Gamification and game-based learning for education in healthy lifestyle habits in children Doctoral thesis Extended abstract in English Ph.D Student Nazaret Gómez del Río Supervisors: Carina Soledad González González Francisco José García Peñalvo Salamanca, June 2021 1 INTRODUCTION Childhood obesity and current status of the problem In 2004, the WHO declared obesity to be the epidemic of the 21st century after it reached global proportions, although as early as 1998 in its World Health Report it spoke of obesity as an emerging health problem. Progress in the fight against childhood obesity has been slow and irregular, and in 2014 the Commission on Ending Childhood Obesity was established with the aim of reviewing existing strategies, developing a set of recommendations aimed at combating obesity adapted to different global contexts [1, 2]. This epidemic mainly affects developed and developing countries, although it is no longer exclusive to high-income countries and is beginning to be present in poor countries, affecting the entire population from childhood to adulthood. Obesity has been increasing progressively in recent decades, and in the pediatric population it has become one of the most serious public health problems, estimating that about 41 million children under five years of age were overweight or obese in 2016, and if current trends continue, the number will increase to 70 million by 2025 [1, 3]. Those responsible for the growth of childhood obesity figures in the world are the changes in lifestyles, and the social and occupational development that most populations have undergone traditional foods have been replaced by foods richer in calories, fats, and sugars, in addition to favoring a poor diet based on pastries (food industry) snacks, salt and poor in fruit, vegetables, legumes and fish. Little or no physical activity is performed due, among other reasons, to the higher level of urbanization and mechanization, the evolution of transport systems, changes in social and health policies, the urban approach that leaves little space for green areas, and the long time spent by schoolchildren in sedentary leisure activities in front of the computer or television are some of them . In addition, childhood obesity has a complex and multifactorial etiology, in which genetic and environmental factors are involved . Although there is some genetic predisposition, unhealthy eating habits and sedentary lifestyle are the main factors in its appearance . This is confirmed by the low proportion of patients diagnosed with obesity due to genetic disease or hormonal disorders, as well as the association between the physical activity of fathers and mothers and their children and their weight, thus demonstrating that weight is determined by modifiable factors, not only by genes . Nor can we underestimate the influence of other risk factors such as parental obesity, low educational and socioeconomic status of the family, having few hours of sleep, high birth weight, or exclusive breastfeeding, which have been shown to play an important role in the development and maintenance of obesity in adulthood in different populations studied [8-13]. For example, in countries with a high per capita income, children from families with a lower socioeconomic status are more likely to be overweight or obese compared to those children from families with a higher socioeconomic status . 2 Spain has a high prevalence of obesity, with the Canary Islands and the south of the peninsula at the top of the list. The association between childhood obesity and risk factors for chronic diseases, its persistence into adulthood and the poor success in its treatment makes the efforts of governments and health agencies focus on prevention at this stage of life, knowing that most behaviors and habits are acquired at an early age, it becomes crucial to promote healthy lifestyles from all areas. In recent years, social policies, research and educational programs for prevention and treatment from different areas (school, society, families) have been appearing. In view of the above, we proposed the development of a study to assess the effectiveness of a gamified educational intervention model using active video games and motor games in changing attitudes and healthy habits in children with obesity compared to the current model of treatment carried out in doctors' offices, as well as to serve as a tool for the prevention and promotion of health in healthy lifestyles from the family environment. This research project was entitled PROVITAO, acronym for "Active Video Game Program for the Outpatient Treatment of Obesity", Ref OBE05. The intervention described and studied in this doctoral thesis is framed within this research project. Hypothesis and objectives The hypothesis we set out in this research is the following: "The proposed intervention is an effective tool to favor the acquisition of healthy habits in children and their families, and that it has an impact on the improvement of the quality of life, current and future, of minors suffering from childhood obesity." The main research objectives of this doctoral thesis are organized into general and specific objectives, as cited below. -General objectives: 1. to promote the acquisition and permanence of healthy life habits in overweight/obese children through health education. 2. To evaluate the influence of the educational intervention program in children with overweight/obesity. 3. 1. overweight/obese children. 2. To promote social awareness of the importance of childhood obesity prevention (short and long term complications, health and social costs). 3. -Specific objectives: 1. diagnose the situation of overweight/obese children in relation to their physical condition and needs. 2. To assess the previous habits and lifestyles (habits, customs and beliefs) of overweight children and their families. 3. To give truthful information about healthy behavioral habits, and to eliminate myths. 4. Create a family environment that reinforces the educational program on healthy eating habits and frequent physical activity. 3 5. Analyze the effectiveness of the intervention for the promotion of healthy habits, through periodic evaluations. 6. Communicate and disseminate the activities and results obtained to the entire scientific, medical and social community. 7. To measure the motivation of the child to the physical activity developed with motor games and active video games. This doctoral thesis is presented in the form of a compendium of articles whose original works are published in scientific journals indexed in the Journal Citation Reports (JCR), as detailed below: 1. González-González, C.S.; Gómez del Río, N.; Toledo-Delgado, P.A.; García- Peñalvo, F. (2021). Active game-based solutions for the treatment of childhood obesity. Sensors 2021, 21, 1266 (JCR, Q1). DOI: https://doi.org/10.3390/s21041266. Available at: https://www.mdpi.com/1424-8220/21/4/1266 2. Gómez del Río, N.; González-González, C.S.; Toledo-Delgado, P.A.; Muñoz-Cruz, V.; García-Peñalvo, F. (2020). Health Promotion for Childhood Obesity: An Approach Based on Self-Tracking of Data. Sensors 2020, 20, 3778. (JCR, Q1) DOI: https://doi.org/10.3390/s20133778. Available at: https://www.mdpi.com/1424-8220/20/13/3778 3. Gómez del Río, N.; González-González, C.S.; Martín-González, R.; Navarro- Adelantado, V.; Toledo-Delgado, P.A.; García-Peñalvo, F. (2019). Effects of a gamified educational program in the nutrition of children with obesity. Journal of medical systems, 43(7), 198. (JCR, Q1) DOI: 10.1007/s10916-019-1293-6 Available at: https://link.springer.com/article/10.1007/s10916-019-1293-6 In addition to the articles, which support the thesis modality by compendium of publications, other scientific contributions have been made, which are cited in the corresponding section, in addition to being included in the bibliographical references of the document. Therefore, we proceed to present a list of the publications related to the different objectives of the thesis, considering that, in responding to these, some objectives are closely linked and are answered (Table 0): Table 0. Relation of the objectives of the doctoral thesis with published results. General objetive Specific objetives Published results 1. To promote the acquisition and permanence of healthy lifestyle habits in overweight/obese 1. Diagnose the situation of overweight/obese children in relation to their physical condition and needs. Presentation of the design and gamified training program on healthy lifestyle habits [23,24]. 4 children through health education. 2. To assess the previous habits and lifestyles of overweight children and their families. 3. To give truthful information about healthy behavioral habits, and to eliminate myths. 4. Create a family environment that reinforces the educational program on healthy eating habits and frequent physical activity. Exposure of active video games and technological tools that complement the gamification of the program [25,26]. 2. To evaluate the influence of the educational intervention program in children with overweight/obesity. overweight/obesity. 5. Analyze the effectiveness of the intervention for the promotion of healthy habits, through periodic evaluations. Partial results of all study areas within the project. [25,27] Results focused on learning food-related habits [27,28]. Results focused on the use of sensors and ICT tools [24,29]. Exposure of the single case study to give a global view of the program . 7. To measure the child's motivation for the physical activity developed with motor games and active video games. Results on satisfaction with the games of program participants . 3. Promote social awareness of the importance of childhood obesity prevention (short- and long-term complications, health, and social costs). 6. Communicate and disseminate the activities and results obtained to the entire scientific, medical, and social community. Workshops conducted with minors in different schools on healthy lifestyle habits . 5 To achieve the objectives proposed in the doctoral thesis, a methodology divided into different phases was proposed. The methodological approach applied in the research was a mixed quasi-experimental approach for intervention in educational centers, hospitals, and case analysis, combining qualitative and quantitative techniques. EXPERIMENTAL RESEARCH The research design was quasi-experimental, longitudinal, and prospective for 3 years (2014-2017). There were no problems or risks derived from the study for the participants. The legal guardians of all participants have been informed and have signed a consent to use their data for the study and to share them with the scientific community. The processing, communication and transfer of personal data of all participating subjects complied with the provisions of Organic Law 15/1999, of 13 December, on the protection of personal data. The protocols used in the study were approved by the Ethics Committee of the Hospital Universitario de Canarias and the Ethics Committee of the University of La Laguna, Reference CEIBA2020-0410. The study was divided into two annual phases, in each of which the same intervention was repeated in different groups of subjects. Each annual intervention phase was designed to be carried out with an experimental group and a control group of 10 to 15 boys and girls aged 6 to 12 years, all of them from the northern area of the island of Tenerife. The inclusion criteria were age (6-12 years); body mass index (BMI) in the 97th percentile or higher; permission from the parents or legal guardians to participate in the study; no pathologies that would prevent them from participating in the study; and not having participated in another clinical trial in the last 12 months. The exclusion criteria were participation in a clinical trial during the last 12 months; that the children did not present cognitive impairment that would prevent them from participating in the project; and that they did not have basic network technologies at home (computer and internet) and television (only for the experimental group). The project will provide the rest of the technological tools required for the intervention at home (Kinect sensor, Wii console and Wii balance board) and in the group sessions. In Phase 1, the sample consisted of children selected from the Pediatric Outpatient Clinic of the University Hospital of the Canary Islands (HUC) who were undergoing outpatient treatment for childhood obesity. The Experimental Group (G1) consisted of 13 children with obesity/overweight (5 boys and 8 girls) who participated in the intervention program. The Control Group (G2) consisted of 10 obese/overweight children (7 boys and 3 girls) who did NOT participate in the intervention program. In Phase 2, because not enough participants were found to meet the inclusion criteria of the study at the HUC, participants were selected from different public education schools in the district of La Laguna. The Experimental Group (G3) consisted of 12 obese/overweight minors (5 boys and 7 girls) who participated in the intervention 6 program. The Control Group (G4) consisted of 11 obese/overweight children (4 boys and 7 girls) who did NOT participate in the intervention program. The assignment of the participants to the experimental and control groups in both phases was made according to the commitment and availability of the families to attend all the face-to-face sessions (experimental group) or only the evaluations (control group). Participants A total of 46 children between 6 and 12 years of age participated in this study, divided into an experimental group (25 children) and a control group (21 children). The educational level of the families was considered as a socioeconomic indicator, considering three categories: high (university studies); medium (secondary education) and low (no education or only primary education). Instruments The study involved the use of different instruments to analyze different data in each study area. The following variables were collected: name, sex, date of birth and age, place of residence, grade, educational center, anthropometric measurements (weight, height, skinfolds, and body perimeters to assess not only body mass index, but also the amount of fat, muscle and bone mass), and analytical parameters. The following instruments were used to measure body composition and biomedical measurements: digital weight with measuring rod, lipocaliper and caliper, inextensible tape measure, growth curve to determine percentiles, and blood tests were used to determine biochemical values (cholesterol, triglycerides, insulin, hormones). Also recorded at the time anthropometric measurements were taken date and time of measurement, clothing worn at the time of measurement. The scale and measuring rod were checked and calibrated frequently, and at least at the beginning of each day the measurements were taken. To analyze emotions during the intervention we used the Emodiana , an instrument that allows us to measure 10 basic emotions, represented with different expressions of a character associated with their corresponding labels, adjusted to the language used by the children. This instrument is represented as a target allowing the intensity of each emotion to be measured, on a Likert-type scale, with a 5 being the most intense emotion in the center and a 1 the weakest outside the target. It was used during the group intervention sessions at the beginning and end of each session. To assess the effort perceived by the participants when exercising, the Children's Perceived Effort Rating Table (CERT)  was used, this scale presents a range of intuitive numerical categories (1-10) and verbal expressions of effort widely understood by children and adolescents. It was used at the end of the group intervention sessions. To study the behavior and personality of the children we selected the BASC (Behavioral Assessment System for Children and Adolescents) Spanish adaptation of the Reynolds and Kamphaus questionnaire , it is a multidimensional questionnaire that measures 7 numerous aspects of behavior and personality. In the self-report the child or adolescent describes his or her emotions and perceptions and provides information on clinical scales (negative attitude towards school, negative attitude towards teachers, sensation seeking, atypicality, locus of control, somatization, social stress, anxiety, depression and sense of inadequacy) and adaptive scales (interpersonal relationships, relationships with parents, self-esteem and self-confidence). Four global dimensions were obtained: school maladjustment, clinical maladjustment, personal adjustment and a general index, the emotional symptoms index. To find out about physical activity habits and the perception of well-being, we have opted for an adaptation of the questionnaire designed by Manuel Delgado and Pablo Tercedor in 2002 in the "Strategy for intervention in health education from education" . The Adaptation of the Questionnaire on physical activity-sport and health-wellbeing is a 22- item questionnaire that assesses: physical activity status (physical activity or sport practiced, days and hours per week, hours of inactivity, etc.), enjoyment of physical activity, self-perception of motor competence and usefulness of physical activity and sport, diet, health and personal well-being. On the other hand, to determine adherence to and the quality index of the Mediterranean diet, considered to be heart-healthy, the KIDMED questionnaire was used . This test has 16 dichotomous items with affirmative or negative answers that include the main dietary indicators. The affirmative answers in the questions that represent a negative connotation in relation to the Mediterranean Diet (items 6, 12, 14 and 16) are worth -1 point, and the affirmative answers in the questions that represent a positive aspect in relation to the Mediterranean Diet are worth +1 point. If the answer is don't know/no answer, no points are given. Therefore, this index can range from -4 to 12. 8 Finally, to evaluate the children's video game player profile, we chose the Gamer Profile Test, an adaptation of the Questionnaire on use and attitudes towards video games by Alfageme, B., & Sánchez, P. , which is a questionnaire with a total of 12 questions that focus on the type of video games played by the child, the hours per week dedicated to them, and the values and beliefs regarding video games. As an exception, in phase 2 we designed a questionnaire entitled Child Health Report, in which we asked parents for their children's demographic data and medical information regarding health history (past illnesses), health problems (current illnesses) and medical treatment they were receiving in order to make an initial assessment, since these children were not selected from the hospital as was the case in the previous year. This report was under the data protection law and was only treated by the health personnel of the project for scientific purposes. This document was filled out only at the beginning of the study. For the collection and recording of the variables: heart rate, distance covered, time, speed and caloric expenditure, the biometric sensors used in the intervention and the movement sensors for the TANGO:H exercises were selected and studied as instruments . In the group intervention sessions, the wearable wristwatch + belt type heart rate monitors and accelerometers of the Decathlon brand (Geonaute Onmiles 600) were used; these commercial sensors have their own analysis software. On the other hand, the use of the TANGO:H platform is highlighted in the different sessions carried out in the project. Procedure The procedure for this study was as follows: First, the corresponding permissions and informed consent forms were requested. In Phase 1, approval for the research was requested from the Ethics Committee of the Hospital Universitario de Canarias, and in Phase 2, authorizations were also requested from the Territorial Directorate of Education of the Canary Islands Government and, subsequently, from the Administration in each participating center. Next, the study's medical professionals conducted the search for potential participants. Once the sample was selected, an informative letter was sent to the parents or legal guardians detailing the main characteristics of the study to be carried out, ensuring the anonymity of the data and the scientific purposes of the study. During a face-to-face meeting with the families, their doubts were clarified, and they were asked to participate in the study, either in the experimental or control group. The study sample was confirmed once the fathers, mothers or guardians who decided to participate signed the informed consent form. Finally, the study was conducted to coincide with the corresponding academic school year (September to June) for each annual phase. The work sessions were divided into three quarterly stages: intervention, creation of the vocational project and development of the vocational project (Figure 1). Evaluations using the instruments described in the 9 previous section were carried out before, during and at the end of each of the annual phases. Figure 1. Stages and instruments used in each annual phase. Educational Intervention First trimester During the first quarter of the intervention, the educational program was developed for the participating children, with a total of 12 sessions. All sessions were designed from a playful point of view, this meant that after each theoretical content a game was played to reinforce it (using motor games and the active video game TANGO:H as a review before each session), thus each session included a motor game designed explicitly for that content and its emotional impact was evaluated with the EMODIANA before and after the session. For the different activities that were worked on with the children, expository and participatory methods were used, through group dynamics, the use of debates and games, and the use of the EMODIANA. For the development of the sessions, different types of formative exercises (physical and cognitive and free) were created and adapted in TANGO:H Designer to work on healthy lifestyle habits in individual, collaborative, and competitive mode. In addition, a gamification module was added to TANGO:H Designer to be able to assign and create prizes and gifts, exercises with difficulty levels and time restrictions. During this phase, two weekly physical exercise sessions were also requested at home, using the Wii Balance Board with the Wii Fit Plus videogame, favoring physical activity Pre-intervention Design Sample selection Ethical consensts Pre-tests 1er Trimester Group sessions Motor Play + Active Videogames Home sesión with WII Family training 2do Trimester: Creation of Vocational Project Home sesión with WII Tele-sessions Videoconferences Virtual learning environments Supporting families and children. Group sessions 3er Timester: Development of Vocational Project Home sesión with WII Tele-sessions Videoconferences Virtual learning environments Supporting families and children. Group sessions Post- Intervention Post-tests Collect and análisis of data Analisys of data 10 in the family context. For this purpose, the sessions with the Wii were selected and planned to work different body areas with each session. In addition to the immediate feedback provided by the activities (score in TANGO:H, Wii; knowledge of point gains in the other face-to-face activities), their scores were transferred to a general ranking, which was made public to the group in the face-to-face sessions to gamify all the activities carried out in the intervention. On the other hand, serious mobile games and other Internet activities were recommended to promote healthy lifestyle habits to be carried out at home, such as: Diana eats healthy, Activilandia, Healthy heroes, Cool-E's revenge, among others. The place where the sessions were held was the sports facilities of the Aneja School, in La Laguna. The group sessions were held in the afternoon from 5 to 7 pm. For fathers, mothers and/or guardians, a single 120-minute educational session was established, where three topics were addressed: healthy lifestyle habits in nutrition and physical activity, obesity as a disease, and false beliefs about video games. Second and third trimester During the second and third trimester, the intervention was individual and home-based, supported by technologies and focused on the creation by the children themselves of a vocational project related to the discovery of healthy activities that they might like in their environment (change of habits towards healthier ones). The development of this phase consisted of programming a physical activity (second trimester) that they had to carry out autonomously (third trimester). Aspects such as resistance to change versus openness to experience and the perception of self-efficacy and the discovery of the resources of the immediate environment to implement healthy behaviors were worked on. This activity was tutored through a weekly videoconference session, accompanied by sessions on the Moodle platform where the work team guided, supported and dynamized the behavioral change of the children, in collaboration with their parents. Activities with the children included discussion of videos and podcasts related to change or resistance to it, dynamics to promote self-esteem within the group, dramatizations/role-playing, discovering their environment using computer applications and narratives. The gamification of this phase was carried out by awarding points according to the fulfillment of the activities and participation in them (for example, 10 points were awarded if they carried out an activity and 5 points if they participated in the forum) and at the end of each quarter a diploma was awarded with the different roles of the narrative used (pirates). The search for healthy activities organized by the municipalities and in the children's environment was not favorable, since, except for sports, there is a lack of free public offer of physical and healthy activities throughout the year that are appropriate to the interests of the children. This posed a difficulty for the development and execution of the healthy vocational project that could remain when the research team withdrew the direct intervention, as planned in this phase. Therefore, monthly meetings were included to reinforce the social component and commitment to the project and its objectives. 11 During the third quarter, monthly group sessions were held with the children in the experimental group, in which cognitive and social skills were addressed, focused on problem solving with peers, given the high frequency with which they are related to childhood obesity. For parents, training and orientation activities were carried out on a monthly basis, these appointments coincided with the monthly meetings of the participating children. The purpose of this activity was to support the development of the children's vocational project, as well as to resolve doubts regarding the use of the different technological tools (videoconference, Moodle platform, Classdojo). This led the research team to contact the town councils and associations in the area where the children lived to find out about the resources and healthy activities available when the parents reported the difficulties encountered, or to hold a workshop with the parents on the bullying suffered by some of them in their environment. The sessions of this phase were held at the School of Engineering and Technology of the University of La Laguna in the afternoon from 5 to 7 p.m. according to the availability of the families. In phase 2, the children were given the activities in a notebook in order to facilitate access to the activities as some parents reported connection problems (for example, not having a computer and it being difficult to do the tasks from a cell phone). Whorkshops in schools Focused on the topic of dissemination and promotion of healthy lifestyle habits and the importance of preventing childhood obesity, educational and interactive training workshops were held with students and teachers in the different schools that participated in the project. The schools where the workshops were held were the following: CEIP Las Mercedes, CEIP Aguere, CEIP Aneja, CEIP San Rosa de Lima, and CEIP La Verdellada belonging to San Cristobal de La Laguna, Tenerife, Spain. The activities were carried out for grades 3 to 6 of primary school (boys and girls from 8 to 12 years old). A total of 581 students and the teachers responsible for each class (16 teachers) from the five schools involved participated for three months. The age range of the teachers was 38 to 59 years, although 75% were older than 50 years (mean age=51.62). Most of the teachers who participated in the study were women (81.25%). 12 The activities carried out in the schools, aimed at students from third to sixth grade of primary school and the teachers responsible, were structured as follows: teaching hours and 45 minutes and gamified theoretical-practical activities, which included a brief presentation on the subject focused on healthy eating and games to improve healthy lifestyle habits in a gamified way using the Kahoot tool in a group setting (4-5 students per digital tablet) and continued with the performance of motor games and active video games using TANGO:H on an individual basis. In total, 17 Kahoots related to healthy eating were passed. Taking into account the reports of the gamified questionnaires that were passed, the knowledge about healthy eating in schools is 51%. The children had difficulties in the questions about the food pyramid, in the frequency of eating certain foods such as olive oil, or difficulties in distinguishing the types of meat (red, white). After conducting the group Kahoots and analyzing the knowledge and myths about food, we moved on to active games, which had physical exercises with content related to healthy eating. As an active video game we used TANGO:H. Overall satisfaction with the workshops was measured using a Likert scale (1=Very insufficient/inadequate; 5=Very good/Very adequate), and we can say that in the case of the overall intervention it was very high (4.69), as well as with the use of the active video game TANGO:H (4.75). Other variables measured related to satisfaction with the intervention were: time (4.69), session duration (4.44), use of Kahoot (4.67), educational content (4.63), program objectives (4.63). Variables related to dynamization were also measured, such as the knowledge of the facilitators (4.88), communication skills (4.63), their ability to answer questions (4.67) and their ability to create interest (4.75). RESULTS Nutritional knowledge throughout the study In this section, we analyze participants' responses involving their knowledge of healthy nutrition. In all cases, higher scores indicate better habits, knowledge and satisfaction. All variables involved in these analyses exhibit a normal distribution, according to the Kolmogorov-Smirnov test. Comparison of the means of the two groups at baseline indicates that both presented similar scores at the beginning of the study in the four indices studied. For each indicator, repeated measures analysis is performed, with group as an inter-subject factor and an intra-subject factor with three levels that we have named "Follow-up". Each level is defined by a phase of the intervention: the baseline (measures taken before starting the intervention), the immediate follow-up (evaluation carried out at the end of the face-to-face intervention phase), the long-term follow-up (evaluation carried out after the end of the intervention with the children and the withdrawal of the follow-ups). When the sphericity of the variance-covariance matrices is not met, the epsilon correction is performed using the Greenhouse-Geisser method. In the case of main effects of the intrasubjects factor, a posteriori analyses are performed with Bonferroni adjustment, likewise, if the main effects analysis does not meet the homogeneity of variances criterion, the Welch robust test is performed. The interaction between the Follow-up factor and Group is not significant (F(2,50) = 2.582; 13 p = .086; η2p = .094; P = .492), nor is there a significant effect of Group (F(1,25) = 0.503; p = .485; η2p = .020; P = .105). In contrast, there is significant effect of the Follow-up factor (F(2,50) = 28.647; p = .000; η2p = .532; P ≥ 0. 999), attending to pairwise analyses with Bonferroni adjustment, we find the scores at long-term follow-up are significantly different from those at baseline (t(23) = 7.002; p ≤ .001; d= 1.2) and immediate follow- up (t(23) = 6.234; p ≤ .001; d= 0.99). Analyzing the evolution of the means considering the two groups jointly, in both cases the highest means in knowledge occur in the long term. Adherence to the Mediterranean diet In this section we analyze the responses of the children in the questionnaire on the quality of the Mediterranean diet (KIDMED). We will analyze the data from the preliminary questionnaire and post questionnaire in the short term (after the face-to- face intervention). As the data show, at baseline both groups had an average KIDMED index of 7 (average adherence). However, after the intervention, the experimental group showed a slight improvement in this index, while in the control group it decreased. The differences in the KIDMED index are not significant. Therefore, we decided to analyze each item of the KIDMED questionnaire, as shown in Table 4, with percentages of compliance, both for the control group and the experimental group. These tables show significant differences in the intake of vegetables (one or more) and the consumption of fish, pasta and cereals. Also significant is the number of children who have stopped eating industrial pastries for breakfast. Regarding the impact of the program on eating habits, as Table 5 shows, in the experimental group, the KIDMED index shows a slight improvement that is not significant, while the control group sees a worsening in its KIDMED index that is significant. When analyzing all the items that make up the KIDMED test according to the group to which they belonged, it became evident that there were improvements in the experimental group such as in the consumption of vegetables, pasta or breakfast cereals, and that all participants stopped eating industrial pastries for breakfast. In contrast, the control group stopped eating vegetables regularly and also showed worse indicators related to industrial bakery and sweets. Then, the t- test for related samples was performed, which allowed us to confirm whether there were significant differences between the pre-test and post-test of the test, both in the experimental group and in the control group. In both cases, we must accept that the measure in the population in both the experimental group (0.72) and the control group (0.563) is the same, and no significant differences were found when the values were greater than 0.5. Subsequently, the t-test for independent samples was performed, first relating the pretest in the experimental and control groups. This revealed no significant differences in the questionnaire between the experimental and control groups (0.54). Thus, we started with a sample with homogeneous measures in relation to the quality of the Mediterranean diet, but after the intervention, we found significant differences in the post-tests of the experimental and control groups (0.23). So, we can affirm that the children who participated in the experimental group managed to improve the quality of their diet. 14 Single case of obesity-diabetes To exemplify the different activities carried out and their impact on health, we will present a single case study. The patient is an 11 year old female who was referred to the study from the Pediatric Outpatient Clinic of the University Hospital of the Canary Islands with a diagnosis of obesity and insulin resistance (prediabetes type II), under pharmacological treatment with Metformin 850mg. Family history: Mother and father both overweight. The mother suffers from obesity and Diabetes type II. Father is asthmatic, smoker, suffers from psoriasis. Maternal grandmother: Diabetes type II, asthma, uterine cancer and Lupus. Maternal grandfather: hypertension, type I diabetes, nephropathy, and heart disease. Paternal grandmother: AHT. Paternal grandfather: Lung cancer. Personal history: This is an asthmatic girl who requires treatment and has been followed up in the Pneumology Department of the University Hospital of the Canary Islands (HUC) since birth due to respiratory problems, the main reason for a continuous demand for care during most of her childhood due to bronchial asthma, upper respiratory tract catarrh and laryngitis on multiple occasions. Regarding obesity, this pathology was detected for the first time in the Primary Care consultation with her pediatrician at the 3-year check-up. This increase in weight above the 97th percentile was maintained in all health controls up to the time of the evaluation in this project, maintaining normal percentiles with respect to her height. The first data available in the electronic medical record in this regard is at the 3-year check-up, where her weight is 21.800kg (greater than 97th percentile) and her height is 94.5cm (25th- 50th percentile). It was not until the 4-year check-up that the alarm bells rang, and she was diagnosed with Obesity II. At that visit the child weighed 29g (percentile >> 97), was 103cm tall (percentile 50-75), and her body mass index (BMI) was 27.3; her mother said that "she eats everything and a variety of foods". At that time, strict dietary control is prescribed (avoiding fatty, fried foods and refined sugars, ensuring a balanced diet by teaching the use of fresh fruits, vegetables, salads, grilled or broiled meats, etc.), regular sports, and weight and height control in 3 months. However, the child did not attend the control. In later years, weight and height controls were resumed and the nursing and pediatrician's office insisted on the measures to be taken to improve lifestyle habits and help control weight gain, in spite of this, most of these controls are punctual in time and do not prove to be effective. After the 7-year check-up, and for a short period of time (between January-June 2011), periodic visits and controls are made that seem to achieve an improvement in eating habits and weight control (reduction of 1.6kg in 2 months), but these controls are interrupted again and it is not until the 9-year check-up (June 2013). She joined the PROVITAO Experimental Group in October 2014 and underwent anthropometric and analytical controls pre and post intervention, the follow-up at 6 months and the last control at one year after the start of the intervention. The results showed an improvement both in BMI and in behavioral and motivational indicators.