Virtual Reality Intervention in Children With Hyperlipidemia

Body weight will be measured using the Tanita body composition analyzer (MC-780MA) and recorded in kilograms.

Children's physical activity levels will be assessed using the Physical Activity Questionnaire for Children (PAQ-C). The PAQ-C is a self-report instrument designed to evaluate general physical activity levels in children and adolescents over the previous 7 days. It consists of 10 items, of which 9 are used to calculate the activity score. The first item includes a culturally adapted activity checklist consisting of 14 common activities and is scored on a 5-point scale (1 = no activity, 5 = 7 times or more). The remaining 8 items assess physical activity during specific periods of the day or week, such as physical education classes, recess, after school, evenings, and weekends, and are also rated on a 5-point scale. The final PAQ-C score is calculated as the mean of items 1-9, with higher scores indicating higher levels of physical activity.

Functional capacity will be assessed using the Six-Minute Walk Test (6MWT). The 6MWT is a simple, practical, and objective exercise test widely used to evaluate functional exercise capacity in children. Participants will be instructed to wear comfortable clothing and appropriate footwear. They will rest before the test, and heart rate, blood pressure, oxygen saturation (SpO₂), and perceived dyspnea using the Modified Borg Scale will be recorded before and after the test. Participants will be asked to walk back and forth along a marked 30-meter flat corridor for six minutes, aiming to cover the longest possible distance. Standardized verbal encouragement will be provided at each minute. The total distance walked in six minutes will be recorded in meters.

Participation and environmental factors will be assessed using the Participation and Environment Measure for Children and Youth (PEM-CY). The PEM-CY is a parent-reported questionnaire designed to evaluate participation of children and adolescents aged 5-17 years in home, school, and community settings, as well as environmental influences on participation. The participation section includes 10 activities for the home setting, 5 for the school setting, and 10 for the community setting. For each activity, parents report the frequency of participation over the past four months, the child's level of involvement using a five-point Likert scale, and whether they desire a change in the child's participation. The PEM-CY has demonstrated acceptable validity and reliability in Turkish populations.

Body mass index will be calculated as body weight divided by height squared (kg/m²) using measurements obtained from the Tanita body composition analyzer (MC-780MA).

Body fat composition will be assessed using the Tanita body composition analyzer (MC-780MA). Measurements will include total body fat percentage (%) and total body fat mass (kg), which together will be used to evaluate changes in overall adiposity.

Body image will be measured using the Children's Body Image Scale. There are separate versions of the scale for boys and girls. The scale contains 7 gender-specific images in anatomical position. There are 7 male and 7 female photos on the scale for each version. Each photo represents a different BMI range. The images are ranked from A to G according to increasing BMI.

Balance will be assessed using the Flamingo Balance Test. The test requires a wooden beam measuring 50 cm in length and 4 cm in height, and a stopwatch. Participants will be asked to stand barefoot on the beam for one minute, balancing on one leg while the other leg is flexed at the knee and held with the hand on the same side, mimicking a flamingo stance. Before the test, one practice trial will be provided to familiarize the child with the procedure. The test begins with a start command and is interrupted each time balance is lost, defined as the free leg touching the ground. After each loss of balance, the test is resumed until a total of one minute is completed. The score is recorded as the number of balance attempts within one minute. If balance is lost more than 15 times within 30 seconds or if the child falls, the test is terminated and a score of zero is recorded. The test is performed for both legs.

Dynamic balance will be assessed using the Y Balance Test. Participants will stand on one leg with both hands placed on their hips, positioning the great toe of the stance foot at the center starting line. While maintaining single-leg stance, participants will reach as far as possible with the free limb in the anterior, posteromedial, and posterolateral directions. The maximum reach distance in each direction will be measured with a measuring tape and recorded. The procedure will be repeated for the opposite lower extremity. Trials will be repeated if the participant fails to maintain balance, moves or lifts the stance foot, touches the ground with the reaching foot before reaching the maximum distance, or fails to return the reaching foot to the starting position. Lower extremity length will be measured from the anterior superior iliac spine to the medial malleolus for score normalization. The composite reach distance will be calculated as [(maximum anterior + maximum posteromedial +

Speed and agility will be assessed using the Single-Leg Side Hop Test on the preferred leg. Participants will stand on their preferred leg with their hands placed on their hips, while the non-stance leg is held in neutral hip position with the knee flexed at 90 degrees. While maintaining this position, participants will be instructed to hop laterally to the right and left of a marked line as many times as possible within 15 seconds. A stopwatch will be used to time the test, and the number of correctly performed hops will be recorded. The test will be terminated if the participant removes their hands from their hips or if the stance foot loses its position or drops below the required level.

Flexibility will be assessed using the Sit-and-Reach Test. This test is commonly used to evaluate flexibility of the hamstring and posterior lower limb muscle groups. Participants will be barefoot and dressed in comfortable clothing, seated on the floor in a long-sitting position with the ankles positioned in neutral. They will be instructed to lean forward from the hips and reach as far as possible without bending the knees, holding the final position for approximately two seconds. The test will be performed twice, and the best distance reached will be recorded in centimeters.