Health Points Series 2 Launches with a bang!

Ben and Pete introduce series two of the Health Points podcast, featuring experts in health gamification. They discuss the success and impact of series one and express their excitement for the new guests in series two. The first guest, Noah, a professional game developer since 1980, shares his journey into game design and how he got involved in serious games for health. He discusses his work on a game to help children with chemotherapy adherence and his involvement in Neuroracer, the first doctor-prescribed video game for ADHD. Neuroracer has been cleared by the FDA as a digital therapeutic and has shown comparable effects to medication but with fewer side effects. Noah explains that dynamic difficulty adjustment is crucial for engaging individuals with ADHD in gaming experiences.

Noah, a game developer, explains how games can help with focus and distraction issues related to ADHD. He discusses the importance of finding the right level of challenge in games to engage players and promote learning. Noah also reflects on the early days of game development and how they experimented with different concepts. He mentions that while games have potential for behavior change, they are not a panacea and face challenges in changing unhealthy behaviors. However, he believes that games can be effective in treating diseases or rehabilitation due to their ability to make tasks more enjoyable and engaging. Finally, Noah talks about the difficulties of behavior change due to evolutionary factors and present bias, highlighting the role that gamification can play in health education by providing distraction and excitement to motivate individuals towards healthier choices.

The episode discusses the unique aspects of working as a freelancer and how each project brings new learning opportunities and creative challenges. It highlights the evolutionary reasons for enjoying games and sports, which help in developing skills necessary for survival. The discussion also explores the potential of video games to counteract sedentary behavior by promoting physical activity. Examples like Pokemon Go and Ingress are mentioned, which encouraged people to get out of their houses and explore while playing games. The conversation further delves into the future potential of augmented reality (AR) glasses in combining digital gaming experiences with real-world activities, such as exercise. Additionally, it mentions the application of game technology in various health-related areas, including addiction recovery and rehabilitation. The speaker emphasizes that there is no one path or solution but rather a multitude of possibilities for integrating games and health interventions using innovative technologies like AR headsets, eye-tracking devices, and sensor technologies.

Noah discusses the positive impact of shared experiences and connections through a golfing game. He emphasizes that gamification is not easy and requires careful thought and understanding of psychology. Mutual respect between doctors and game developers is crucial for effective partnerships. Noah shares an anecdote highlighting the importance of respecting each other's expertise. The host summarizes Noah's contributions on the early evolution of video games, health gamification, and its role in modern healthcare.

Outline:

• Chapter 1: Introduction to Health Points (00:00 - 00:20)
  • Series one success and the broad world of health gamification
• Chapter 2: Introduction of Guest Noah (01:01 - 01:56)
  • Noah's extensive background in game design
  • Introduction of his role as a chief game designer
• Chapter 3: Noah's Journey in Game Design (04:07 - 06:30)
  • Starting with graph paper and colored pens
  • Shifting towards design, writing, and project management
  • Collaboration with various companies and institutions
• Chapter 4: Early Gamified Health Management Project (09:25 - 11:27)
  • Collaboration with Dr. Adam Ghazali
  • Developing a video game to monitor brain activity
  • Early days and grassroots nature of the project
• Chapter 5: Effectiveness of Games in Engagement (15:33 - 18:59)
  • The connection between gameplay and learning
  • Drawing from psychology research, including flow state concept
  • Role of gamification in addressing lifestyle change
• Chapter 6: Future of Gamification in Health (19:06 - 33:01)
  • Exploring various facets of gamification in health
  • Integration of augmented reality (AR) and potential for gamification
  • Worldwide community and real-time interactions
  • Examples of gamification improving mental preparedness
• Chapter 7: The Multitude of Paths in Games and Health (39:30 - 40:39)
  • The diversity of possibilities in games and health
  • Differentiating between games and game technology
• Chapter 8: Recommendations for Further Exploration (40:48 - 43:10)
  • Suggestions for individuals working in health gamification
  • Peer support and shared experiences
• Chapter 9: Challenges and Persistence (43:56 - 45:46)
  • The difficulty of implementing gamification in health
  • The necessity of putting in effort and not expecting easy solutions
• Chapter 10: Anecdote on Engaging Users (45:44 - 46:50)
  • The challenge of engaging users in a prototype game
  • Collaboration with a neuroscientist on sound alternatives
• Chapter 11: Summary and Conclusion (46:50 - 47:23)
  • Recap of the discussion with Noah
  • Acknowledgment of his insights and contributions to health gamification

Episode Transcript:

00:00
Ben
Hi everyone, welcome to series two of health points. Series one was a huge success with some of the biggest names in health gamification, research, development, and some of the biggest health games and brands on the planet.

00:13
Pete
I'd be hard pressed to pick a favorite episode. What it showed me is how broad and growing the world of health gamification is. In the interim between series we've seen the huge impact of these projects and are inspired to continue be searching them out for you.

00:27
Ben
Series two is here with more big hitters in the world of health gamification to share their insight, knowledge, wisdom, tricks and chips to you all the health points listeners. We're hoping you enjoy series two as much as we've enjoyed recording it and meeting our brilliant guests who are all experts in health gamification. The rolled over hey everyone, and welcome to another episode of Health Points where we talk about anything and everything. Gamification Health. I'm Ben and here today is my co host, Pete. Hi everyone, and joining us today is Noah, who has been a professional game developer since 1980 with many hit title credits and was an early hire at Lucas Arts, three do and DreamWorks Interactive. Most recently, he was Google's chief game designer. His freelance design business, the Inspiracy, is focused on games for health, specifically neurogaming.

01:28
Ben
The inspiracy has offered design and production consultancy for companies and individuals interest in top quality game development and business contacts. He was part of the design team at Neuroracer that sparked the formation of Achille. He also lectures and conducts seminars on game design and development for both traditional and serious games, and he has chapters published in six different game industry books. Noah, it's fantastic to have you on the show today.

01:56
Noah
Glad to be here.

01:59
Ben
So you've probably got one of the most extensive backgrounds in game design of any of our guests. So take us back to the 1980s. What led you into the interest in gaming and game design?

02:12
Noah
Well, I've contemplated on that many times, and as a child, a lot of my peers who got into the games industry early on, before it was an industry, in fact, were board game players, toy designers, or enjoyed all of that. And it was an exposure to very early computer games all the way back in the 1970s that made me start to realize it was an interesting thing. I still didn't believe it was a career move, but I went to a college that let you design your own curriculum and was studying physics and astronomy when I got in there at first and started to learn a lot more about computer programming and thought it would be great to tie all that together by making an elaborate computer game about mining asteroids in the future.

03:00
Noah
Something actually very much like the tv series the expanse turned out to be many years later. But that was something that had been kicking around in science fiction circles. And it never occurred to me that making it into a game was anything but a fun way of showing my programming and physics and astronomy background. But in fact, it got me right into the games industry directly as soon as I graduated, starting at Milton Bradley, when they were just starting to play with electronic games and toys there. So, yeah, and ever since then, I would have people early on who would tell me, aren't you worried this is a fad that's going to blow over? And I actually took them quite seriously because if it was, I figured I should enjoy it as much as I could until it all went away.

03:44
Noah
And as you know, it so far hasn't gone away. So I think we're pretty good shape now.

03:50
Ben
It has definitely not gone away. Some of my favorite stats are that the game industry is bigger than the music industry and the film industry combined. No, gaming is gigantic. So it would be great to hear about some of your experiences on that journey. You've worked for some of the biggest studios on the planet, kind of. What was that journey and where did you start to, where you got to the point where you were a chief game designer?

04:12
Noah
Well, I started, I think, as almost everybody in games as early as I did as a programmer, that you really didn't have much differentiation at that point. You essentially had one person, usually one man, because then, as now, it was a very male dominated area who was creating the entire game. Some of the first games I worked on, I was doing the programming, the artwork, such as, it was basically very primitive pixel art. You use graph paper and colored pens to figure out how stuff would look, even sounds. And basically every aspect of game development tend to be a one person deal at those days. And it wasn't until I'd been in the industry for, I think, two and a half years before I met the first person who was a full time game designer man named John, newcomer at Williams Electronics.

05:08
Noah
And that just really changed my perception because design had always been my favorite part of it all. And I felt that I needed to do all the other work I did just so I could get to do more of the fun stuff of design. And it really set me on a path of trying to figure out how I could become primarily a game designer, seeing that was a potential career path. And I basically didn't move quickly into that. I continued to program through the first couple of companies I worked for, but I always met people who are much better at coding than I was. And I was happy to shift more and more into the design and writing and sometimes project management. But even then, it was an excuse to get to do the fun stuff, usually.

05:51
Ben
So in that case, that shift over a few decades, kind of. When did you start seeing the connection between games and game mechanics and health or lifestyle?

06:00
Noah
Well, the first serious game I encountered, and I'm not fond of any of the names of that, by the way, that Jesse Shell's company has been pushing transformational games, which I think is a really nice alternative, but hasn't really gotten much traction yet. But. So I'll call it serious games for now. First one was in the late 90s. Shell Oil actually had a very forward thinking person there who was looking to the games industry to help them with some of the work they were doing. And they brought a bunch of us out to their headquarters in the Netherlands. And it just opened my eyes to the idea that maybe we could make games whose primary purpose was not purely entertainment and really appealed to me.

06:44
Noah
I think largely it's always been interesting because it keeps stretching the boundaries of what games are able to do and what even the definition of a game is. And so I did a number of projects starting in late 90s, but particularly the early 2000s. Some of it was very corporate stuff, some of it was educational on all levels, from children up to postgrad level corporate training. But then, see, I think 2001, I was lucky enough to connect with a company called Hope Lab that was started by the wife of the man who founded eBay. And they were using a lot of their personal wealth to do some passion projects. And in his wife's case, was to create a company to make games for children to have their health improve.

07:35
Noah
And I worked on a project there that was involved in helping kids who were on chemotherapy and radiation treatment to stick with their chemotherapy, because a lot of teenagers would find that they were feeling fine after the radiation had worn off. And now they're given pills that make them nauseous. And they just would lie about having taken the pills. Not all of them, obviously, but a significant percentage. And surprising to me, were able to make a game that then went through clinical tests with several hundred patients to prove that it was actually effective. And it was really making a big difference in people's adherence to taking drugs.

08:15
Noah
And that in turn, launched me onto the medical side, because it seemed to me to be the sweet spot where corporations in education often were either very sort of seriously focused or sometimes even technologically phobic, particularly in terms of some of the early childhood. Educators would see games as the enemy. That was what kids did when they weren't going to school and learning. So it was a really hard sell. But the medical profession has been very technologically dependent and they're always adopting new technology. They're very well funded. It is worldwide, it affects people at every level. And it's just really been a sweet spot for experimenting with ways that games can expand into that area and help people worldwide.

09:04
Ben
Incredible. In that case, now we've made the bridge into serious games and health gamification. It'd be great to know more about Neuroracer, which became the precursor to endeavor Rx. And if I'm right in saying this, that was the first doctor prescribed video game for ADHD. Where was your journey through that? What was your involvement? And what do you learn around one of the first ever gamified services for health management?

09:31
Noah
Yeah, well, I could say it is not only one of the first. It is currently the only game that has been cleared by the FDA to treat any sort of condition on its own. There are a number of companies that have FDA cleared treatment that involve games along with cognitive behavioral therapy or some type of physical rehabilitation. A lot of games for stroke recovery or injury recovery. But Killy's Endeavor Rx is only available through doctor's prescription. It's called a digital therapeutic is the term that's come up of essentially it's like a pharmaceutical, but there are no pills involved, no injections. With digital therapeutics, it's all online. And with this in particular, it is purely a game. And I've since then started to work with other companies who are hoping to also enter this field, but they're the only ones so far.

10:26
Noah
And I was approached by because of my Lucas arts background. This was a local San Francisco Bay Area project 1314 years ago. Dr. Adam Ghazali, who has been head of brain imaging at University of California, San Francisco, he had been doing some interesting studies using eeg and experimenting on people's attention abilities and neurocer was his thought that maybe making a video game that would help train people would be a good way to be able to then monitor their eeg and figure out what their brain was doing while they were either being distracted or paying attention fully. And it was quite successful. He had some friends at LucasArts because it's a local company. They said, oh well, there's this guy Noah, who is also ex Lucas arts, but is working in this field, and maybe you should talk to him.

11:25
Noah
I actually just saw him two days ago. There was a party for somebody leaving Akili, and were reminiscing about those early days when it was very speculative and a little grassroots thing that we're mostly doing because it was so fascinating. And his Neuroracer project got on the COVID of the journal Nature, the only time they've actually had a video game on the COVID of that magazine, and really sparked this whole company that uses a game to treat add. And they've shown that it has effects comparable to Adderall or Ritalin. But unlike those drugs, the biggest side effects are occasional headaches and frustration. So it's much easier for people to consider adopting it as a way to deal with their adhd.

12:13
Pete
So what's the secret to the success of a game like Neuroracer?

12:17
Noah
Well, in this particular case, this is part of what fascinates me and why the neurological side of this is so interesting, is that as game developers, we've been empirically experimenting with how to engage people's brains and get them excited. The neuroscientists have been doing similar work, but a lot of the tests they do are so boring that they have trouble getting people to do them enough to actually get the data they need. And so it's been one of these marriages made in heaven, where we get to really learn what's going on inside the brain from people who are experts at it. They get to entertain people enough to actually increase the quality of their research.

12:54
Noah
And with Akili product being attention based, it has a lot to do with what we call dynamic difficulty adjustment in the games industry, that in order to appeal to somebody with ADHD, you need an exceptionally high level of stimulation and excitement that you can't break through their attention barrier unless you really get them to a point where then they become hyper focused. And a lot of parents of kids with ADHD would complain that I can't interest my son in his homework for more than five minutes at a time, but then he puts in 3 hours on Fortnite, no problem, and I have to pull him away from the computer. And it's because that offers a certain degree of stimulation that really grabs all of their attention.

13:43
Noah
And so you need to actually have it constantly adjusting the difficulty level, literally on multiple times a second, in order to make it a little bit easier when they're getting too frustrated, making it a little bit harder when it's getting too easy, and they may be getting bored. It's central to a lot of games, but you need a higher threshold for somebody with ADHD. And the other part of it that I've been fascinated to learn from the scientist is that I would always think of attention and distraction as simply two sides of the same coin. If you're good at paying attention, you're not going to be distracted. And if you're easily distracted, you can't pay attention. But it turns out the neural circuitry in those things are quite independent.

14:24
Noah
And you can be very good at focusing, but still be easily distracted by something that pulls you away. And that's often something people with ADHD struggle with. Or conversely, you could be really good at ignoring distractions, but not so good at staying focused on something. Maybe you're really good simply at clearing your mind and not hearing somebody yelling at you to stop staring into space. So anyway, the game works on both those pathways at once, and specifically tries to push you to the level of performance that you're just at the sort of sweet spot of succeeding often enough that you're excited to keep going, but failing often enough that you have to actually keep putting maximum effort into it. And that's when your neurons make new connections.

15:12
Noah
And it's at the heart of not only all gameplay, but literally all learning is focused in a similar way.

15:20
Ben
I think this whole thing about what you've just mentioned around dynamic difficulty and into autonomy mastery purpose about this need to have the right level of challenge, not too easy, not too hard to have that engagement. There are so many acronyms, there are so many frameworks now around game mechanics and how to build the perfect game in the. Most of these terms didn't exist. Most of these acronyms didn't exist. How were you designing the features and functions of the game that made games so effective for this engagement? Were you taking from psychology research, were you just trialing things out? Kind of. Where did the concepts come from?

15:58
Noah
Well, I would say a little bit of everywhere. One of the things that was both wonderful positive and negative at the same time was that when I started in 1980, there was just nobody who had been doing this for more than a few years. Nolan Bushnell and Pong and the predecessor to Pong were some of the earliest things that were being done, and even that was only less than ten years old. And so we didn't have anybody looking up our shoulders saying, oh, no, don't do that, do this. That's going to be failure. So there's tremendous freedom. But also we made crazy mistakes because we thought, oh, this will be great fun because it works fine in a board game. And it turned out it didn't translate it well at all to computer games or something.

16:46
Noah
That I think is interesting is that I remember it was, I think, the late 1980s that I started to see computer role playing games that didn't use the concept of rolling dice, which was so ingrained in dungeons and dragons and its ilk from before that we all thought of it as being inextricably intertwined. But in fact, hardly any of the computer games. Video games now use dice rolls as a sort of literal know. It just took a long time for us to realize, oh yeah, we don't really need to actually have dice on the screen that roll, know, that sort of thing. So a lot of it was just trying things that had worked with board games. Mihai Chiksant Mihai, a psychologist who was pushing the idea of the flow state and the flow channel.

17:34
Noah
That was something game developers locked onto early on because it was exactly up our alley, but really wasn't, I think, until at least the late 80s that I started hearing about it frequently. So that early period was just kind of wild west experimentation and making a game in your bedroom and putting it in plastic ziploc bags and selling it to local stores. And a lot of people got started that way. So it was really a very exciting time.

18:03
Ben
I mean, a huge thank you for going out there into the wild west and testing and learning and failing, because I would hazard a reasonable guess that the work you did and your colleagues did back a couple of days ago is the reason we have the foundations, the kind of principles of game mechanics now. And actually game design and game mechanics are taught as degree subjects. Without a doubt, it was your willingness and desire and passion to pioneer. That is the reason we are where we are today. So in that case, where are you seeing the role of gamification or serious games in changing behaviors in health? The challenges is facing the planet around health at the moment. The reason why we created this podcast is a huge amount of non communicable diseases. The challenges of the 21st century is around lifestyle change.

18:53
Ben
A lot of these long term health conditions can be really well managed and prevented by lifestyle management. Where do you see the role of gamification now? Where do you see it going in the future?

19:06
Noah
Really interesting question. Boy, a lot of facets. So I'll try and be briefer. I know I've been talking for a long time and let you tease out different directions.

19:15
Ben
Oh, no, you are more than welcome to go for it, Noah. That's the reason you're here.

19:20
Noah
Well, my pleasure. Then I won't be so concerned about it. But I do think games are potentially a great tool for behavior change, and that certainly comes up. I'm often hired by the medical companies of different types because they realize that trying to get people to change dangerous behaviors, or just unhealthy behaviors in general, despite it being a logical thing to do, is really hard to get people to change those sorts of things. And I have to say, games are inherently not great at behavior change. They're great at teaching and learning. But, for example, one of the things that has been a relief is that back in the early 2000s in particular, there was a lot of press about how games were making kids violent, and they needed to be reined in and regulated. And huge amounts of research were done.

20:20
Noah
And gradually, over time, people started to realize, well, no, in fact, there's nothing at all to suggest that games are causing violent behavior. In fact, there was some significant suggestion that playing violent video games was giving people an outlet, that they then didn't actually become violent in real life. But by the same token, it suggests that simply playing a game that encourages a certain type of behavior within the game doesn't transfer to the real world. And that has been the biggest hurdle for a lot of games where they. For example, I worked on a game about child nutrition called Hungry Red Planet many years ago that really didn't go very far at all. It was funded by a National Institute of health grant.

21:06
Noah
But we learned that we could teach kids, for example, that when you want a healthy snack, much better to reach for an apple than a pizza and test them. And they said, oh, yeah, that's a healthy snack. And then if you say, so, you want to go out for something to eat after this, they'd say, yeah, let's have some pizza. I'm really thinking about it now. And as we all know that, oh, we should cut back on sugar, we're having too much saturated fat in our diet or whatever. And I can't resist this donut. It's just this once. Well, it's the fifth time this week, but I'll stop next week. Games are better than a lot of methods, I think, at making those behavior changes.

21:44
Noah
But the most successful games are ones that don't have to fight and urge, for example, what Akili does, being able to pay attention to something that's interesting and ignore things that are potential distractions. We're not inherently biased not to do that sort of thing. So that's helpful. I'm working with a company, a german company now called Dopavision, that is using a game to treat myopia, nearsightedness. And in that case, certainly none of the kids who are nearsighted want to remain near sighted, and simply playing the game itself lets them administer a treatment that involves shining a certain frequency of blue light into a certain spot on people's eyes. So there's nothing to put the kids off to it all. It really is all a positive change.

22:36
Noah
So, games, I think the two biggest features are helping people do behavior change in at least the most friendly and fun way that we can manage, but also treating diseases or problems, rehabilitation from injuries or strokes, for example, where there really is no resistance at all. It's just that games make it much more fun and easy to do some potentially painful or boring thing for a very long period of time that may be necessary for health reasons and the number and type of applications that games can handle. I am constantly floored. I mean, just this week, earlier this week, somebody came to me with an app they have that analyzes people's coughing and uses AI to figure out whether this is a serious cough or what might be causing it, or is this early signs of emphysema or tuberculosis.

23:36
Noah
And he wants to add gameplay to it. And it just, again, sounds logical when you hear about it, but never would have occurred to me before last week. So lots of new things opening up all the time.

23:50
Pete
This is really interesting, because what Ben was saying was, some of the lifestyle choices are those that we resist. And you're saying that's not necessarily the sweet spot for games and gamification.

24:02
Noah
I think games are better than a lot of other methods, but they're still not the panacea for it.

24:09
Ben
So where is the sweet spot? Can games be a panacea for something if not behavior change? Or have we all been barking at the wrong tree?

24:17
Noah
Well, I mean, I think behavior change is just really hard. I'm very interested in evolutionary biology, in understanding why we are the way we are. And in general, there's a kind of if it ain't broke, don't fix it rule that evolution applies to things that if something is working reasonably well, they tend to be part of our genome. And it's really hard to sort of throw that out and try something radically new, because most of the time when you try something radically new, it's a disaster. I mean, to put it in another way, a more scientifically rigorous way, you get random variations in our genes through radiation and to some degree, through the mixing of different genomes, as fathers and mothers come together, and a lot of the mutations and new directions just don't work very well.

25:16
Noah
And nature being kind of brutal, those people either die off or they don't reproduce as often. And not just people, obviously, but every living thing. And it can take thousands or millions of years, but it's a very effective thing. And instincts. Take an example. I talked about how hard it is to use games to teach somebody not to eat donuts. Well, donuts are not something that primitive man or our Simeon ancestors before that had to worry about. But if you wanted something sweet, the only options were usually things like ripe fruit, which is actually quite good for you, and often not available in big enough quantities, or you're competing with bears, eating berries and you don't want to fight a cave bear to try and get to the blueberries.

26:06
Noah
So there are a lot of reasons why we're kind of hardwired to crave sugar and grab it whenever we can. That work great for literally millions of years and terribly for the last few hundred. And we've had sugar for a longer time than that, but it's been plentiful and cheap only for a very short time, even historically, much less genetically. So anyway, bottom line is behavior change in some of these cases is extremely difficult. Addiction to drugs, for another thing, opioid addiction, another example of something that's brand new evolutionary wise, but it has, and I won't get into depth on this, but there are really good reasons why we're hardwired to want something that can help us not be in pain or have us feel good and release the kind of endorphins and the right neurotransmitters that make people feel good in life.

27:00
Noah
Because everything before that, for millions of years, it was a positive thing to have those tropisms. And now it's actually a very dangerous thing when these pills are available.

27:11
Ben
Yeah, I've given many talks talking about inherently, as humans, we are lazy, evolutionary. We were meant to conserve energy, and when there was opportunity to take on calories and those that were particularly calorific, we'd go and gorge on them. It's really difficult in society when they are everywhere. It's so easy to be sedentary and so easy to have high calorie, high sugar, high fat meals all the time. In that case, then, one of the challenges that I see is around present bias. So the outcomes immediately in front of us are far more motivating than those in the future. And this is one of the challenges of health in behavior change is that there's still this mandate that health education alone will change behavior. And if you tell people the bad thing is bad for you, they'll stop it.

27:59
Ben
Well, they won't, because that heart attack is ten years away. That cigarette, that chocolate cake, that kind of ten hour Netflix bin session, that's today. And now, in that case, is there a role for games there, if they're distracting enough? Is that where health gamification can really get in? Is it distraction? Is it excitement? So you want to engage in activity even if it can't create true, inherent behavior change to avoid that non present bias element? Where does health gamification sit as a tool for the 21st century and health services?

28:35
Noah
Well, it's definitely all of the above. One of the things that I love about this sort of work and working as a freelancer is that every single project is unique in some way. So I'm constantly having to learn new things myself, which has always been a passion of mine, but also creatively challenged to solve problems in new ways. And there are many promising things. As you say, people are inherently fairly sedentary. And again, it's an evolutionary thing. Why should you waste your energy if it's not critical? And I would say games and sports, both not just video games, but sports going much farther back, are precisely the reason that we're hardwired to enjoy games.

29:20
Noah
And competition or cooperation in gaming cases, is that games are entertainment almost in general, are ways to exercise skills that will help us evolutionarily in survival, very darwinian things in a safe way. So, for example, going out with a spear, you've never used one before. You need to hunt down that cave bear or fend off the saber toothed tiger, sending you out to do it without any kind of practice, a lot of those people are going to die. Somebody who happened to be born with the quirk where they said, well, let me stick a leaf on this tree side and see if I can hit it with a spear. And people say, well, are you nuts? You're not going to get any food that way. But no, let me try it.

30:07
Noah
You're not also going to get eaten by the tree as you practice that, and you might get really good at throwing a spear. So the people that had that urge to try stuff like that became part of our gene pool. And if you think of all the most hugely successful video games, they push on those types of survival, training things on all sorts of levels, not just sort of physical things that you can do, but also mental processes, finding patterns and things being aware of dangers around you, situational awareness, that's true. Pushed in so many games. All of those are ways to get better at this sort of thing. And if we can tap into those urges and the fact that people have that in their gene pool as well, we can somewhat counteract some of the sedentary or the resistance.

30:55
Noah
I'm going to give you one more example. I have known John Hankey, the head of Niantic, for many years, and were both at Google together when he was working on a product called Ingress that later got spun off to become Niantic and create the Pokemon Go, which the first month that came out, it made more revenue for the Google Play Store than every other app on the Google Play store combined. Not just games, but everything that they ever sold. I think it was 60% of the sales that month. And he did it because he's passionately interested in getting people out of their houses and exercising, moving around. And that was not the reason people played Pokemon go.

31:42
Noah
In fact, I'm sure a lot of people hated the fact that they had to get up and move around and run sometimes to get to this park before somebody else caught the Pokemon they wanted. But it has done tremendous things. I can't imagine the number of the billions of calories expended in people walking around in the outside who normally would have just stayed at a computer if had they been given that chance. So there are clever ways that we can subvert some of those evolutionary resistance to exercise, to healthy living, that sort of thing.

32:15
Pete
I really like what you're saying there a lot. What you were saying was about training people in terms of the mental side of it, like planning and getting ready for situations. And then you hinted there with Pokemon go and ingress, which, by the way, I used to like playing a lot. Ingress, it was a big fan. You hinted at getting people moving, and I was thinking, like, where do you feel the limit is for video games in terms of changing these behaviors? How much should we actually be doing in the physical world? Or is there, what's that phrase I heard the other day, physical and digital combined? Where could we go?

32:58
Noah
Well, it's an interesting area. There's been a lot of peaks and valleys in it. The Wi balance board was, I think, the single best selling accessory to a video game console it's ever been made. But it's a running joke that 22 million people, I think, bought that, and maybe 500 used it for more than about a month before putting it in their closet. And better note dance Revolution, first as an arcade game and then as a home game, has had tremendous, sometimes anecdotal but clear impact in getting, again, sedentary people to exercise or even become good dancers. Intriguingly enough, niantic and not just pokemon go. But as I said, john's philosophy is really, he's furiously resisted making people sit or letting people sit at a computer be sedentary. He really wants people to get up and move.

34:02
Noah
And I would say we're about to see a renaissance or going to go into evolution again. A cambrian explosion of new types of games when either Apple's AR headset or other successors, I believe those are going to become ubiquitous really quickly because they are so useful. The time I spent wearing Google Glass as a Google employee, people would make fun of it in the news, but it was like having superpowers, even with a really primitive early AR glasses version. And that will enable a huge number of real world out in the wild, and also exercise related gameplay, things people can do. During COVID I discovered supernatural, which had perfect timing without them planning to. It came out literally just as people were going into lockdown.

35:02
Noah
And it's a VR exercise game, and it was really great for getting exercise when all the gyms were closing. Except for the fact that when you exercise wearing a VR headset, the sweat has nowhere to go but pooling inside. It was very uncomfortable, and that's a problem VR has not been able to solve very easily. But AR, where you're wearing something that's much more like open glasses and just has some projected information and also lets you see the real world around it, so you don't suddenly smash a lamp over with your controller. Much more beneficial. And we are maybe two or three years, maybe five or ten years. I don't really want to project too much from a point where it's going to be almost as universal, I think, as people carrying cell phones, as having some type of heads up glasses.

35:57
Noah
In fact, just talking to people a few weeks ago about generative AI, it suddenly hit me that is also a thing that pairs incredibly well with AR glasses. And I mean, all these technologies are kind of combining interesting ways, and the health applications for that sort of thing, as well as other great applications, are just multifaceted and very exciting.

36:22
Ben
In that case, then around behavior change, maybe that's not the important thing. So one of our series two guests is also the creator of the quit app, which is very much around smoking cessation and also reducing alcohol into it as well, and being relatively successful in the short, medium and long term to get people to change that behavior. Maybe this is unique things because there are a lot of really big motivators for people to give at smoking around, kind of like having kids or big health scares. So maybe there are some ways that gamification can result in behavior change, but maybe that isn't the goal. Maybe the goal shouldn't be. Maybe the focus shouldn't be any different to a lot of health interventions.

37:03
Ben
If you take things like patient generally for physical conditions, people only engage in a rehab when they're with a clinician or a physical therapist or a physiotherapist to do the rehab. But having those interactions result in long term benefit and outcomes. But if the games themselves can make it entertaining and a user experience that people want to do more of it, so get more of the benefit long term, maybe that's good enough. And I guess part of the reason for coming into health points between Pete and I was to really explore this area more. Some people hold it up as the holy grail, the panacea. Some people see it as a fad that will fade away. I think it's neither.

37:43
Ben
I think it's better understanding where it fits as a tool within the health systems box, where is great, where it could maybe create solutions for certain things like true behavior change. But maybe there's a lot to learning to be done there. Really good to explore that with you, I guess just in some final thoughts and feedback. I know you said about the projections of the use of AR and the potential for that to do more gamification. Where do you see the health gamification sector going? Where do you see the next five to ten years?

38:14
Noah
Well, I completely agree with everything you just said. As I said, games are not panacea, but they are multifaceted in the approaches that are possible. And the list of things you just gave me instantly because I've trained my brain for this sort of thing, I kept firing off on all the different ways that games can help these types of things. We can't stop you from craving having a drink, for example, but we can do like what we did with the remission game, as I said, with getting people to take chemotherapy pills, even though that made them feel sick, because we are able to show them the consequences of what happen when you don't take them. So games that can help show you in ways that maybe you weren't thinking about how your addiction is causing trouble. And that's a mild one.

39:06
Noah
Another one is you have things like alcoholics anonymous that's been quite successful, but getting your sponsor waking up out of bed at three in the morning can be really difficult. Games are really good at having a worldwide community, people where there are people awake at any given time and you can see them instantly and again with those types of headsets, maybe even feel like you're actually with them personally. There you are, and somebody offers you a drink and you want to say no, and you can instantly have your friend pop in and say, hey, I got an alert. Because your headset heard the word, oh, come on, just one. It won't hurt. Are you okay? Can I help you out? It's not a game, but that's all game technology and a lot of the stuff that we're learning to do so many different ways.

39:54
Noah
So bottom line is, I don't think there's any one path. There are a huge multitude of paths and I'm just seeing the entire games and health sector and game technology, just to differentiate. It doesn't have to actually be games or gamification, it can be simply using game technology or game techniques. It's undergoing an explosion that reminds me very heavily of the entire games industry in the mid 1980s, where it was just kind of a small group of enthusiasts, and then it just got bigger and bigger. And I'm seeing that happen with games and health in many different facets and too many to list, even in multiple sessions with you here.

40:39
Pete
Although if you had to list one or two, that maybe we should interview about what's happening, what's exploding in terms of games and health. Where might you point us that you think is going in the great direction?

40:53
Noah
Well, certainly, as I say, I think AR headsets are a sort of underserved area, partly from my bias from actually having used Google Glass and seeing what it was like to have sort of superpowers. That ability, I think, will work with a lot of health related areas. Eye tracking in VR headsets as well is another really interesting developing thing that I think we're going to see a lot more of. Direct all the different ways that sensors are starting to hook up to people's bodies, doing everything from right now we have the watches that are checking our heart rate, but they're also starting to check blood sugar levels and headsets that can measure your EEg or pick up other aspects of your brain health.

41:52
Noah
All of those are very promising because in a lot of cases they don't work all that well in their first early versions. And that's fine for a game. Games, you can tolerate it not working perfectly and use it to perfect it to the point where it can actually become a standardized medical procedure. So I think those are all areas to look at where games are going to be at the cutting edge, simply because games already always have been. The reason we have great graphics on our computers now is because we didn't need them for spreadsheets or word processors. It was the games industry that kept pushing that stuff. Same thing with sound on all our audio devices, really pioneered by the games industry.

42:33
Noah
So looking for these new technologies right now, particularly the sensor technologies, I think are going to be real gold mines for new types of medical and health procedures.

42:45
Ben
Yeah, I can definitely see what the future is from everything you described. And what I really liked was the example of the hypothetical, the AR glasses that people wearing would sense that just one more and result in a gamer friend making a call. Weirdly, one of the games that I enjoy on my phone is a golfing app. I hate golf. I have no interest in golf whatsoever, but I really enjoy this game, and I'm part of a clan on that golfing game. And there's a clan chat. And one of the people in that chat said a couple of weeks ago, saying, I've been playing well. At the moment, I'm really struggling with a few things. The response from other complete strangers was unreal through no connection at all. But they played this golfing game.

43:27
Ben
People were posting links and advice and saying, do you want to message me directly to have a chat? They have no idea who this person is. But it's amazing. Through this shared experience, this shared understanding through one element of our life can result in connections to other people who are going above and beyond as a peer to support us. So I can completely see that as a future. Final question for me, Noah, is for our listeners out there, from people working in health gamification, what are your key wisdoms? What are your key insights, tricks and tips that you could share with people?

44:00
Noah
Well, I would say the first thing I'll say is that it's not easy. One of the reasons why I'm not terribly fond of the term gamification is because it tends to imply, oh, it's simple. Slap on a high score table, some badges, maybe a streak counter, and people will play forever. And if it was that easy, every game that's ever released would then become a huge hit. And of course, it's impossible. As multifaceted and interesting as all this is, it requires a lot of very careful thought as to which parts of games or game technology or game mechanics are best to apply and a good understanding of the psychology behind it to know whether it's actually going to help or not or be a waste of time and money.

44:50
Noah
So the first thing I would say is, don't expect it to be an easy solution. You're going to have to put a lot of work in to figure out how to do this. Well, another thing, and this came up not just from me, but from a bunch of people I respect. Just recently I've been hearing people also saying this, is that when you combine games with medicine or with anything that isn't games, and you really want it to be an effective partnership, the people involved from all sides have to have mutual respect for each other. You can't have a doctor who looks down on video games, but is reluctantly being told to do this.

45:28
Noah
You can't have a game developer who says, well, you don't know anything about games, so just tell me what kind of medical names to put in there, I'll shove them in there. I've seen both of those things happen and it never works. It's only when both sides with Akili. Just one quick anecdote. We were looking to get people more involved in this early prototype game where you had an EEG headset to measure what was going on, and we asked Adam, the scientist on this, so can know, maybe add some sound to this to make it more engaging. He said, well, it's going to light up a whole new part of your brain that involves audio processing and we'd rather not have that. And somebody said, well, what if we had a little flashing light to alert you? And he almost went pale.

46:12
Noah
It's like, don't you know what flashing lights do to an EEG? That's why they have all those epilepsy warnings when they're flashing lights in any sort of tv show. And it was fascinating just to hear from a neuroscientist point of view and rather than saying, oh, damn, he's a stick in the mud, it's like, whoa, this is great. How can we get people to be engaged and be alerted without using sound or flashing lights? And it's that kind of mutual respect that I think is absolutely key. Not just respect, but enjoyment in trying to learn what the other person does and is good at so that you can work with them as effectively as possible.

46:48
Ben
That was a fantastic summary. Noah, it's been great having you on the show today to talk about the early evolution of video games that had led to the foundation of health gamification. The taking of health gamification to the front cover of one of the most prestigious research journals on the planet, test, learn and fail approach, which has pioneered the gamification framework we see in the industry today and exploring where health gamification fits into the 21st century health system. Noah, thank you so much for your time to come.

47:17
Pete
The show today, it's been brilliant. Noah, real insightful.

47:23
Noah
Thank you. It's been a great pleasure.