eSports gamers and the new WHO physical activity guidelines.
The World Health Organisation (WHO) publishes physical activity guidelines designed to offer physical and mental health benefits and mitigate health risks (1). The latest guidelines, published in 2020, have been expanded to cover recommendations to limit sedentary behaviour due to the evidence that has built over the last decade linking sedentary behaviour and adverse health effects. eSports gamers have high levels of sedentary behaviour as they spend a long time sitting in front of screens whilst training and competing (14) and so this review paper will examine the adherence of gamers to the WHO recommendations and provide some guidance to coaches working with gamers.
The WHO states that regular physical activity has a number of health benefits including reduced rates of all-cause mortality, coronary heart disease, type 2 diabetes and some forms of cancer and has mental health benefits including the reduction of symptoms associated with anxiety and depression (1). In order to achieve these benefits the WHO sets out four activity recommendations (for adults aged 18-64):
- All adults should undertake regular physical activity.
- Adults should perform at least 150-300 minutes of moderate-intensity aerobic physical activity throughout the week or at least 75-150 minutes of vigorous-intensity activity (or a combination of the two)
- For additional benefits adults should aim for more than 300 minutes of moderate-intensity activity, or 150 minutes vigorous aerobic activity (or a combination thereof).
- Muscle strengthening activities should be performed on at least 2 days per week.
The WHO’s Every Move Counts campaign video.
The 2012 European Social Survey (2) found that 60.8% of adult males and 62.1% of female respondents achieved the activity recomendation of at least 150mins moderate to vigorous activity per week. When broken down by age groups the 18-24 age group had the lowest level of activity (of those pre-retirement age). This is relevant to eSports gamers as according to the 2019 survey of German eSports Gamers (3) this low activity group fits the demographic of the average gamer (23 years old, with the average age of retired gamers being 26 and 92% of respondents being male it appears that gaming in Germany is very much a young man's sport). Given that the mean time spent in sedentary behaviours was 7.7±3.6 hours per day this could indicate that gamers are a very high risk group for not meeting physical activity targets, however the survey revealed that 66% of German gamers reached the 150 hours per week target. This percentage was higher than the European average and much higher than the German male average (48%). A positive association has been found between self-reported wellness and the frequency of physical activity participation (9) and correspondingly the majority of gamers reported their health status as being between excellent and good with only 5% reporting poor or very poor health.
In contrast to these positive German findings a recent study of American collegiate gamers (4) found that they only exercised an average of 1.7±1.9 day per week (some previous guidelines have recommend at least 5 days per week (15) and indeed the aged matched control group of students in the study achieved 4.8±1.2 days/week). The American gamers also had a higher game time than their German counterparts (32h/w compared to 24h/w) and the American gamers had higher levels of other recreational computer usage than the study control group, further increasing the time they spent displaying sedentary behaviours.
Another factor which can affect a gamer's attainment of physical activity targets is the level at which they play (4,10). High level professional teams will have access to health and fitness professionals and structures in place to encourage physical activity (4), with elite gamers undertaking one hour per day of physical training (11). These starkly contrasting results between the American collegiate, German and world elite gamers show that a fitness coach working with gamers should not make assumptions based on preconceptions of their lifestyle, but conduct a personalised needs analysis when designing exercise interventions.
Whilst the WHO does state that higher levels of activity may help management of weight and adiposity (1) care should be taken when assessing these in gamers. When compared to an age matched group of students, American collegiate gamers had significantly higher levels of body fat and significantly lower lean body mass measurements (4), with the lean body mass being so low that it would place them in the 10th percentile of Americans overall (5). This low lean body mass, combined with the relative inactivity previously discussed, places the gamers at a higher risk of disease and injury than the general population (4). However, despite these differences in body composition there was no significant difference between the BMIs of the gamer and control groups. A recent international survey of gamers also found that the majority of gamers were of a healthy weight or marginally pre-obese (10) and that in Australia and the USA gamers were more likely to have a normal BMI than the general population. These result combined show that BMI and body weight may not be useful measures when assessing gamers.
Some new additions to the 2020 WHO guidelines are the sedentary behaviour recommendations (1). Whilst they state that there is insufficient evidence to lay down specific time limit guidelines the WHO does recommend that sedentary behaviour should be limited, however this is obviously difficult for gamers who can spend up to eight hours per day training and competing (3). The UK Chief Medical Officers came to a similar conclusion that there is insufficient evidence to set specific limits, but does go slightly further than the WHO in recommending that long periods of inactivity should be broken up with periods of at least light exercise (7). Both the UK and WHO have dropped the requirement for physical activity to be a minimum of 10 minutes (1,7) and therefore these short periods of activity or 'movement breaks' can count towards the overall physical activity targets. Whilst the inclusion of movement breaks in a gamer's day may therefore help to meet the minimum physical activity targets they may not be enough to offset the detrimental affects of prolonged sitting as the WHO states that people who sit for long periods should aim to do more than the recommended levels of activity and for the best results aim for moderate to vigorous activity (1). Results from a large scale study using accelerometers to measure activity levels in American adults (17) also found that extra activity for active individuals made little difference to mortality rates, but in those classed as sedentary replacing 1 hour of sedentary time with light activity reduced mortality rates by 18% and with moderate-to-vigorous-intensity by 42%. Movement breaks will help a gamer to achieve an extra hour of light activity time, but it is unlikely that a gamer will perform vigorous activity multiple times a day during movement breaks and so there remains a need for dedicated training sessions in order to include vigorous activity in a gamer's training program.
None of the studies into gamers health quoted so far have directly reported on if the gamers met the WHO requirements for strength training. These investigations are not unique in overlooking the strength training guideline, indeed they are often described as the 'forgotten guideline' (6,7,13). Strain et al. (6) looking at adherence to the WHO guidelines in Scottish adults found that only half as many people met the muscle strengthening guidelines compared to the aerobic activity guidelines and therefore question the emphasis placed on the aerobic guidelines in public health messages. Similarly Bennie et al's review paper looking at strength training and chronic disease (13) found that only 10-30% of adults met the ≥2 sessions per week guideline (looking at studies from several large countries) and states that strength training has been largely overlooked in chronic disease prevention.
Muscular weakness in young adults has been shown to have a long term correlation to health problems (8). In a 30 year follow-up study of 1.2 million Swedish military conscripts strong associations were found between muscular weakness and disability in later life (as assessed by the participant claiming disability pension benefits) and a combination of muscular weakness and low aerobic fitness was described as being an especially important risk factor. Given the similar demographic between these young male conscripts and the average gamer (3,11) these findings further highlight the importance of strength training for gamers. Coaches working with gamers therefore need to consider all parts of the WHO guidelines, aerobic and strength, when designing an activity/fitness programs. This statement is supported by findings that it is a combination of aerobic and strength training that is the most beneficial to the prevention and management of chronic health conditions, compared to an either/or approach (13).
When discussing strength training for health the question arises as to what exactly constitutes strength training. Some reviews have concluded that many activities provide a sufficient stimulus to be deemed muscle-strengthening in the general population ranging from sports such as athletics, climbing, cycling, dancing, running and skiing to activities of daily living such as carrying shopping and gardening (6,7,12). If one accepts such a wide range of qualifying activities then the strength guideline adherence rate amongst the German gamers previously discussed would be very high, however if the definition of strength training activities is narrowed to only include exercise with the intent purpose of muscle strengthening, including body weight exercises, free weights, machines etc. (13) then compliance would drop to 36% (3) roughly in line with the German average (16). The WHO states that muscle-strengthening activities should involve all major muscle groups and be performed at moderate or greater intensities. Where the research does agree is that there has to be some element of physical loading in the activity that is above what is usually experienced by the individual in order to stimulate an adaptation (6,12). Again it will fall on the coach to decide upon appropriate activities in order to achieve the desired adaptation (strength gains) in the individual gamer, but it may be worth favouring activities which induce higher loads or impacts on the body in order to maintain bone health (7,12). For example, resistance training is more beneficial to bone health than cycling (7) and rather than upping a gamer's cycling intensity in order to chase strength gains it may be worth keeping cycling as an aerobic activity and adding resistance training exercises to the gamers plan as these will be better at inducing strength changes and have addition benefits to bone health.
In conclusion, whilst gamers display high levels of sedentary behaviour coaches should not assume that that makes them inactive, there are groups within the gaming community who do regularly meet the WHO minimum recommendations for physical activity. That does not mean that these gamers should become complacent though, as the WHO states that in order to offset the detrimental effects of a gamer's sedentary behaviour high levels of moderate to vigorous intensity exercise are required. Prolonged gaming time should be broken up with regular movement breaks (which also help to accumulate activity time) and finally, special emphasis should be given to strength training activities as this is the WHO recommendation which is most often overlooked.
References
1. World Health Organisation. (2020). World Health Organisation guidelines on physical activity and sedentary behaviour. (Link)
2. Marques, A., Sarmento, H., Martins, J., & Nunes, L. (2015). Prevalence of physical activity in European adults - compliance with the World Health Organisation's physical activity guidelines. Preventive Medicine 81, 333-338. (Link)
3. Rudolf, K., Bickmann, P., Froböse, I., Tholl, C., Wechsler, K., & Grieben, C. (2020). Demographics and health behaviours of video game and eSports players in Germany: The eSports study 2019. International Journal of Environmental Research and Public Health, 17, 1870. (Link)
4. DiFrancisco-Donoghue, J., Werner, W., Douris, P., & Zwibel, H. (2020). eSports players got muscle? Competitive video game players' physical activity, body fat, bone mineral content and muscle mass in comparison to matched controls. Journal of Sport and Health Science, 00, 1-6. (Link)
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7. Department of Health and Social Care. (2019). UK Chief Medical Officers' physical activity guidelines. (Link)
8. Henriksson, H., Henriksson, P., Tynelius, P., & Ortega, F. (2019). Muscular weakness in adolescence is associated with disability 30 years later: a population-based cohort study of 1.2 million men. British Journal of Sports Medicine. 53(19), 1221-1230. (Link)
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10. Trotter, M., Coulter, T., Davis, P., Poulus, D., & Polman, R. (2020). The association between eSports participation, health and physical activity behaviour. International Journal of Environmental Research and Public Health, 17(9), 7329. (Link)
11. Kari, T., & Karhulahti, V. (2016). Do e-athletes move? A study on training and physical exercise in elite e-sports. International Journal of Gaming and Computer-Mediated Simulations, 8(4), 53-66. (Link)
12. Foster, C., & Armstrong, M. (2018). What types of physical activities are effective in developing muscle and bone strength and balance? Journal of Frailty, Sarcopenia and Falls, 3(2), 58-65. (Link)
13. Bennie, J., Shakespear-Druery, J., & De Cocker, K. (2020). Muscle-strengthening exercise epidemiology: A new frontier in chronic disease prevention. Sports Med - Open, 6, 40. (Link)
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15. Department of Health and Social Care. (2011). UK physical activity guidelines. (Link)
16. Bennie, J., De Cocker, K., Smith, J., & Wiesner, G. (2020). The epidemiology of muscle-strengthening exercise in Europe: A 28-country comparison including 280,605 adults. PLoS ONE, 15(11), e0242220. (Link)
17. Matthews, C., Kozey Keadle, S., Troiano, R., Kahle, L., Koster, A., Brychta, R., Van Domelen, D. Caserotti, P., Chen, K., Harris, T., & berrigan, D. (2016). Accelerometer-measured dose-response for physical activity, sedentary time, and mortality in US adults.American Journal of Clinical Nutrition, 104(5), 1424-1432. (Link)