVG condition is reported as 116.9 ± 41.0 mg/dL. This extreme standard deviation suggests either severe data skewness or the presence of significant outliers, which might violate the assumptions of ANOVA. Furthermore, a mean fasting glucose of around 114–116 mg/dL places the average participant in the pre-diabetic category. The authors should clarify the glycemic status of their participants in the inclusion/exclusion criteria and consider non-parametric tests or data transformation if normality assumptions are not met.

Thank you very much for your observation. Although some study conditions showed significant results in the normality tests while others did not, we retained the two-way repeated-measures ANOVA because this analysis is considered relatively robust to moderate deviations from normality, particularly in crossover and within-subject study designs. Additionally, the study involved repeated measurements obtained from the same participants under all experimental conditions, making repeated-measures ANOVA the most appropriate approach for simultaneously evaluating condition, time, and interaction effects. This clarification was added to the Statistical Analysis section of the manuscript.

6

The study measures glucose 24 hours post-exercise but lacks rigorous control or monitoring of the participants' dietary intake during this recovery window. Since capillary blood glucose is highly sensitive to diet, merely instructing participants to "eat what you usually eat" might be insufficient. This represents a potential confounding variable and could be emphasized more clearly as a limitation in the Discussion.

We thank the reviewer for this important observation. We agree that dietary intake during the 24-hour recovery period is a potential confounding factor when interpreting capillary blood glucose responses, given the sensitivity of these responses to meal composition, timing, and caloric intake. We have now expanded the Limitations section in the Discussion to more clearly acknowledge this issue and its potential influence on the 24-hour glucose outcomes. Additionally, we note that the repeated-measures crossover design may have reduced some interindividual variability; however, future studies should incorporate dietary logs, standardized meals, or continuous glucose monitoring to better isolate the effects of exercise modality on glycemic responses.

7

The exact same participant characteristics (age, mass, height, BMI, muscular mass, and fat mass) are reported twice in the text: first in section "2.1 Participants" and again at the beginning of section "3. Results". This redundancy should be eliminated. It is recommended to present this data in a single "Table 1 (Participant Characteristics)" and simply reference the table in the text.

Thank you very much for your comment. The data were removed from Section 2.1. Additionally, a table (Table 2) containing the characteristics of the participants was created to facilitate interpretation and provide readers with easier access to this information.

8

In the demographic description, the term "mass" is used (e.g., mass of 85.6 ± 19.8 kg). While scientifically acceptable, it would be more precise and symmetrical with the surrounding text to use "body mass", especially since "muscular mass" and "fat mass" are used immediately after.

We appreciate your comment. The term “body” was added to maintain consistency with the other variables.

9

The manuscript consistently uses the abbreviation "MICT" for Moderate Intensity Continuous Training throughout the text and in the Abbreviations list. However, in Table 1, this condition is labeled as "Traditional". This should be corrected to "MICT" for consistency.

Thank you very much for your observation. We addressed the comment and changed the label to MICT.

10

The caption for Figure 3 lacks necessary details and is not entirely self-explanatory. The authors should specify the exact time points or conditions for the measurements shown (e.g., explicitly stating that HR and RPE represent the averages taken during the 30-minute intervention, while Enjoyment represents post-intervention scores).

Thank you very much for your comment. The caption of Table 3 was revised to ensure that the information was more precise.

11

The presentation of results can be further optimized. It is recommended to expand the tables to include detailed statistical outputs (e.g., F-values, p-values, and effect sizes from the two-way ANOVA) to declutter the text. Once data and statistics are clearly presented in the tables, avoid redundantly repeating the exact numerical values in the main text.

We greatly appreciate your comment and the idea provided. We created a table (Table 3) including the statistical results of the two-way ANOVA, incorporating the complete statistical model and the main effects.

12

For the figures (particularly Figure 2), please consider adding individual data points (scatter plots) alongside the mean and SD bars. This will provide greater transparency regarding data distribution, which is especially important given the large standard deviations observed in the capillary blood glucose data.

Thank you very much for your comment. We created a figure similar to the previous one; however, we additionally included the individual data of each participant for every condition and measurement.

#

Reviewer comment

Comment to reviewer

1

The manuscript inconsistently alternates between the spellings "active video games" and "active videogames"(Line 83) throughout the text. Please choose one consistent spelling convention for the entire manuscript.

Thank you for the observation. The term “video games” was retained because it is more commonly used in formal academic documents. In contrast, “videogames” is more frequently used in gaming or technology blogs.

2

The current layout and headers in Table 3 are non-standard and visually cluttered. The equals signs in the headers (e.g., "F=", "P=") are unnecessary and should be removed, Please use standard italicized letters (F, p,). For the main effects, it is not necessary to list all the individual levels in the headers (e.g., "AVG-MICT-Control" or "Baseline-Immediately after-After 24h"). Please simplify these headings to standard factor names: "Condition", "Time", and the interaction "Condition × Time".

We greatly appreciate your comment. We removed the equal sign from F and p and changed them to italic font. Finally, we replaced the headings with the factor names: condition and time. In this way, we believe the table is much improved.