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Impact of Game-Based Health Promotion Programs on Body Mass Index in Overweight/Obese Children and Adolescents: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Abstract
Background:
Sedentary lifestyle is growing among children and adolescents that may contribute to problems such as overweight and obesity. Consequently, interventions to improve weight loss in this population are necessary. The aim of this current review was to evaluate the effectiveness of game-based interventions to reduce body mass index (BMI) among children who were overweight or obese.
Methods:
All randomized controlled trials with a game-based approach for lowering weight in obese/overweight youths aged 5-18 years old were identified from January 2005 to June 2017 across PubMed, Web of Science, Embase, Scopus, and ScienceDirect. Two independent reviewers completed data extraction sheets on information such as sample size, country of origin, age of participants, type of interventions, and BMI change from pre- to posttest. A consensus on collected data was obtained, and a final list of studies meeting inclusion and exclusion criteria was arrived at. Data were analyzed using Comprehensive Meta-analysis software, and effect size was measured by standardized mean difference (SMD) and Hedges' g measure. Heterogeneity and publication bias were also examined using I2 index and funnel plot.
Results:
A total of 388 articles were identified from electronic and manuals' searches. After deletion of duplicated articles, 138 articles remained that were then screened in terms of relevance. Of those, 41 articles were examined to determine eligibility. Finally, 10 articles met inclusion/exclusion criteria and were entered into the quantitative meta-analysis. Results indicated a small but significant effect size in terms of BMI reduction [SMD, -0.234; standard error (SE), 0.069] among included studies. The average BMI z-score reduction was -0.181 (SE, 0.071). Trials which used other types of interventions along with active game-based approaches achieved greater effect sizes than single game-based interventions. There was a significant difference between studies based on their country of origin, BMI value, and intervention type. Those conducted in United States, those including participants with BMI ≥30, and studies with multicomponent intervention reported a higher reduction of BMI than others. However, no significant difference in BMI was found in terms of variables such as age, sample size, type of participant (overweight/obese), intervention duration, or participant gender. No publication bias was identified, and studies were homogenous (I2 = 22.5%).
Conclusions:
Interventions that involve active gaming may produce small effects in terms of improving BMI among children who are overweight/obese. Therefore, we recommend that supplemental interventions be used to enhance the effectiveness of game-based interventions.
... Of the 28 reviews, four focused on diet therapy only; 14-17 five on supervised exercise training; [18][19][20][21][22] one on sedentary behaviors; 23 and 18 on multicomponent behaviorchange lifestyle interventions, including three with gaming tools; three with eHealth, mHealth, or telehealth, with one in each category; and two with motivational interviewing. [5][6][7][24][25][26][27][28][29][30][31][32][33][34][35][36][37][38] For a detailed description of the included reviews, see Appendix II in the Supporting Information. ...
... Interventions involving digital technology that integrated games, 19,24,25 eHealth, 26 mHealth, 27 and telehealth 28 body weight: −3.67 kg, 20 trials, 1993 participants; low-to-moderatequality evidence) was similar with other younger age groups, and the effects of diet therapy were the same as that in multicomponent lifestyle interventions. 7 Most trials used multidisciplinary intervention approaches with a combination of diet, physical activity, and behavioral components. ...
... , well-designed studies are needed before conclusions on the effect of digital technology on obesity management in children and adolescents can be made.24,[26][27][28] DISCUSSIONMain findingsBehavior-change lifestyle interventions combining diet, physical activity intervention, and behavior-change strategies may be useful for obesity treatment in children and adolescents. ...
Behavior‐change lifestyle interventions are fundamental in children and adolescent obesity management. This scoping review discusses optimal behavior‐change lifestyle interventions in the treatment of overweight and obesity in children and adolescents. A literature search on diet, physical activity, and behavioral intervention for obesity treatment in children and adolescents aged 0–19 years was conducted in the Cochrane Library, MEDLINE (OVID), EMBASE, and ClinicalTrials.gov. Systematic reviews and meta‐analyses with randomized controlled trials (RCTs) published in English from June 2016 to November 2022 were retrieved to identify recent advancements. Obesity outcomes included body weight, body mass index (BMI), BMI z‐score, and fat percentage, among others. The 28 located reviews included: four studies on diet therapy; five on physical activity (exercise training); one on sedentary activities; 18 on multicomponent behavior‐change lifestyle interventions, including three that incorporated gaming; three with eHealth, mobile health (mHealth), or telehealth, with one in each category; and two on motivational interviewing. Behavior‐change lifestyle interventions to reduce obesity in children and adolescents were associated with moderate effects, with low‐quality evidence for diet therapy and high‐quality evidence for exercise training, both for weight or BMI reduction. Long‐term intensive multicomponent behavioral interventions with parental involvement demonstrated better effects.
... The majority of children spend time playing digital games [26][27][28][29] and mobile games are the most popular of its forms [30]. They offer a conducive channel to engage children in health promotion [31] [32] and a healthy lifestyle in fun and effective ways [27] [33][34][35][36][37][38][39]. Evidence shows that health games can increase energy expenditure [33] [36] and improve cardiovascular functioning [34]. ...
... It may also help in regulating Body Mass Index (BMI) to recommended levels [33] [34], promote healthy eating habits [35], and increase self-efficacy as well as self-esteem [38]. Moreover, it can be useful for the rehabilitation of children with special needs [36] [39]. ...
... The use of digital games to promote health such as exergames has increased over the years due to its potential to provide evidence-based health interventions to its target users [35][38] [39]. Exergames or active video games [40] [41] are digital games combined with physical exercise to induce physical activity [42]. ...
A theory-based exergame was developed for tweens to promote their self-efficacy towards physical activity and increase their physical activity levels. We used protocols from both health science and gamification research in piloting the exergame. First, we assessed the usability and feasibility of the exergame and conducted a preliminary exploration of its effectiveness. After technical improvements were made based on our findings, we reiterated the pilot study and analysed the gamification elements of the exergame by using Octalysis analysis. The overall findings suggest that a theory-based exergame can positively influence the self-efficacy of tweens towards physical activity. The exergame showcased theoretical strength, achieved using diverse gamification elements but its overall game design and usability can be further improved. The study concludes that health-related components of the purpose of intervention must be incorporated in parallel with the engaging design of the game, taking into utmost consideration the theories, evidence as well as the needs and perceptions of its target users. This study provides valuable insights on future development and evaluation of gamified health interventions.
... Thus, increasing exercise adherence and active life among adolescents is of crucial importance. To overcome the main two problems of inactivity (i.e., absence of facilities, loss of motivation) and the high incidence of obesity, exergames has been proposed in previous studies (6,13). Exergames, video games (i.e., game played on a digital device) that combine body movement with gaming skills, is one of the strategies used to turn sedentary screen time into physically active screen time (6,13). ...
... To overcome the main two problems of inactivity (i.e., absence of facilities, loss of motivation) and the high incidence of obesity, exergames has been proposed in previous studies (6,13). Exergames, video games (i.e., game played on a digital device) that combine body movement with gaming skills, is one of the strategies used to turn sedentary screen time into physically active screen time (6,13). A meta-analysis study indicated that children with overweight Abbreviations: RPE, Rating of perceived exertion; DBP , Diastolic blood pressure; SBP, Systolic blood pressure; RIF, Ramadan intermittent fasting; BMI, Body mass index; LDL, low-density lipoprotein; HDL, High-density lipoprotein; TC, Total cholesterol; TG, Triglycerides. ...
... A meta-analysis study indicated that children with overweight Abbreviations: RPE, Rating of perceived exertion; DBP , Diastolic blood pressure; SBP, Systolic blood pressure; RIF, Ramadan intermittent fasting; BMI, Body mass index; LDL, low-density lipoprotein; HDL, High-density lipoprotein; TC, Total cholesterol; TG, Triglycerides. aged 5-18 years old observed a slight decrease in body mass after using exergames (13). Several studies on exergaming were mainly focused on physical activity and health promotion [e.g., cardiovascular disease risk factors in the home setting (6)]. ...
The effects of exergaming on biochemical responses has been investigated; however, no data is available for this effect during Ramadan intermittent fasting (RIF). RIF is a daily fasting characterized by abstaining from eating and drinking from sunrise to sunset for 29–30 days. The purpose of this study was to investigate the effect of exergaming during RIF on body composition, physical performance and hematological parameters in overweight and adolescents with obesity. Twenty-four adolescents with obesity were divided into two groups [control group (CG), n = 12, or cooperative sport exergaming group (EG), n = 12: 45 min per session during five days per week)]. Participants completed a 6-min walking test (6MWT), a squat jump test and a 10 and a 30m sprint tests in four different occasions: before Ramadan (T0), the second week of Ramadan (T1), the fourth week of Ramadan (T2), and after Ramadan (T3). Blood pressure, rating of perceived exertion (RPE), body composition, central obesity index, dietary intake and profile of mood states (POMS) were, also, assessed over the four periods. The results showed that body weight, body mass index and body fat percentage were significantly lower at T2 compared to T0 and T1 in the EG. After RIF, body composition returned to the values recorded before RIF. The POMS score was significantly lower during T2 compared to T0, T1 and T3 in the EG. The vertical jump and the 6MWT distance were significantly higher (i) at T2 compared to T0, T1 and T3 in the EG and (ii) in EG compared to CG at T2. RPE was significantly lower (i) at T2 compared to T0, T1 and T3 in the EG and (ii) in EG compared to CG at T2. Blood pressure was lower during T2 compared to the other periods in EG. The EG experienced significant decreases in total cholesterol and triglycerides during T2. However, no significant changes between groups and periods was reported for all the other parameters. In conclusion, exergaming during RIF has a positive effect on body composition and physiological and psychological responses in adolescents with obesity.
... 11 Nevertheless, similar results were shown between the two groups in general PA level in another MA. 12 Among weight management outcomes, small effect sizes were observed in the AVG group compared with the no AVG group for reducing BMI in multiple MA. [12][13][14] However, AVGs were found to be ineffective in reducing body fat compared with the minimal AVG-applied groups. 12 Inconsistent results were observed in reducing body weight; one MA showed that AVGs were more effective than no AVGs, whereas two other MAs showed no effects in both groups. ...
... Overall, 17 SRs were included in this overview for the subsequent literature screening for eligible RCTs. [11][12][13][14][15][35][36][37][38][39][40][41][42][43][44][45][46] The SR selection process details are shown in Figure 1. ...
... All 17 SRs with or without MA were assessed in domains 1-10, 13-14, and 16. Among the 17 SRs, 5 included MA[11][12][13][14][15] ; therefore, domains 11, 12, and 15 were assessed only in these five SRs. Among all SRs, authors performed particularly well on domains 1 and 16 in which more than 80% of the SRs could score "yes" for these two domains. ...
We synthesised evidence on the effectiveness of active video games (AVGs) versus no AVG‐applied comparators on various physical activity (PA) levels and weight management outcomes in children and adolescents. We analysed the comparative evidence on different sub‐categories of AVGs and ranking the best option. An overview of systematic reviews (SRs) and network meta‐analysis (NMA) (PROSPERO: CRD42021248499) was employed. A search for relevant literature published in English was conducted in six electronic databases from their inception until April 2021. SRs consisting of randomised control trials (RCTs) and satisfying our PICOS inclusion criteria were included. RCTs included were a comparison of groups among children and adolescents between 6 and 21, where groups with AVG interventions were compared with groups without them. Direct head‐to‐head pairwise meta‐analyses were conducted using weighted mean difference between the two groups, and the comparative effectiveness of different sub‐categories of AVGs was analysed indirectly using NMA. Overall, 17 SRs were identified from the 6,036 screened citations. Of these, 350 citations were retrieved, and 12 RCTs were finally included. Compared to no AVG group, AVG groups were shown to be more effective in achieving vigorous, moderate‐to‐vigorous, and moderate PA levels, and decreased BMI and body fat. NMA showed that rhythmic dance games had the highest probability of being the most effective sub‐category for reducing BMI. AVGs are effective in attaining vigorous, moderate to vigorous, and moderate PA levels and reducing BMI and body fat among children and adolescents. Dance appears to be the best option for reducing BMI among AVG subcategories.
... Seventeen studies were included [18,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45], from which 7 were systematic reviews and meta-analysis [18,32,33,36,37,44,45]. All studies focused on children and adolescents of both sexes with an age ranged from 3 to 19 years. ...
... Seventeen studies were included [18,[30][31][32][33][34][35][36][37][38][39][40][41][42][43][44][45], from which 7 were systematic reviews and meta-analysis [18,32,33,36,37,44,45]. All studies focused on children and adolescents of both sexes with an age ranged from 3 to 19 years. ...
... Most of the systematic reviews and/or meta-analyzes included were of moderate quality (12 studies), that is, although there are some methodological flaws, these studies are able to accurately summarize the results. Two studies with high quality [44,45], two studies with low quality [34,39] and one study with critically low quality [31] were included in the review. The results of the analyzes are shown in Table 2. ...
Abstract: The aim of this study was to synthesize the evidence on the effects of active video games
(AVGs) on mental health, physical fitness and body composition of children and adolescents. A
search was conducted in the following databases: PubMed; MEDLINE (by Ovid); SportDiscus,
Cochrane library systematic reviews (CENTRAL) and EMBASE with no language restrictions during
October 2020. Reviews on the use of AVGs were included in the study. We use the AMSTAR (A
MeaSurement Tool to Assess systematic Reviews) scale to analyze the methodological quality of
the studies. Seventeen systematic reviews and meta-analyzes were included on the effects of AVGs
with 30 to 4728 children and adolescents of both sexes with ages ranging from 6 to 19 years. In five
studies, the population was overweight or obese. Regarding the quality, 12 studies were of moderate
quality, two had high quality, two had low quality and one showed very low quality. The analyzed
data indicate that the use of AVGs with a frequency of 1 to 3 times a week with durations of between
10 and 90 min per day shows positive effects on mental health and physical functioning. There
was moderate quality evidence that AVGs can result in benefits for self-esteem, increased energy
expenditure, physical activity and reduced body mass index in children and adolescents who used
AVGs in the home environment. Further research is needed on this tool to help in the process of
social isolation and consequently in promoting health and well-being.
... To date, most of the very few attempts to gamify weight loss have prioritized increasing physical activity and shown only modest success [21]. Gamification may be more effective in programs that primarily emphasize dietary intake, the stronger determinant of weight loss [22,23]. ...
... The study design is also rigorous in that the controls for gamification and neurotraining are robust (a professionally designed gold-standard behavioral weight loss mobile app, and a sham, respectively). The few previous studies of gamified weight loss [21,23,35,58] have relied on rudimentary games created by university teams and/or created simple and narrow gamification targets that were limited to physical activity [18][19][20]. Another strength is the use of an advisory panel of men with overweight/obesity throughout study design to inform development of the gamified weight loss app and ICT. ...
Over 70% of men are overweight, and most desire weight loss; however, men are profoundly underrepresented in weight loss programs. Gamification represents a novel approach to engaging men and may enhance efficacy through two means: (1) game-based elements (e.g., streaks, badges, team-based competition) to motivate weight control behaviors and (2) arcade-style “neurotraining” to enhance neurocognitive capacities to resist the temptation of unhealthy foods and more automatically select healthy foods. This study will use a 2 × 2 factorial design to examine the independent and combinatory efficacy of gamification and inhibitory control training (ICT). Men with overweight/obesity (N = 228) will receive a 12-month mobile weight loss program that incorporates behavioral weight loss strategies (e.g., self-monitoring, goal setting, stimulus control). Men will be randomly assigned to a non-gamified or gamified version, and an active or sham ICT. A game design company will create the program, with input from a male advisory panel. Aims of the project are to test whether a gamified (versus non-gamified) weight loss program and/or ICT (versus sham) promotes greater improvements in weight, diet, and physical activity; whether these treatment factors have combinatory or synergistic effects; to test whether postulated mechanisms of action (increased engagement, for gamification, and inhibitory control, for ICT) mediate treatment effects; and whether baseline gameplay frequency and implicit preferences for ICT-targeted foods moderate effects. It is hoped this study will contribute to improved mHealth programs for men and enhance our understanding of the impact of gamified elements and neurocognitive training on weight control.
... but this loss was less pronounced in the EGrlt, since in this group, there were no significant differences between the first and second measurements (p = 0.069; 95% CI − 0.815 to 28.581) or between the second and third measurements (p = 0.950; 95% CI − 6.816 to 10.11). In contrast, in the other two groups, we did observe significant losses between the first and second measurements (EGpmc: p = 0.013, 95% CI 3.446- 35 Fig. 3). ...
... Although infants treated with RLT showed a lower weight than the group treated with PMC, the EGrlt significantly increased their weight in each measure, showing a gain similar to those of the remaining groups, since no differences were observed in terms of interaction (Fig. 3) and they ended showing better improvements in QUS. An explanatory hypothesis of this result may be due to the consideration of RLT as a non-voluntary active exercise, taking into account the results of different meta-analyses that relate active physical exercise and weight control, which, although performed in the paediatric population, could be extrapolated to the neonatal population 35,36 . ...
Preterm infants have a low level of bone mineralization compared to those born at term. The purpose of the present study was to investigate the effect of reflex locomotion therapy (RLT) on bone mineralization and growth in preterm infants and compare its effect to other physiotherapy procedures. Forty-six preterm infants born at 29–34 weeks were randomized into three groups: one group received RLT (n = 17); the other group received passive movements with gentle joint compression (n = 14); and the control group received massages (n = 15). All the treatments were performed at the neonatal unit for one month. The main outcome measure was bone mineralization, which was measured using the tibial speed of sound (Tibial-SOS). All the groups were similar in terms of gestational age (31.8 ± 1.18), birth weight (1,583.41 ± 311.9), and Tibia-SOS (1,604.7 ± 27.9) at the beginning of the intervention. At the end of the study, significant differences were found among the groups in the Tibial-SOS [F(4,86) = 2.77, p = 0.049, ηp² = 0.114] in terms of the benefit to the RLT group. In conclusion, RLT has been effective at improving Tibial-SOS levels and has been more effective than other physical therapy modalities; therefore, it could be considered an effective physiotherapeutic modality for the prevention and treatment of osteopenia from prematurity.
... The lifestyle classes generated in the present study were identified from different behavioral measures of the Broad literature shows obesity to be the biggest public health issue across the world and to have been considerably increasing in the past years, thanks to the confluence of multiple lifestyle-related factors [3]. Childhood and adolescence are key periods of interest because they may potentially be a prime opportunity for the development of obesogenic behaviors, which can stabilize or further increase during adult life [31]. ...
... The consumption of alcoholic beverages by adolescents is worrisome because of both the greater tendency to impulsivity at this stage of life and the damage caused to brain development by alcohol. Adolescents' use of alcohol, tobacco, marijuana, and other illicit drugs is a significant public health concern due to its prevalence and associated negative health and psychosocial consequences [31,42]. ...
Background
Lack of regular physical activity, high sedentary behavior and presence of unbalanced alimentary practices are attitudes associated with an inadequate lifestyle among female adolescents.
Objective
to assess the lifestyle of female adolescents based on measurements of behavioral variables.
Methods
Cross-sectional study with 405 female adolescents between 14 and 19 years old, resident and attending public schools in Viçosa (state of Minas Gerais). Their lifestyle was analyzed by the Physical Activity Recall, number of steps, screen time (ST), cellphone time (CT), sitting time, food frequency questionnaire (FFQ), and alcohol and tobacco consumption. With multiple correspondence analysis it was possible to observe dispersion and approximation of the variables’ categories. Latent class analysis (LCA) was used for modeling the “lifestyle” variable, having been conducted in the poLCA (Polychromous Variable Latent Class Analysis) package of the R statistical software.
Results
The mean age was 15.92 ± 1.27 years. Most of the adolescents were considered physically inactive (78%) and with low number of steps (82.57%); 41.45% reported not performing Moderate to Vigorous Physical Activities (MVPA) adequately. Sedentary behavior was found high when assessing ST (72.90%) and CT (65.31%). It was found the best fitted latent class model for the lifestyle (p-G² = 0.055, p-χ² = 0.066) featured three latent classes and one covariate (alcohol): Class 1, ‘Inactive and Sedentary’ (γ = 77.5%); Class 2, ‘Inactive and Non-sedentary lifestyle (γ=16.31%); and Class 3, ‘Active and sedentary’ (γ=6.19%). Female adolescents that had ‘never consumed alcohol’ were 2.26 times as likely (log OR = 0.8174; p = 0.033) to belong to class 3 (Active & Sedentary lifestyle) than to class 1 (Inactive & Sedentary lifestyle).
Conclusion
Latent class analysis model with five manifest variable (MVPA, number of steps, ST, sitting time and number of meals) and alcohol consumption like covariate showed itself to be an accurate and objective method in the assessment of female adolescents’ lifestyle. Female adolescents that had ‘never consumed alcohol’ were more as likely to belong to class ‘Active & Sedentary lifestyle’ than to class Inactive & Sedentary lifestyle. An inactive and sedentary lifestyle is coupled to other unhealthy behaviors during adolescence, possibly carrying over into adult life.
... Systematic reviews with meta-analysis [42,43] suggest that the strategy of active game decreases Therefore, decrease in BMI [44] and improvement of pulmonary function and cardiorespiratory fitness [13,45] could benefit adolescent students. ...
Objective: To verify the effects of physical exercise using a gamified exergame on pulmonary function and cardiorespiratory fitness of adolescents with overweight in their school environment. Methods: This controlled clinical trial was conducted in two schools. Adolescents aged 10-16 years with overweight or obesity were eligible. Control group received physical education classes and orientations provided by school. Intervention group performed physical exercise using the exergame associated with gamification in school, with four adolescents per group, three times per week during eight consecutive weeks. For gamification, the performance was scored every week, generating a weekly classification and a final at the end of the study. Cardiorespiratory fitness was assessed indirectly using the maximal oxygen consumption (VO2max) from the 20-meter shuttle run test. Pulmonary function was assessed using manovacuometry and spirometry. Results: Intervention and control groups were composed of 36 and 27 adolescents, respectively. Adolescents that performed the exergame presented lower forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) and higher FEV1/FVC ratio than the control group. Intervention group increased FEV1 (p = 0.041) and maximal expiratory pressure (PEmax) (p = 0.009), decreased body mass index (BMI) (p < 0.001), and improved VO2max (p = 0.007), compared to baseline. Control group increased FEV1 (p = 0.021), FVC (p = 0.014), and FEV1/FVC ratio (p = 0.033) and decreased BMI (p < 0.001), compared to baseline. Conclusion: Exergame improved pulmonary function, and intragroup analysis showed the gamified exergame improved pulmonary function, nutritional status, and cardiorespiratory fitness. Keywords: Adolescent; overweight; pediatric obesity; respiratory function test; cardiorespiratory fitness.
... Systematic reviews with meta-analysis [42,43] suggest that the strategy of active game decreases Therefore, decrease in BMI [44] and improvement of pulmonary function and cardiorespiratory fitness [13,45] could benefit adolescent students. ...
Objective: To verify the effects of physical exercise using a gamified exergame on pulmonary function and cardiorespiratory fitness of adolescents with overweight in their school environment. Methods: This controlled clinical trial was conducted in two schools. Adolescents aged 10-16 years with overweight or obesity were eligible. Control group received physical education classes and orientations provided by school. Intervention group performed physical exercise using the exergame associated with gamification in school, with four adolescents per group, three times per week during eight consecutive weeks. For gamification, the performance was scored every week, generating a weekly classification and a final at the end of the study. Cardiorespiratory fitness was assessed indirectly using the maximal oxygen consumption (VO2max) from the 20-meter shuttle run test. Pulmonary function was assessed using manovacuometry and spirometry. Results: Intervention and control groups were composed of 36 and 27 adolescents, respectively. Adolescents that performed the exergame presented lower forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) and higher FEV1/FVC ratio than the control group. Intervention group increased FEV1 (p = 0.041) and maximal expiratory pressure (PEmax) (p = 0.009), decreased body mass index (BMI) (p < 0.001), and improved VO2max (p = 0.007), compared to baseline. Control group increased FEV1 (p = 0.021), FVC (p = 0.014), and FEV1/FVC ratio (p = 0.033) and decreased BMI (p < 0.001), compared to baseline. Conclusion: Exergame improved pulmonary function, and intragroup analysis showed the gamified exergame improved pulmonary function, nutritional status, and cardiorespiratory fitness. Keywords: Adolescent; overweight; pediatric obesity; respiratory function test; cardiorespiratory fitness.
... Some studies explored the effect of serious games on healthy lifestyle promotion regardless of age, covering healthy diet, physical activity, social behavior, health responsibility, stress management, and selfactualization [14], but the effects on children and adolescents still remain inconclusive. A. Ameryoun et al. [15] examined the effect of active games in overweight/obese children or adolescents only, while both overweight/obese and normal children or adolescents were included in our study. Suleiman-Martos et al. examined the effect of gamification on BMI among children and adolescents based on only 2 studies [11]; our analyses generated com-prehensive and updated evidence based on 10 studies on body composition, which offers a more definitive summary estimate and may inspire further research in the development and application of serious games. ...
Over the past four decades, obesity in children of all ages has increased worldwide, which has intensified the search for innovative intervention strategies. Serious games, a youth-friendly form of intervention designed with educational or behavioral goals, are emerging as a potential solution to this health challenge. To analyze the effectiveness of serious games in improving body composition, physical activity, and dietary change, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) from PubMed, Web of Science, EMBASE, and Scopus databases. Pooled standardized mean differences (SMD) were calculated for 20 studies (n = 2238 the intervention group; n = 1983 in the control group) using random-effect models. The intervention group demonstrated a slightly better, although non-significant, body composition score, with a pooled SMD of −0.26 (95% CI: −0.61 to 0.09). The pooled effect tends to be stronger with longer duration of intervention (−0.40 [95% CI: −0.96, 0.16] for >3 months vs. −0.02 [95% CI: −0.33, 0.30] for ≤3 months), although the difference was not statistically significant (p-difference = 0.24). As for the specific pathways leading to better weight control, improvements in dietary habits due to serious game interventions were not significant, while a direct positive effect of serious games on increasing physical activity was observed (pooled SMD = 0.61 [95% CI: 0.04 to 1.19]). While the impact of serious game interventions on body composition and dietary changes is limited, their effectiveness in increasing physical activity is notable. Serious games show potential as tools for overweight/obesity control among children and adolescents but may require longer intervention to sustain its effect.
... This difference was believed to be caused by the fact that the physical activity was not performed by the practitioner in the study but left to the free-will of children in the study. In the systematic review and meta-analysis study by Ameryoun et al, 27 it was stated that AVG had a small effect on lowering BMI values. In the meta-analysis study conducted by Bochner et al, 28 it was stated that there was no difference between the pre-post test results of AVG, and it was reported that the duration of the analysed studies was short, the biases were high, and that better quality studies should be conducted in order to understand the effect of AVG. ...
Purpose: The study was conducted in order to determine the effect of the Nintendo Wii game and Colour MyPyramid Nutrition Education Programme in overweight and obese school-age children's Body-Mass Index, percentile values, healthy food consumption behaviours at school and depression levels. Methods: Overweight and obese students aged between 10 and 13 years were included in the randomised-controlled intervention study (N=78). After the participants participated in Colour MyPyramid Nutrition Programme and played Nintendo Wii game, their pre-intervention and post-intervention Body-Mass Index (BMI), and percentile values, healthy food consumption behaviours at school and depression levels were evaluated. Findings: It was determined that there was a significant decrease on the BMI and percentile values of the children in the experimental group (p<0.05), and they developed a healthier consumption behaviours at school and their depression levels decreased after the intervention (p<0.001). Conclusions: Active video games applied together with nutrition education within the scope of school health programmes make positive contribution due to the effects on weight loss, healthy food consumption behaviours at school and depression levels among overweight and obese school age children. Nutrition education applied with active video games in preventing childhood obesity is an important opportunity to increase the motivation of children.
... This difference was believed to be caused by the fact that the physical activity was not performed by the practitioner in the study but left to the free-will of children in the study. In the systematic review and meta-analysis study by Ameryoun et al, 27 it was stated that AVG had a small effect on lowering BMI values. In the meta-analysis study conducted by Bochner et al, 28 it was stated that there was no difference between the pre-post test results of AVG, and it was reported that the duration of the analysed studies was short, the biases were high, and that better quality studies should be conducted in order to understand the effect of AVG. ...
Purpose: The study was conducted in order to determine the effect of the Nintendo Wii game and Colour MyPyramid Nutrition Education Programme in overweight and obese school-age children's Body-Mass Index, percentile values, healthy food consumption behaviours at school and depression levels. Methods: Overweight and obese students aged between 10 and 13 years were included in the randomised-controlled intervention study (N=78). After the participants participated in Colour MyPyramid Nutrition Programme and played Nintendo Wii game, their pre-intervention and post-intervention Body-Mass Index (BMI), and percentile values, healthy food consumption behaviours at school and depression levels were evaluated. Findings: It was determined that there was a significant decrease on the BMI and percentile values of the children in the experimental group (p<0.05), and they developed a healthier consumption behaviours at school and their depression levels decreased after the intervention (p<0.001). Conclusions: Active video games applied together with nutrition education within the scope of school health programmes make positive contribution due to the effects on weight loss, healthy food consumption behaviours at school and depression levels among overweight and obese school age children. Nutrition education applied with active video games in preventing childhood obesity is an important opportunity to increase the motivation of children.
... El problema del sobrepeso y la obesidad se ha extendido mundialmente entre niños y jóvenes. Según estimaciones globales presentadas por la Organización Mundial de la Salud, en 2014, más de 41 millones de niños entre 0 y 5 años eran obesos y casi el 20% de los niños en edad escolar tienen sobrepeso u obesidad (7). ...
Introducción: la obesidad y el sobrepeso infantil se han convertido en un problema de salud pública debido al aumento de la prevalencia y el riesgo futuro de esta población para desarrollar enfermedades crónicas no transmisibles. Existen factores de riesgo establecidos como los hábitos alimentarios y el patrón de actividad física, siendo las actividades de prevención se encuentran enfocadas en controlar estas variables. Los datos estadísticos a nivel local son limitados frente esta problemática. Sin embargo, el aumento en el ámbito nacional acerca la prevalencia de obesidad y sobrepeso infantil permite conocer la epidemiología local para dar seguimiento y evaluar diferentes medidas de prevención e intervención a estas enfermedades. Objetivo: determinar la prevalencia de sobrepeso y obesidad, y factores de riesgo en niños de 7 a 12 años de una Institución Educativa de la ciudad de Cartagena -Colombia. Métodos: un estudio descriptivo en 269 escolares de una institución educativa de Cartagena. Respondieron una encuesta conformada por tres instrumentos. Se midió peso y talla, y se calculó el Índice de Masa Corporal. Se utilizó como referencia el patrón de crecimiento de referencia internacional para el grupo de 5 a 18 años del NCHS/OMS del 2007. Las variables se analizaron mediante estadísticas descriptivas. Resultados: los resultados indican que el exceso de peso afecta al 24,1% de los escolares: sobrepeso 15,99 % y obesidad 8,18%. El sobrepeso en hombres, 58,14% y en mujeres, 41,86%. La prevalencia de obesidad en hombres 59,09%, en mujeres 40,91%; el grupo de 10-12 años presenta mayor porcentaje de sobrepeso (65,12%), y de obesidad (64,63%). Se presentaron conductas alimentarias inadecuadas y un nivel de actividad física bajo, predominio de poca actividad física diaria, escasa práctica de deportes, un promedio elevado de horas frente al televisor, a los videojuegos o al computador. Conclusión: es evidente que existen períodos durante el crecimiento y el desarrollo, como en el caso de los escolares, en donde el riesgo de desarrollar sobrepeso y obesidad es más alto, no solo por la etapa biológica en la que se encuentran, también por los hábitos alimentarios y la reducción de la actividad física. Plantear y ejecutar acciones, que proporcionen soluciones efectivas, para controlar estos eventos.
... Although it is seen as an occupation for children, game is an activity that individuals of all ages can perform. It has been reported that game-based physical activity between children and adults have very important effects 10,11 . ...
Objective:
This study was planned to evaluate effects of game-based physical activity model on mother-child relationship and parental attitudes during the prolonged COVID-19 pandemic period.
Subjects and methods:
This study was designed using a web-based quasi-experimental model with a pre-test/post-test evaluation, with a control group. The mothers who accepted to participate in the study and their children were divided into experimental (group I, n=28) and control groups (group II, n=31). The mothers and children in the experimental group were asked to apply web-based game-based physical activity model for 20 minutes/day for 4 weeks. The online questionnaire included socio-demographic data form, Child Parent Relationship Scale (CPRS), and Parental Attitude Scale (PAS).
Results:
There were no significant differences between mean scores of pre-test and post-test subscales of the PAS in group I (p>0.05 for all subscales). It was found that post-test scores of democratic subscales of PAS statistically significant decreased (p=0.047) and the authoritarian attitude subscale scores significantly increased (p=0.033) in group II. The mean pre- and post-activity scores of positive/close relationship and conflictual relationship subscales of CPRS differ between groups (p<0.05 for both subscales). Pre-post test scores of group II were found to be significantly lower compared to group II.
Conclusions:
Our study provides a moderate improvement in parameters evaluated; however, we suggest that longer-term activities may have a more permanent and statistically significant effect.
... This resulted in an average study overlap of 29% within a meta-analysis, indicating that, on average, almost one-third of studies included in a meta-analysis were included in other meta-analyses on the same or similar topic. A single meta-analysis [26] consisted of articles with no (0%) overlap among articles included in the other meta-analyses, while all (100%) the studies included within one meta-analysis [19] were included in the other meta-analyses. Table 1 presents the median and interquartile range for the originally estimated summary SMD, the re-estimated summary SMD, the absolute difference, and the percent difference in the estimates across study classifications for both the fixed and random effects models. ...
s
Background
Pilot/feasibility or studies with small sample sizes may be associated with inflated effects. This study explores the vibration of effect sizes (VoE) in meta-analyses when considering different inclusion criteria based upon sample size or pilot/feasibility status.
Methods
Searches were to identify systematic reviews that conducted meta-analyses of behavioral interventions on topics related to the prevention/treatment of childhood obesity from January 2016 to October 2019. The computed summary effect sizes (ES) were extracted from each meta-analysis. Individual studies included in the meta-analyses were classified into one of the following four categories: self-identified pilot/feasibility studies or based upon sample size but not a pilot/feasibility study ( N ≤ 100, N > 100, and N > 370 the upper 75th of sample size). The VoE was defined as the absolute difference (ABS) between the re-estimations of summary ES restricted to study classifications compared to the originally reported summary ES. Concordance (kappa) of statistical significance of summary ES between the four categories of studies was assessed. Fixed and random effects models and meta-regressions were estimated. Three case studies are presented to illustrate the impact of including pilot/feasibility and N ≤ 100 studies on the estimated summary ES.
Results
A total of 1602 effect sizes, representing 145 reported summary ES, were extracted from 48 meta-analyses containing 603 unique studies (avg. 22 studies per meta-analysis, range 2–108) and included 227,217 participants. Pilot/feasibility and N ≤ 100 studies comprised 22% (0–58%) and 21% (0–83%) of studies included in the meta-analyses. Meta-regression indicated the ABS between the re-estimated and original summary ES where summary ES ranged from 0.20 to 0.46 depending on the proportion of studies comprising the original ES were either mostly small (e.g., N ≤ 100) or mostly large ( N > 370). Concordance was low when removing both pilot/feasibility and N ≤ 100 studies (kappa = 0.53) and restricting analyses only to the largest studies ( N > 370, kappa = 0.35), with 20% and 26% of the originally reported statistically significant ES rendered non-significant. Reanalysis of the three case study meta-analyses resulted in the re-estimated ES rendered either non-significant or half of the originally reported ES.
Conclusions
When meta-analyses of behavioral interventions include a substantial proportion of both pilot/feasibility and N ≤ 100 studies, summary ES can be affected markedly and should be interpreted with caution.
... SSVGs and MBVGs can be utilized by physical educators to motivate students [7], increase sport knowledge [15,16,17], and may provide students with disabilities greater sport-related opportunities [18]. However, while MBVGs can be used by students to expend calories through contributing toward moderate levels of daily physical activity [19] and have been shown to improve body mass index for overweight or obese children [20], they do not always mimic accurate sport-related biomechanical movements and should be used with caution regarding motor skill instruction [21,22]. In addition, evidence suggests positive transfer for perceptual-cognitive skill (e.g., recognizing patterns in developing sequences of soccer game play) with expert FIFA (i.e., a soccer SSVG) players and real-life semi-professional soccer players compared to a control group, indicating playing this SSVG facilitates sport-specific perceptual-cognitive skills [23]. ...
The two-pronged purpose of this study was to determine: 1) whether playing a sedentary sport video game (SSVG) is more effective than traditional hands-on instruction in learning a new sport, and 2) whether playing a SSVG motivated the future viewing or playing intentions of the authentic sport. A mixed-method multi-phase intervention was conducted with two quasi-experimental groups. Participants (n = 38) were college students
enrolled in an undergraduate physical activity course with little prior knowledge of rugby. The first semester of data collection included the Instruction First (IF; n = 19) group taking a rugby pre-test, performing two rugby instruction sessions, taking a mid-test, performing two rugby gaming sessions, taking a post-test, and finished with a focus group session. The next semester, the Video Gaming First (GF; n = 19) group replicated these procedures, but the order of gaming and instruction sessions were switched. Results indicated the gaming sessions alone significantly (p <.05) increased overall rugby knowledge test scores for the GF group. Focus group findings revealed the SSVG motivated intentions to watch rugby, but not to physically play it. Overall, SSVGs
might be used to augment, but certainly not replace, traditional sport instruction.
... The use of games (e.g., card and video games) as teaching tools is an emerging educational approach that has been applied to address sensitive topics such as obesity prevention and sex education. [4][5][6][7] Games designed in the context of developmental stages may improve health behaviors more effectively than tradi-tional instruction. 8 Consequently, age-appropriate games adapted to developmental stages of psychomotor function may hypothetically improve the oral hygiene of preschool children. ...
Aim: To compare the benefits of didactic versus board game-based oral health instruction on oral health knowledge (OHK) and oral hygiene of preschool students. Materials and Methods: Participants were selected through computer-assisted randomization. (Eighty students were selected in both the 3- to 4-year-old and 5- to 6-year-old age groups, respectively, for a total of 160 participants). Forty participants of each age group were assigned randomly to Group A (PowerPoint® presentation) and 40 to Group B ("Dental Truth or Dare" board game-based instruction). OHK and debris index-simplified (DI-S) were assessed at preintervention, and at 1-week, 1-month, and 3-month postintervention timepoints. Results: OHK scores increased significantly in the 3- to 4-year-old subset of Group A at the 1-week postintervention timepoint but declined and approximated the baseline value at the 3-month timepoint. In contrast, compared to baseline, significantly improved OHK scores were observed at all 3 timepoints in both age groups in Group B, and were especially pronounced in the 5- to 6-year-old subset. Although the 3-month scores were slightly lower than the 1-week scores, they were well above baseline values. Pre- and postintervention DI-S scores did not change significantly in the 3- to 4-year-old subset of Group A. However, significant increases in good DI-S scores and decreases in fair and poor scores were observed between baseline and 3-month timepoints in the 5- to 6-year-old subset of Group A and in both age subsets of Group B (P ≤ 0.05). OHK and DI-S scores were significantly higher among 5-6-year-olds than among the 3-4-year olds in both Groups A and B (P ≤ 0.05). Age and board game intervention were the main determinants of higher OHK and lower DI-S scores. The impact of intervention mode (board game) was greater than that of age. Conclusion: Board game-based oral hygiene education conferred significant short-term retention, enhanced OHK, and reduced DI-S. We conclude that gaming is an easily implemented and cost-effective educational tool for the improvement of oral hygiene in preschool children.
... However, all the preschool-based randomised controlled trials in the study were done in the United States of America (USA), which involved low-income or ethnic minority populations. Another systematic review study found that more than half of the health-related behaviour change intervention studies were conducted in the USA [26]. Most studies were done in developed countries, making it challenging to generalise the results globally. ...
Introduction
Unhealthy weight, especially childhood obesity, is emerging as a growing epidemic and a challenge in developed and developing countries. Partnership with parents to promote healthy lifestyle changes may have a lifelong impact on weight-related outcomes in children. This study aims to determine the efficacy of an Interactive Malaysian Childhood Healthy Lifestyle (i-MaCHeL) intervention programme to change weight-related behaviour in preschool child-parent dyads.
Materials and methods
The i-MaCHeL programme is a single-blind, theory-driven intervention, two-group cluster randomised controlled trial that evaluates the efficacy of a 3-month health promotion intervention in preschool child-parent dyads. In recognition of the value of multiple theoretical approaches, the strong theoretical basis consists of Social Cognitive Theory, Health Belief Model, and Trans-Theoretical Model principles underpinning the development of the intervention programme. In total, 460 child-parent dyads from 12 preschools in Terengganu, Malaysia, will be recruited. The children in the intervention group will expose to the i-MaCHeL classroom activities, while the parents will access the i-MaCHeL Web-based educational programme and numerous parent-child home-based online activities. The children in the control group will continue with any existing health-related activities, while the parents will receive the link to the general health newsletters. BMI z-score, dietary intake, physical activity, screen time duration, health-related quality of life, parental self-efficacy, parental role modelling, and parental policies will be assessed at baseline, 3 months’ post-baseline, and at 6 months’ follow-up (9 months’ post-baseline). General linear model repeated measure analysis will be used to determine differences between groups at the 3- and 9-month surveys with adjustment for potential covariates. Statistical analyses will follow intention-to-treat principles.
Conclusion
We hypothesise that the combination of the classroom and interactive Web-based activities will have a strong potential to be effective strategies to sustain child-parent engagement and participation in the weight-related behaviour change programme.
Clinical trial registration
ClinicalTrials.gov Identifier: NCT04711525.
... Lo mismo ocurre si se fomenta el uso de videojuegos activos en detrimento de los videojuegos de tipo sedentario, especialmente si esta conducta ayuda al cumplimiento de las recomendaciones de actividad física como algunos estudios sugieren (Beltrán-Carrillo, Beltrán-Carrillo, González-Cutre, Biddle, y Montero-Carretero, 2016;Sween et al., 2014;Valencia-Peris, Úbeda-Colomer, Lizandra, Peiró-Velert, y Devís-Devís, 2019). Así lo indican algunas evaluaciones de programas de intervención basados en el uso de videojuegos activos que ayudan a reducir el tiempo de actividad sedentaria y aumentar el de actividad física (Ameryoun, Sanaeinasab, Saffari, y Koenig, 2018). ...
Disponible en https://zaguan.unizar.es/record/112418/files/BOOK-2022-012.pdf
... Digital games often offer stimulating audiovisual game worlds and appealing rewards [36,37]. Given these motivational aspects [38,39], serious gaming is already widely applied in educational, psychological, and medical contexts [40][41][42][43][44], including the field of language learning (eg, game-based interventions specifically targeting vocabulary [45]). However, when designing a commercial serious digital game, detailed knowledge of game enjoyment is of crucial relevance. ...
Background:
Enjoyment plays a key role in the success and feasibility of serious gaming interventions. Unenjoyable games will not be played, and in the case of serious gaming, learning will not occur. Therefore, a so-called GameFlow model has been developed, which intends to guide (serious) game developers in the process of creating and evaluating enjoyment in digital (serious) games. Regarding language learning, a variety of serious games targeting specific language components exist in the market, albeit often without available assessments of enjoyment or feasibility.
Objective:
This study evaluates the enjoyment and feasibility of a tablet-based, serious story-listening game for kindergarteners, developed based on the principles of the GameFlow model. This study also preliminarily explores the possibility of using the game to foster language comprehension.
Methods:
Within the framework of a broader preventive reading intervention, 91 kindergarteners aged 5 years with a cognitive risk for dyslexia were asked to play the story game for 12 weeks, 6 days per week, either combined with a tablet-based phonics intervention or control games. The story game involved listening to and rating stories and responding to content-related questions. Game enjoyment was assessed through postintervention questionnaires, a GameFlow-based evaluation, and in-game story rating data. Feasibility was determined based on in-game general question response accuracy (QRA), reflecting the difficulty level, attrition rate, and final game exposure and training duration. Moreover, to investigate whether game enjoyment and difficulty influenced feasibility, final game exposure and training duration were predicted based on the in-game initial story ratings and initial QRA. Possible growth in language comprehension was explored by analyzing in-game QRA as a function of the game phase and baseline language skills.
Results:
Eventually, data from 82 participants were analyzed. The questionnaire and in-game data suggested an overall enjoyable game experience. However, the GameFlow-based evaluation implied room for game design improvement. The general QRA confirmed a well-adapted level of difficulty for the target sample. Moreover, despite the overall attrition rate of 39% (32/82), 90% (74/82) of the participants still completed 80% of the game, albeit with a large variation in training days. Higher initial QRA significantly increased game exposure (β=.35; P<.001), and lower initial story ratings significantly slackened the training duration (β=-0.16; P=.003). In-game QRA was positively predicted by game phase (β=1.44; P=.004), baseline listening comprehension (β=1.56; P=.002), and vocabulary (β=.16; P=.01), with larger QRA growth over game phases in children with lower baseline listening comprehension skills (β=-0.08; P=.04).
Conclusions:
Generally, the story game seemed enjoyable and feasible. However, the GameFlow model evaluation and predictive relationships imply room for further game design improvements. Furthermore, our results cautiously suggest the potential of the game to foster language comprehension; however, future randomized controlled trials should further elucidate the impact on language comprehension.
... Despite the non-significant small effect of physical training with AVG on BMI, this type of intervention gains strength when used in combined approaches. Electronic games can help reduce sedentary screen time, bring motivation to adolescents through playing, understanding and adherence to healthy habits (Ameryoun et al., 2018). Furthermore, subgroup analysis showed that improvement in muscle resistance occurs in overweight sedentary adolescents (n=7), but not in eutrophic peers (n=7). ...
Objective: the aim of our study was to assess the effect of a physical activity that uses active video games in body composition, physical fitness, cardiovascular and biochemical parameters with sedentary adolescents. Methods: a non-controlled clinical trial design with a convenience sample of adolescents, separately, from ages ten to 17, of both genders. The intervention protocol consisted of physical activity with active video games (AVG), lasting two months, in 24 sessions, evolving into three levels (basic, intermediate and advanced) according to the maximum heart rate of the individuals. The adolescents’ body composition, physical fitness, cardiovascular and biochemical parameters were assessed. Data analysis was performed with a 95% confidence interval. Results: among the 14 adolescents that completed the physical training, we observed a improvement of muscle resistance (Δ= 8.26; p= 0.02) and decrease in post-exercise heart rate and systolic blood pressure (p< 0.01). However, were found a non-significant decrease in body fat percentage (Δ= -3.83; p= 0.24) and strength (Δ= 4.26; p= 0.57). A high level of satisfaction with the proposed activity was identified. Conclusion: a physical activity program based on AVG can reduce cardiovascular risk factors and improve muscle resistance in sedentary adolescents.
... Digital games often offer stimulating audiovisual game worlds and appealing rewards [36,37]. Given these motivational aspects [38,39], serious gaming is already widely applied in educational, psychological, and medical contexts [40][41][42][43][44], including the field of language learning (eg, game-based interventions specifically targeting vocabulary [45]). However, when designing a commercial serious digital game, detailed knowledge of game enjoyment is of crucial relevance. ...
BACKGROUND
Game enjoyment plays a key role in the success and feasibility of digital serious gaming interventions. Unenjoyable games will not be played and in the case of serious gaming, learning will not occur. Given this importance, a so-called GameFlow model has been developed, intending to guide (serious) game developers in the process of creating and evaluating enjoyment in digital (serious) games. Regarding language learning, a variety of serious games, targeting specific language components, exist on the market, albeit often without available assessments of enjoyment or feasibility.
OBJECTIVE
The current study evaluates enjoyment and feasibility of a tablet-based serious story listening game for kindergarteners, developed based on the principles of the GameFlow model. Given the focus on story listening, this study additionally aims at preliminary exploring the possibility of the game to foster language comprehension.
METHODS
Within the framework of a broader preventive reading intervention, 91 five-year old kindergarteners at cognitive risk for dyslexia were asked to play the story game for 12 weeks, six days per week, either combined with a tablet-based phonics intervention or tablet-based active control games. The story game mainly involved story listening and rating, and responding to content-related questions. Game enjoyment was assessed through post-intervention questionnaire outcomes, a GameFlow-based evaluation, and in-game story rating data. Feasibility was determined based on in-game general question response accuracy (QRA), reflecting the difficulty level, attrition rate, and final game exposure and training duration. Additionally, in order to investigate whether game enjoyment and difficulty could influence feasibility, final game exposure and training duration were predicted based on in-game initial story ratings and initial QRA. The possible growth in language comprehension was explored by analyzing in-game QRA as a function of game phase and baseline language skills.
RESULTS
Questionnaire and in-game data suggested an overall enjoyable game experience. The GameFlow-based evaluation however, implied room for improvement concerning the game design. General QRA confirmed a well-adapted difficulty level for the target sample. Moreover, despite an overall attrition rate of 39%, 80% of the participants still completed 90% of the game, albeit with a large variation in training days. Higher initial QRA resulted in a significantly higher game exposure (P<.001) and lower initial story ratings significantly slackened the training duration (P=.003). In-game QRA was positively predicted by game phase (P=.004), baseline listening comprehension (P=.002), and vocabulary (P=.010), with larger QRA growths over game phases in children with lower baseline listening comprehension skills (P=.044).
CONCLUSIONS
Generally, participants experienced the story game as enjoyable and feasible. Yet, the GameFlow-model evaluation and predictive relationships imply room for further game design improvement. Additionally, our results cautiously suggest a potential of the story game to foster language comprehension. Yet, future randomized controlled trials need to elucidate the actual gaming impact on language comprehension.
CLINICALTRIAL
S60962
... Therefore, preventive and rehabilitation interventions applied in this "window of opportunity" can be more effective in promoting changes to healthy behavior and, thus, in improving health throughout life [8]. In this regard, evidence suggests that behavioral-based interventions with a multidisciplinary approach, which includes individual and social aspects, are effective in improving the health status of overweight young people [9,10]. ...
Physical exercise reduces the biochemical markers of obesity, but the effects of multicomponent interventions on these markers should be explored. The present study aimed to elucidate how overweight/obese adolescents respond to a multicomponent program approach on body composition, physical fitness, and inflammatory markers, using a quasi-experimental study with 33 overweight/obesity adolescents (control group (CG) = 16; intervention group (IG) = 17). The intervention consisted of 24 weeks with physical exercises and nutritional and psychological guidance. Both groups were evaluated at the pre/post-intervention moments on body mass index (BMI); body fat (%Fat); waist circumference (WC); waist/hip ratio (WHR); waist-to-height ratio (WHtR), cardiorespiratory fitness (CRF); abdominal strength, flexibility; leptin; interleukin 6; interleukin 10; and tumor necrosis factor-alpha. Mixed-analysis of variance and generalized estimation equations were used for statistical analysis. There was an interaction effect between groups and time on %Fat (p = 0.002), WC (p = 0.023), WHR (p < 0.001), WHtR (p = 0.035), CRF (p = 0.050), and leptin (p = 0.026). Adolescents were classified as 82.4% responders for %Fat, 70.6% for WC, 88.2% for WHR, and 70.6% for CRF. Further, there was an association between changes in %Fat (p = 0.033), WC (p = 0.032), and WHR (p = 0.033) between responders and non-responders with CRF in the IG. There was a positive effect on body composition, physical fitness, and leptin. In addition, reductions in body composition parameters were explained by CRF improvements.
... 7 Recently, exergaming has been developed as a tool to improve player's health, but research to fully evaluate its health effects has only begun in recent years, and there are still few reports. Research on the therapeutic effects of exergaming may lead to improvements in a variety of conditions, including obesity in children, 8 as well as cognitive function in people with cognitive impairment due to neurodegenerative diseases such as Alzheimer's disease, 9 attention-deficit/ hyperactivity disorder, and depression. 10,11 An exergaming intervention study in patients with chronic neck and back pain found improvements in athletic performance and physical conditioning. ...
Objective:
In recent years, there has been an increase in research on the therapeutic effects of exergaming, but there have been few studies on these types of interventions for chronic low back pain. In this study, we hypothesized that the Nintendo Ring Fit Adventure (RFA) exergame would be effective for patients with chronic low back pain, and we conducted a randomized prospective longitudinal study.
Materials and Methods:
Patients with chronic low back pain were included in this study. Twenty randomly selected patients (9 males and 11 females, mean age 49.3 years) were included in the RFA group, and RFA exergaming was performed once a week for 40 minutes for 8 weeks. Twenty patients (12 males and 8 females, mean age 55.60 years) served as the control group and received oral treatment for 8 weeks. Pain and psychological scores (pain self-efficacy, pain catastrophizing, and kinesiophobia) were measured and analyzed before and after 8 weeks of treatment in both groups.
Results:
In the RFA group, low back pain, buttock pain, and pain self-efficacy were significantly improved after 8 weeks of RFA exergaming, but there was no significant improvement in lower limb numbness, pain catastrophizing, or kinesiophobia. In the control group, no significant improvement was observed after 8 weeks of oral treatment.
Conclusion:
RFA exergaming increased pain self-efficacy and reduced pain in patients with chronic low back pain. Future treatment protocols should be developed to improve pain self-efficacy.
Approval code:
2894, School of Medicine, Chiba University.
... This article is protected by copyright. All rights reserved game-based interventions showed a significant but small reduction of children and adolescents' BMI in the ten included RCT studies (17). ...
Aim
Web‐based interventions have shown promising results in paediatric obesity treatment with the potential to increase coverage of care. This study aimed to explore parental experiences about participating in an intervention to improve healthy behaviours and lower BMI‐SDS in children with obesity.
Methods
This was an interview study with an inductive qualitative approach. Data were collected from individual interviews with 14 parents to 5‐13 years old children with obesity. The respondents had participated in a family‐based treatment intervention consisting of four group sessions followed by 12‐week web‐based support. The interviews were analysed using qualitative manifest and latent content.
Results
The overarching theme “A transformative journey of lifestyle changes for the whole family” described how the participation impacted the lifestyle of the whole family. Four categories: parental awareness, introducing new routines, negotiating family battles, and a feeling of support, represented various experiences made by respondents. The parents shared predominantly positive experiences of the intervention but also expressed feelings of guilt and struggled to address their child´s obesity.
Conclusion
Parents who participated in a study for children with obesity with a web‐based component found the program helpful for achieving healthier lifestyles for the whole family.
... Among children and youth, games have showed positive results as regards health outcomes. Active games increased energy expenditure among healthy adolescents [28] and improved Body Mass Index (BMI) among overweight and obese children [29]. Active games improved motor skills among healthy pre-school aged children [30] and among children with movement disorders [31,32]. ...
Because of their attractive and engaging nature, games offer a potential method to be used for different purposes in healthcare. Health games are accessible and enable reaching the patients and clients without the restrictions of time and distance. Games have shown to increase knowledge and skills and support learning and communication. Games can also be tailored based on individual needs of the gamer. Thus, health games are potential not only for healthy people and people with different health conditions, but also for educational purposes among health students and healthcare professionals. In addition to benefits of games for healthcare, there are also challenges to consider when planning implementing game-based solutions in healthcare. Many of these challenges are issues that may be tackled through rigorous development and evaluation process. This chapter highlights recent research evidence on health games in healthcare; issues of challenges are also discussed. Finally, a user-centered approach for the development and evaluation of health games is represented.
... As exergames persuade users to exercise and enhance their concentration through leisure, these are used by the subjects of various categories such as children, adolescents, older people, and patients [20][21][22][23]. Exergames have been reported to enhance the physical activity in low-or mid-intensity exercise regimes, similar to walking or jogging [24,25], and cognitive function related to concentration [26]. However, it is not yet known whether these effects are achieved by VR exercise rather than non-VR exercise. ...
Background
Recently, ski exergames have been gaining popularity due to the growing interest in health improvement. Conventional studies evaluating the effects of ski exergames only considered exercise capacity and overlooked concentration. Ski exergames consist of a motion platform for exercise and virtual reality (VR) content in the game. The VR content enhances the exercise capacity and concentration of the user by providing a challenging goal.
Objective
The aim of this study is to evaluate the effects of VR and non-VR exercises on the exercise capacity and concentration of users in a ski exergame.
Methods
To examine the effects of the VR content in ski exergames, we performed 2 experiments, non-VR exercise and VR exercise, where participants exercised on the motion platform. If a user performs an exercise without using any VR content, it is a non-VR exercise. Contrastingly, in the case of VR exercise, a user exercises according to the VR content (a downhill scenario). In addition to the range of motion (ROM) of the ankle and rated perceived exertion (RPE) to assess exercise capacity, we used electroencephalography (EEG) to assess users’ concentration.
Results
We evaluated the effects of the VR content by comparing the results obtained from VR and non-VR exercises. The ROM of the ankle with VR exercise was wider than that with non-VR exercise. Specifically, ROM of the ankle was 115.71° (SD 17.71°) and 78.50° (SD 20.43°) in VR exercise and non-VR exercise, respectively. The RPE difference between the 2 exercises was not statistically significant. The result of the sensorimotor rhythm waves (which are concentration-related EEG signals) was more favorable for VR exercise than non-VR exercise. The ratios of sensorimotor rhythm wave in EEG were 3.08% and 2.70% in the VR exercise and non-VR exercise, respectively.
Conclusions
According to the results of this experiment, higher exercise capability and concentration were achieved with the VR exercise compared with non-VR exercise. The observations confirm that VR content can enhance both exercise capability and concentration of the user. Thus, the ski exergames can be used effectively by those who, in general, do not like exercise but enjoy games.
... For this, innovative and effective practices and interventions need to be developed. Bringing healthy lifestyles using effective interventions is the basis of health education and programs (Ameryoun et al. 2018;Hills, Dengel, and Lubans 2015). Researches in recent years, the feeding style, attitudes, beliefs, and practices of the parents were found to be related to the nutritional status and weight gain in children (Hughes et al. 2017;Seçer and Karabulut 2016). ...
The effect of parents on nutritional habits in preschool children is undeniable. It is known that parental control in child nutrition can affect the child’s eating habits, and bodyweight. Mediterranean Diet (MD) adherence of children (KIDMED), parents’ beliefs, attitudes and practices (Preschool Feeding Questionnaire-PFQ2) were investigated. The questionnaire prepared was applied by researchers face-to-face to 1413 families who agreed to participate voluntarily in the research with preschool children. Parental beliefs, attitudes, and practices regarding child nutrition status of parents were evaluated using 39-item PFQ2 and their child’s eating habits using the 16-item KIDMED index. Children’s KIDMED scores were found optimal in 34.1%, average in 57.0%, very low in 8.9%. The KIDMED scores of children whose parents are together (6.6 ± 2.1) were found to be significantly higher than children whose parents are separated (4.9 ± 2.2) (p <.001). A correlation was found between the KIDMED scores of the children, the parental control (r = 0.156, p <.001), maternal restriction (r = 0.104, p <.001), and structured feeding (r = 0.162, p <.001). Unfortunately, the adherence of most preschool children with the MD which considered a healthy diet pattern was found below the optimal level.
... This resulted in an average study overlap of 64% within a meta-analysis, indicating that, on average, twothirds of studies included in a meta-analysis were included in other meta-analyses on the same or similar topic. A single meta-analysis (26) consisted of articles with no (0%) overlap among articles included in the other meta-analyses, while all (100%) the studies included within one meta-analysis (19) were included in the other meta-analyses. Table 1 and presents the median and interquartile range for the originally estimated summary SMD, the re-estimated summary SMD, the absolute difference, and the percent difference in the estimates across study classi cations for both the xed and random effects models. ...
Background: Pilot/feasibility or studies with small sample sizes may be associated with inflated effects. This study explores the vibration of effect sizes (VoE) in meta-analyses when considering different inclusion criteria based upon sample size or pilot/feasibility status.
Methods: Searches were conducted for meta-analyses of behavioral interventions on topics related to the prevention/treatment of childhood obesity from 01-2016 to 10-2019. The computed summary effect sizes (ES) were extracted from each meta-analysis. Individual studies included in the meta-analyses were classified into one of the following four categories: self-identified pilot/feasibility studies or based upon sample size (N≤100, N>100, and N>370 the upper 75th of sample size). The VoE was defined as the absolute difference (ABS) between the re-estimations of summary ES restricted to study classifications compared to the originally reported summary ES. Concordance (kappa) of statistical significance between summary ES was assessed. Fixed and random effects models and meta-regressions were estimated. Three case studies are presented to illustrate the impact of including pilot/feasibility and N≤100 studies on the estimated summary ES.
Results: A total of 1,602 effect sizes, representing 145 reported summary ES, were extracted from 48 meta-analyses containing 603 unique studies (avg. 22 avg. meta-analysis, range 2-108) and included 227,217 participants. Pilot/feasibility and N≤100 studies comprised 22% (0-58%) and 21% (0-83%) of studies. Meta-regression indicated the ABS between the re-estimated and original summary ES where summary ES were comprised of ≥40% of N≤100 studies was 0.29. The ABS ES was 0.46 when summary ES comprised of >80% of both pilot/feasibility and N≤100 studies. Where ≤40% of the studies comprising a summary ES had N>370, the ABS ES ranged from 0.20-0.30. Concordance was low when removing both pilot/feasibility and N≤100 studies (kappa=0.53) and restricting analyses only to the largest studies (N>370, kappa=0.35), with 20% and 26% of the originally reported statistically significant ES rendered non-significant. Reanalysis of the three case study meta-analyses resulted in the re-estimated ES rendered either non-significant or half of the originally reported ES.
Conclusions: When meta-analyses of behavioral interventions include a substantial proportion of both pilot/feasibility and N≤100 studies, summary ES can be affected markedly and should be interpreted with caution.
... Jouer debout à des jeux de type « exergame » (jeu vidéo qui fait faire de l'activité physique comme Wii Sport ou Just Dance) nécessitant des mouvements des membres inférieurs, consomme davantage d'énergie que jouer plus passivement assis, avec uniquement le mouvement des membres supérieurs via une manette (jeux Fifa ou Fortnite). Si les jeux vidéo passifs sont liés à une plus faible activité physique et à un IMC plus élevé [48,49], certains jeux vidéo actifs permettraient de faire de l'activité physique légère ou modérée permettant une baisse de l'indice de masse corporelle chez les enfants obèses ou en surpoids [50]. Si l'OMS a récemment utilisé le terme de « temps d'écran sédentaire/ passif » pour mieux objectiver le niveau de sédentarité, les études épidémiologiques manquent sur les pratiques effectives des populations en lien avec cet indicateur (cf. ...
Les liens entre les usages et le temps d’écrans (télévision, mobile, jeux vidéo, etc.), surpoids et obésité sont bien établis dans la littérature scientifique. L’article présente les quatre principaux mécanismes impliqués : 1) l’usage des écrans incite à des prises caloriques immédiates, 2) les effets, parfois non conscients, de la publicité pour les produits de mauvaise qualité nutritionnelle, 3) la sédentarité, 4) l’usage des écrans le soir est lié à une durée de sommeil insuffisante, facteur de risque d’obésité.
... On the other hand, video game addiction is related to decreased levels of physical activity, since it is important to note that the pathological use of videogames in school children is closely related to physical inactivity [44,56,57], although active videogames, given their high motivating potential, complement levels of physical-sporting activity, allowing adherence to healthy lifestyles [58][59][60][61][62]. ...
The creation of healthy habits and lifestyles is fundamental in the educational field and for acquiring adequate health levels that will prevail in adulthood. The aim of this study was to determine the characteristics and correlations between the level of practice of physical activity, adherence to the Mediterranean diet (MD), body mass index (BMI) and problematic use of videogames and self-concept of primary education students. This non-experimental, cross-sectional study is composed of a sample of 577 students aged 10-12 years (11.1 ± 0.638). Subjects were evaluated using the Mediterranean Diet Adherence questionnaire (KIDMED), Self-Concept Form-5 (AF-5), Experiences Related to Videogames (QERV) and anthropometric measurements were taken following the guidelines of the International Society for the Advancement of Kinanthropometry. Most students have been found to be of normal weight, although one in five has problems with being overweight or experiencing obesity. Likewise, half of them need to improve their adherence to the Mediterranean diet, while they do not have a problematic use of videogames, although one tenth of them in these early ages offer severe problems and it is highlighted that students offer an adequate self-concept. It is also noted that BMI correlates positively with problematic videogame use and social self-concept. Greater addiction to videogames is associated with poorer academic performance, low levels of physical activity and poor adherence to the Mediterranean diet. Finally, it should be noted that the continued practice of physical-sports activity favors emotional competence and academic performance.
Background: Promoting COVID-19 prevention is key to pandemic control and innovative interventions can help communicate reliable science to the public. Under the Hong Kong Jockey Club SMART Family-Link Project, we developed and evaluated a pilot intervention for promoting COVID-19 prevention through a web-based family game, guided by the Theory of Planned Behavior and a strength-based approach.
Methods: The “SMART Epidemic prevention” pilot theme was launched to the public on September 21, 2020 for 4 weeks. The game had two parts: (i) strength recognition and (ii) quiz questions on knowledge and behaviors about COVID-19 prevention. Simple baseline, in-game, and postgame evaluation assessed players' perceived knowledge, behaviors, family well-being, game satisfaction, and perceived benefits.
Results: Of 86 registered families, 55 played actively, including 212 players (51% female, 35% aged below 18) who self-identified as children (44%), parents (39%), and grandparents (11%). In weeks 1 and 4, an average of 7 and 18 game rounds were played per family, and 86.6% and 75.9% of rounds had perfect (2) behavior matches. Postgame evaluation with 51 families showed improvements in epidemic prevention knowledge and behaviors, family communication, family happiness (all P < 0.001), and family relationship (P = 0.002) with small effect sizes (0.15–0.29). Overall game satisfaction was rated 4.49 (scale of 1–5). Ninety-four percent of families shared knowledge from the game with others.
Conclusions: Our pilot web-based family game first showed preliminary evidence on enhancing COVID-19 prevention knowledge and behaviors, and family well-being, with participants recognizing family strengths, reporting high satisfaction and various perceived benefits, and showing sustained gameplay.
Objectives
This study aimed to evaluate the effectiveness of the digital and gamified WellWe intervention on parental self-efficacy for healthy behaviours and mindfulness in parenting at the comprehensive health checks of 4-year-old children.
Methods
Two-arm cluster, randomised, controlled trial with a 4-month follow-up.The data were collected from parents of 4-year-old children. Cluster randomisation was done at the municipality level. Fifteen child health clinics within 4 municipalities located in Southwest Finland were randomly allocated to either an intervention (WellWe intervention) or a control group (usual care). The outcome measures included the Parental Self-Efficacy for Healthy Behaviours (PDAP) and Mindfulness in Parenting (MIPQ) questionnaires. Data were collected at baseline, after the intervention and at the 4-month follow-up.
Results
Initially a total of 110 parents (50 in the intervention and 60 in the control group) participated in the study. At the end of the study, there were 33 parents involved, with 12 in the intervention group and 21 in the control group. Parental self-efficacy and mindfulness in parenting showed no statistically significant difference between the groups or within the groups at the different time points.
Conclusions
The results of the study showed no difference between the intervention and the usual care. The commitment of the subjects was lower than expected. The intervention could be improved by placing a greater focus on engaging and motivating both families and public health nurses (PHNs). Therefore, when refining the intervention further, it's important to involve the target group more actively in the design of both content and delivery.
Exergames are often considered an intriguing opportunity for promoting physical activity (PA) among various target groups. However, due to the large number of diverse products currently available under the term “exergames”, it is not appropriate to label exergames per se as promising tools for addressing physical inactivity. In this chapter, the authors aim to analyze current exergaming products from different perspectives to identify their strengths, weaknesses, potentials, and risks for PA and health promotion. Furthermore, this chapter provides a stimulus for thought, inspiration, and suggestions for researchers, game designers, and publishers dedicated to exergaming. It also gives a broad overview of the history of exergames, focusing on the publishers’ influence on product development and targeting (“gamification” versus “sportification”). Furthermore, the authors aim to provide a structured approach to clustering exergames based on the platforms or devices required to play them. Considering the current literature findings, the authors go on to summarize the physical, psychological, and cognitive effects of exergames and discuss the potential and limitations of current products regarding PA and health promotion. Subsequently, they provide research-based recommendations on what to consider when developing exergames by giving insight into a specific case. The work concludes with some possible future directions and an excursion into the metaverse.
The influence of electronic screens on the health of children and adolescents and their education is not well understood. In this prospectively registered umbrella review (PROSPERO identifier CRD42017076051), we harmonized effects from 102 meta-analyses (2,451 primary studies; 1,937,501 participants) of screen time and outcomes. In total, 43 effects from 32 meta-analyses met our criteria for statistical certainty. Meta-analyses of associations between screen use and outcomes showed small-to-moderate effects (range: r = –0.14 to 0.33). In education, results were mixed; for example, screen use was negatively associated with literacy (r = –0.14, 95% confidence interval (CI) = –0.20 to –0.09, P ≤ 0.001, k = 38, N = 18,318), but this effect was positive when parents watched with their children (r = 0.15, 95% CI = 0.02 to 0.28, P = 0.028, k = 12, N = 6,083). In health, we found evidence for several small negative associations; for example, social media was associated with depression (r = 0.12, 95% CI = 0.05 to 0.19, P ≤ 0.001, k = 12, N = 93,740). Limitations of our review include the limited number of studies for each outcome, medium-to-high risk of bias in 95 out of 102 included meta-analyses and high heterogeneity (17 out of 22 in education and 20 out of 21 in health with I² > 50%). We recommend that caregivers and policymakers carefully weigh the evidence for potential harms and benefits of specific types of screen use.
The complexity of pediatric obesity treatment should always be present in the minds of person(s) providing it. A basic knowledge of this chronic disease is given here regarding the clinical aspects of overweight and obesity from positive energetic balance, together with the main clues for underlying contributing causes. Treatment is then set in three main areas: behavior, pharmacology, and bariatric surgery. Behavior implies the modification of food patterns and physical activity/sedentary lifestyle. At this point, where available, behavioral therapy has a significant role to play. A short review of former drugs still used for children and adolescents is given with detailed information on the present and safer ones (GLP-1 analogs, SGLT 2 i). Finally, and after increasing indications for adolescents, bariatric surgery is considered.KeywordsEnergy IntakePhysical activitySedentary lifestyleBehaviorDrugsBariatric surgery
Lifestyles such as physical exercise, sedentary behavior, eating habits, and sleep duration are all associated with adolescent overweight and obesity. The purpose of this study was to investigate how Chinese adolescents' lifestyles clustered into different lifestyle patterns, and to analyze the correlation between these patterns and adolescent overweight and obesity. The investigated respondents included 13,670 adolescents aged 13–18 from various administrative regions in China. Latent class analysis was employed to cluster the lifestyles of adolescents, χ2 test and Logistic regression were used to explore the relationship between lifestyle patterns and overweight and obesity in adolescents. The results identified 6 types of Chinese adolescents' lifestyle patterns, as well as the significant differences in gender and age. The adolescents with high exercise-high calorie diet had the lowest risk of overweight and obesity, and the adolescents with low consciousness-low physical activity and low consciousness-unhealthy had the highest risk of overweight and obesity, which were 1.432 times and 1.346 times higher than those with high exercise-high calorie diet, respectively. The studied demonstrated that there was a coexistence of healthy behaviors and health-risk behaviors in the lifestyle clustering of Chinese adolescents. Low physical exercise and high intake of snacks and carbonated beverages were the most common. Physical exercise and health consciousness were the protective factors of overweight and obesity in adolescents.
Background
The use of health games is a promising strategy for educating and promoting healthy lifestyle behaviors among children.
Objective
We aimed to describe the design and development of a serious game, called HelperFriend, and evaluate its feasibility, acceptability, and preliminary effects in children in a pilot study. HelperFriend is a vicarious experiential video game designed to promote 3 lifestyle behaviors among young children: physical activity, healthy eating, and socioemotional wellness.
Methods
Participants aged 8 to 11 years were recruited from an elementary school and randomized to receive a healthy lifestyle behavior educational talk (control) or play six 30-minute sessions with HelperFriend (intervention). Assessments were conducted at baseline (T0) and after the intervention (ie, 4 weeks) (T1). The primary outcome was gain in knowledge. The secondary outcomes were intention to conduct healthy behaviors, dietary intake, and player satisfaction.
Results
Knowledge scores of intervention group participants increased from T0 to T1 for physical activity (t14=2.01, P=.03), healthy eating (t14=3.14, P=.003), and socioemotional wellness (t14=2.75, P=.008). In addition, from T0 to T1, the intervention group improved their intention to perform physical activity (t14=2.82, P=.006), healthy eating (t14=3.44, P=.002), and socioemotional wellness (t14=2.65, P=.009); and there was a reduction in their intake of 13 unhealthy foods. HelperFriend was well received by intervention group.
Conclusions
HelperFriend appears to be feasible and acceptable for young children. In addition, this game seems to be a viable tool to help improve the knowledge, the intention to conduct healthy behaviors, and the dietary intake of children; however, a well-powered randomized controlled trial is needed to prove the efficacy of HelperFriend.
Preterm infants have a low level of bone mineralization compared to those born at term. The purpose of the present study was to investigate the effect of reflex locomotion therapy (RLT) on bone mineralization and growth in preterm infants and compare its effect against other physiotherapy procedures. 46 preterm infants born at 29-34 weeks were randomized to three groups: One group received RLT (n=17); other group received passive movements with gentle joint compression (n=14); and control group received massage (n=15). All treatments were carried out at the neonatal unit lasting one month. The main outcome measure was the bone mineralization measured with Tibial Speed of Sound (Tibial-SOS). All groups were similar in terms of gestational age (31.8±1.18), birth weight (1,583.41±311.9), and Tibia-SOS (1,604.7±27.9), at the beginning of the intervention. At the end of the study, significant differences were found among groups in Tibial-SOS [F(4,86)=2.77, p=0.049, η p ² = 0.114] in benefit of RLT group. In conclusion, RLT has been effective in the improvement of Tibial-SOS, and has been more effective than other physical therapy modalities; therefore it could be considered as one of the most effective physiotherapeutic modalities for the prevention and treatment of osteopenia of prematurity.
Background
Preterm infants have a low level of bone mineralization compared to those born at term, since 80% of calcium incorporation occurs at the end of pregnancy. The purpose of the present study was to investigate the effect of reflex locomotion therapy on bone mineralization and growth in preterm infants and compare its effect against other physiotherapy procedures.MethodsA randomized controlled trial carried out over four years from February 2016 to July 2020 was conducted. 52 preterm infants born at 29-34 weeks with hemodynamical stability, full enteral nutrition, and without any metabolic, congenital, genetic, neurological or respiratory disorders, were evaluated for inclusion; 6 were discarded due to exclusion criteria; finally 46 were randomized to three groups but only 76.08% completed the study: One group received reflex locomotion therapy (EGrlt); other group received passive movements with gentle compression (EGpmc); and control group received massage (CG). All treatments were carried out at the neonatal unit lasting one month. The main outcome measure was the bone mineralization measured with Tibial Speed of Sound (Tibial-SOS). A repeated measures ANOVA was used to compare the results of Tibial-SOS, and anthropometric measurements. All the personnel who carried out the measurement tests were blinded to which intervention group the patients belonged. Likewise, participants, family, and data analysts were also blinded. The physiotherapist who carried out the treatments was blinded against the objectives of the study.ResultsInfants were randomized into EGrlt (n=17), EGpmc (n=14), and CG (n=15). All groups were similar in terms of gestational age (31.8±1.18) and birth weight (1583.41±311.9), age (33.5±1.24) and Tibial Speed of Sound (1604.7±27.9), at the beginning of the intervention. At the end of the study, significant differences were found among groups in Tibial Speed of Sound [F(4,86)=2.77, P=0.049, η p ² =0.114] in benefit of EGrlt.Conclusions
The reflex locomotion therapy has been effective in the improvement of Tibial Speed of Sound, and has been more effective than other physical therapy modalities; therefore it could be considered as one of the most effective physiotherapeutic modalities for the prevention and treatment of osteopenia of prematurity.Trial registrationClinicalTrials.gov Identifier: NCT04356807. Registered 22/04/2020 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04356807?cond=Physical+Therapy+to+Prevent+Osteopenia+in+Preterm+Infants&draw=2&rank=1
Because of rapid evolution in exergaming technology and content, the literature on the benefits of exergaming needs ongoing review. Updated syntheses incorporating high-quality critical assessments of included articles can provide cutting-edge evidence to drive research and practice. The objectives were to summarize evidence from systematic reviews and meta-analyses on the association between exergaming and (1) physical activity (PA), sedentary behavior and energy expenditure (EE); and (2) body composition, body mass index (BMI), and other weight-related outcomes among persons younger than 30 years; and to summarize recommendations in the articles retained. The Elton B. Stephens Co. (ESBSCO) database for reviews was searched from January 1995 to July 2019. Data on study characteristics, findings, and recommendations for future research, game design, and intervention development were extracted from articles that met the inclusion criteria, quality scores were attributed to each article, and a narrative overview of the evidence was undertaken. Twenty-eight reviews, with 5-100 articles per review, were identified. Seventeen assessed the evidence on the association between exergaming and PA, EE, and/or sedentary behavior, and 11 examined the association with body composition, BMI, or other weight-related outcomes. There was substantial heterogeneity across reviews in objectives, definitions, and methods. A positive relationship between exergaming and EE is well documented, but whether exergaming increases PA or changes body composition is not established. The reviews retained also provide evidence that exergaming is a healthier alternative to sedentary behavior and that it can be an exciting enjoyable pastime for youth, which adds variety in PA options for health and dietary interventions. Exergaming is likely more physically health promoting than traditional videogames because of higher EE and possibly improved physical fitness and body composition. Longitudinal studies are needed to assess if exergaming reduces sedentary time, has other health benefits, or is a sustainable behavior. We recommend that exergaming interventions be designed using behavior change theory, and that future reviews use standard review criteria and include recommendations for research, game design, and intervention development.
Objective:
The aim of this study was to examine the prevalence of metabolic health across weight statuses and the associations of physical activity and sedentary time within and across metabolic health-weight status groups.
Methods:
Six studies (n = 4,581) from the International Children's Accelerometry Database were used. Sedentary time, light physical activity, and moderate to vigorous physical activity (MVPA) were accelerometer derived. Individuals were classified with normal weight (NW), overweight, or obesity. Strict and lenient composite definitions of metabolic health were created. Binomial and multinomial logistic regressions controlling for age, sex, study, and accelerometer wear time were conducted.
Results:
The metabolically unhealthy (MU) prevalence was 26.4% and 45.6% based on two definitions. Across definitions, more sedentary time was associated with higher odds of MU classification compared with metabolically healthy (MH) classification for the NW group. More MVPA was associated with lower odds of MU classification than MH classification for NW and overweight groups. For multinomial logistic regressions, more MVPA was associated with lower odds of MH-obesity classification, as well as MU-NW, -overweight, and -obesity classifications, compared with the MH-NW group. Furthermore, more sedentary time was associated with higher odds of MU-NW classification compared with the MH-NW group.
Conclusions:
More MVPA was beneficial for metabolic health and weight status, whereas lower sedentary time was beneficial for metabolic health alone, although associations were weak.
Background
Active video games (AVGs) capable of inducing physical activity offer an innovative approach to combating childhood obesity. Unfortunately, children’s AVG game play decreases quickly, underscoring the need to identify novel methods for player engagement. Narratives have been demonstrated to influence behaviors.
Objective
The objective of this study was to test the hypothesis that a narrative would motivate increased AVG play, though a feasibility study that investigated the motivational effect of adding a previously developed narrative cutscene to an originally nonnarrative AVG, Nintendo Wii Sports Resort: Swordplay Showdown.
Methods
A total of 40 overweight and obese 8- to 11-year-olds equally divided by sex played the AVG. Half (n=20) were randomly assigned to a narrative group that watched the narrative cutscene before game play. The other half played the game without watching it.
Results
Children in the narrative group had significantly (P<.05) more steps per 10-second period (mean 3.2, SD 0.7) and overall (mean 523, SD 203) during game play compared with the nonnarrative group (10-second period: mean 2.7, SD 0.7; overall: mean 366, SD 172).
Conclusions
The AVG with narrative induced increased physical activity. Additional research is needed to understand the mechanisms through which narrative increases physical activity during AVG game play.
Although exergaming has been used as a physical activity modality among various populations, the evidence regarding its effectiveness on health-related outcomes in overweight/obese individuals remains unclear. The current study systematically reviewed literature and summarized findings of exergame-based interventions in overweight/obese populations with the goal of clarifying the current perspectives on exergaming and obesity. The initial search yielded 202 articles from six databases; 12 studies were included after evaluating for inclusion criteria and removing duplicates. Among these studies, seven were randomized controlled trials, two were control trials, and three were comparison studies. Overall, exergaming has the potential to attenuate weight gain and shows promise when used for physical activity and physical fitness promotion. Further, exergame play is positively associated with psychological well-being, but its effects on physiological outcomes are inconclusive. Finally, effects of exergaming on energy intake are not clear. Existing evidence supports that exergaming may elicit some health benefits in people who are overweight or/and obese. The limited number of available randomized controlled trials, however, restrict the ability to draw a conclusion that exergaming can trigger a change in all health-related outcomes. More research is warranted to make definitive conclusions regarding the effects of exergaming on health-related outcomes in such populations.
This study assessed the effectiveness of a 6-week, high-intensity, games-based intervention on physiological and anthropometric indices of health, in normal weight (n = 26; 32.5 ± 8.9 kg) and obese (n = 29; 49.3 ± 8.9 kg) children (n = 32 boys, 23 girls), aged 8-10 years. Children were randomised into an exercise or control group. The exercise group participated in a twice-weekly, 40 min active games intervention, alongside their usual school physical education classes. The control group did not take part in the intervention. Before and after the intervention, participants completed both a maximal and submaximal graded exercise test. The submaximal exercise test comprised of a 6 min, moderate- and 6 min heavy-intensity bout, interspersed with a 5 min recovery. The exercise group demonstrated improvements in maximal oxygen uptake (51.4 ± 8.5 vs 54.3 ± 9.6 ml · kg(-1) · min(-1)) and peak running speed (11.3 ± 1.6 vs 11.9 ± 1.6 km · h(-1)), and a reduction in the oxygen cost of submaximal exercise between assessments (P < .05). A decrease in waist circumference and increase in muscle mass were observed between assessments for the obese participants randomised to the intervention (both P < .05). This study demonstrates that a short-term, high-intensity games intervention may elicit positive changes in physiological and anthropometric indices of health in normal weight and obese children.
Objective:
This study explored the intervention effect of the "Nutrition on the Go" strategy on the prevalence of overweight and obesity (OW+O), according to the role played by different patterns.
Materials and methods:
Pattern Groups (PG) were determined based on schools' food availability and other variables at individual level: nutrition knowledge, physical activity, socioeconomic level and self-efficacy, using an ecological approach. The PG classification was achieved using Ward's cluster method.
Results:
The prevalence of OW+O was higher in PGI (intermediate food availability and high socioeconomic index [SEI]) compared to PG 2 (high availability of food and lower SEI) and PG 3 (low availability of food and medium SEI) with a lower prevalence (p<0.00I). The PG-intervention interaction showed differences for PG 3 (p=0.066), the stage-PG interaction showed differences between PGs I and 3 (p=0.014) and between PGs 2 and 3 (p=0.055).
Conclusions:
Differences between PGs have important implications for the prevalence of OW+O.
Obesity is one of the most important underlying risk factors for chronic disease. Dramatically increasing and following complication of obesity should be alerted to health politicians and practitioners to prevent associated health risks. This review aimed to give a better insight into the prevalence of obesity and overweight in different areas of Iran.
All published internal (SID, Irandoc, Iranmedex), and international (Web of Knowledge, Pubmed, Scopus) source studies, reported the prevalence of overweight/obesity among normal population samples, during Jan 2005 through Jan 2014, were assessed in this review. Paper selection processes were done by two researchers separately. Studies which met the eligible criteria were included in this review.
One hundred ninety three eligible studies enter into our review. Of 193 final selected studies, 86 (15 national, 71 sub national) of them were reported the prevalence of obesity/overweight in adult, and 107 studies (11 national, 96 sub national) in under-18 by individual. The range of overweight and obesity prevalence in national studies in adult, was 27.0-38.5 (95% CI: 26.8-27.1, 37.2-39.8), and 12.6-25.9 (95% CI: 12.2-13.0, 24.9-26.8), separately. In under-18 the range of overweight and obesity prevalence in national studies were 5.0-13.5 (95% CI: 4.5-5.5, 13.4-13.6), and 3.2-11.9 (95% CI: 3.0-3.4, 11.3-12.4).
Obesity as an important public health problem has been discussed in recent few decades worldwide. Although the national reported prevalence of obesity in Iran was not considerably diverse, but remarkable differences were seen in the sub national prevalence which must be noticed more in political health programs especially among women and children.
Background and aims:
The metabolic risks associated with obesity are greater for South Asian populations compared with White or other ethnic groups, and levels of obesity in childhood are known to track into adulthood. Tackling obesity in South Asians is therefore a high priority. The rationale for this systematic review is the suggestion that there may be differential effectiveness in diet and physical activity interventions in South Asian populations compared with other ethnicities. The research territory of the present review is an emergent, rather than mature, field of enquiry, but is urgently needed. Thus the aim of this systematic review and meta-analysis was to assess the effectiveness of diet and physical activity interventions to prevent or treat obesity in South Asians living in or outside of South Asia and to describe the characteristics of effective interventions.
Methods:
Systematic review of any type of lifestyle intervention, of any length of follow-up that reported any anthropometric measure for children or adults of South Asian ethnicity. There was no restriction on the type of comparator; randomised controlled trials, controlled clinical trials, and before-after studies were included. A comprehensive search strategy was implemented in five electronic databases: ASSIA, Cochrane Controlled Trials Register, Embase, Medline and Social Sciences Citation Index. The search was limited to English language abstracts published between January 2006 and January 2014. References were screened; data extraction and quality assessment were carried out by two reviewers. RESULTS are presented in narrative synthesis and meta-analysis.
Results:
Twenty-nine studies were included, seven children, 21 adult and one mixed age. No studies in children under six were identified. Sixteen studies were conducted in South Asia, ten in Europe and three in USA. Effective or promising trials include physical activity interventions in South Asian men in Norway and South Asian school-children in the UK. A home-based, family-orientated diet and physical activity intervention improved obesity outcomes in South Asian adults in the UK, when adjusted for baseline differences. Meta-analyses of interventions in children showed no significant difference between intervention and control for body mass index or waist circumference. Meta-analyses of adult interventions showed significant improvement in weight in data from two trials adjusted for baseline differences (mean difference -1.82 kgs, 95% confidence interval -2.48 to -1.16) and in unadjusted data from three trials following sensitivity analysis (mean difference -1.20 kgs, 95% confidence interval -2.23 to -0.17). Meta-analyses showed no significant differences in body mass index and waist circumference for adults. Twenty of 24 intervention groups showed improvements in adult body mass index from baseline to follow-up; average change in high quality studies (n = 7) ranged from 0.31 to -0.8 kg/m2. There was no evidence that interventions were more or less effective according to whether the intervention was set in South Asia or not, or by socio-economic status.
Conclusions:
Meta-analysis of a limited number of controlled trials found an unclear picture of the effects of interventions on body mass index for South Asian children. Meta-analyses of a limited number of controlled trials showed significant improvement in weight for adults but no significant differences in body mass index and waist circumference. One high quality study in South Asian children found that a school-based physical activity intervention that was delivered within the normal school day which was culturally sensitive, was effective. There is also evidence of culturally appropriate approaches to, and characteristics of, effective interventions in adults which we believe could be transferred and used to develop effective interventions in children.
Background
Childhood obesity rates in the U.S. have reached epidemic proportions, and an urgent need remains to identify evidence-based strategies for prevention and treatment. Multi-level, multi-component interventions are needed due to the multi-factorial nature of obesity, and its proven links to both the social and built environment. However, there are huge gaps in the literature related to doing these kinds of interventions among low-income, urban, minority groups.
Methods
The B’More Healthy Communities for Kids (BHCK) intervention is a multi-level, multi-component intervention, targeting low-income African American youth ages 10–14 and their families in Baltimore, Maryland. This intervention prevents childhood obesity by working at multiple levels of the food and social environments to increase access to, demand for, and consumption of healthier foods. BHCK works to create systems-level change by partnering with city policy-makers, multiple levels of the food environment (wholesalers, corner stores, carryout restaurants), and the social environment (peers and families). In addition, extensive evaluation will be conducted at each level of the intervention to assess intervention effectiveness via both process and impact measures.
Discussion
This project is novel in multiple ways, including: the inclusion of stakeholders at multiple levels (policy, institutional, and at multiple levels of the food system); that it uses novel computational modeling methodologies to engage policy makers and guide informed decisions of intervention effectiveness; it emphasizes both the built environment (intervening with food sources) and the social environment (intervening with families and peers). The design of the intervention and the evaluation plan of the BHCK project are documented here.
Trial registration
NCT02181010 (July 2, 2014).
The prevention and treatment of childhood obesity is a key public health challenge. However, certain groups within populations have markedly different risk profiles for obesity and related health behaviours. Well-designed subgroup analysis can identify potential differential effects of obesity interventions, which may be important for reducing health inequalities. The study aim was to evaluate the consistency of the effects of active video games across important subgroups in a randomised controlled trial (RCT).
A two-arm, parallel RCT was conducted in overweight or obese children (n = 322; aged 10-14 years) to determine the effect of active video games on body composition. Statistically significant overall treatment effects favouring the intervention group were found for body mass index, body mass index z-score and percentage body fat at 24 weeks. For these outcomes, pre-specified subgroup analyses were conducted among important baseline demographic (ethnicity, sex) and prognostic (cardiovascular fitness) groups. No statistically significant interaction effects were found between the treatment and subgroup terms in the main regression model (p = 0.36 to 0.93), indicating a consistent treatment effect across these groups.
Preliminary evidence suggests an active video games intervention had a consistent positive effect on body composition among important subgroups. This may support the use of these games as a pragmatic public health intervention to displace sedentary behaviour with physical activity in young people.
Objective. To review the extant literature on the prevalence of overweight and obesity in adolescents (10–19 years old) of both sexes.
Design. The search was carried out using Medline and Scopus considering articles published from the establishment of the databanks until June 7, 2012. Data on the prevalence of children being overweight and obese from the International Obesity Task Force (IOTF) website was also reviewed. Only original articles and one National Health Report were considered. Forty studies met the inclusion criteria. Results. Twenty-five of these studies were nationally representative, and ten countries were represented only by regional data. Conclusions. The prevalence of overweight and obesity among adolescents worldwide is high, and obesity is higher among boys. The IOTF criterion is the most frequently used method to classify adolescents as overweighed or obese in public health research.
Exergames have started to find their way into field-based settings, such as schools, communities and homes, as a possible solution to curbing physical inactivity and childhood obesity. However, a clear view of the effects of field-based exergaming on children's obesity-related outcomes is lacking. Hence, a systematic review on this topic is warranted. This review synthesizes the impact of field-based exergames on children's physical and psychosocial outcomes. A total of 34 articles conducted in field-based settings were identified from 104 peer-reviewed publications that investigated the effects of exergames. Upon screening, these articles met the inclusion criteria and a high inter-rater agreement for inclusion was reached between the authors. The effects of field-based exergames on children's habitual physical activity (PA) and obesity-related outcomes (e.g. weight loss, body composition) remain unclear due to design problems, measurement issues and other methodology concerns. In addition, exergame is appealing to children, although strategies are warranted to sustain their interests. In summary, exergamesare desirable as a promising addition to promote PA and health. Professionals may integrate exergames at field settings to promote a physically active lifestyle among children with the goal of curbing childhood obesity.
Objective:
The high prevalence of adolescent obesity in the United States has been attributed to population changes in physical activity (PA), sedentary behaviors, and dietary behaviors. This study examines 8-year trends in these behaviors in US adolescents ages 11 to 16.
Methods:
Nationally representative samples of US students in grades 6 to 10 were recruited during the 2001-2002 (N = 14607), 2005-2006 (N = 9150), and 2009-2010 (N = 10848) school years by using multistage stratified designs, with census regions and grades as strata, and school districts as the primary sampling units. African-American and Hispanic students were oversampled to obtain better estimates for those groups. Using the Health Behavior in School-aged Children quadrennial surveys, identical questions assessed BMI, PA, and sedentary and dietary behaviors at each school year. Logistic and linear regression analyses were conducted taking into account the sampling design and controlling for age, gender, race/ethnicity, and family affluence.
Results:
Across the quadrennial surveys, significant increases were identified in number of days with at least 60 minutes of PA, daily consumption of fruits and vegetables, eating breakfast on weekdays and weekends, and BMI. Television viewing and consumption of sweets and sweetened beverages decreased across this same period. These same patterns were seen in all racial/ethnic groups.
Conclusions:
These patterns suggest that public health efforts to improve the obesity-related behaviors of US adolescents may be having some success. However, alternative explanations for the increase in BMI over the same period need to be considered.
Nutrition, physical activity and behavior-modifying techniques are widely applied components of interventions treating obesity. Our aim was to review available information on the short and long term effects of intervention treatment on body fat composition of overweight and obese children and adolescents and, to obtain a further understanding on how different body composition techniques detect longitudinal changes. In total, thirteen papers were included; seven included a multidisciplinary intervention component, five applied a combined dietary and physical activity intervention and one a physical activity intervention. Body composition techniques used included anthropometric indices, bioelectrical impedance analysis, and dual energy X-ray absorptiometry. Percentage of fat mass change was calculated in when possible. Findings suggested, no changes were observed in fat free mass after 16 weeks of nutritional intervention and the lowest decrease on fat mass percentage was obtained. However, the highest fat mass percentage with parallel increase in fat free mass, both assess by DXA was observed in a multi-component intervention applied for 20 weeks. In conclusion, more studies are needed to determine the best field body composition method to monitor changes during overweight treatment in children and adolescents.
Active video games (AVGs) have gained interest as a way to increase physical activity in children and youth. The effect of AVGs on acute energy expenditure (EE) has previously been reported; however, the influence of AVGs on other health-related lifestyle indicators remains unclear.
This systematic review aimed to explain the relationship between AVGs and nine health and behavioural indicators in the pediatric population (aged 0-17 years).
Online databases (MEDLINE, EMBASE, psycINFO, SPORTDiscus and Cochrane Central Database) and personal libraries were searched and content experts were consulted for additional material.
INCLUDED ARTICLES WERE REQUIRED TO HAVE A MEASURE OF AVG AND AT LEAST ONE RELEVANT HEALTH OR BEHAVIOUR INDICATOR: EE (both habitual and acute), adherence and appeal (i.e., participation and enjoyment), opportunity cost (both time and financial considerations, and adverse events), adiposity, cardiometabolic health, energy intake, adaptation (effects of continued play), learning and rehabilitation, and video game evolution (i.e., sustainability of AVG technology).
51 unique studies, represented in 52 articles were included in the review. Data were available from 1992 participants, aged 3-17 years, from 8 countries, and published from 2006-2012. Overall, AVGs are associated with acute increases in EE, but effects on habitual physical activity are not clear. Further, AVGs show promise when used for learning and rehabilitation within special populations. Evidence related to other indicators was limited and inconclusive.
Controlled studies show that AVGs acutely increase light- to moderate-intensity physical activity; however, the findings about if or how AVG lead to increases in habitual physical activity or decreases in sedentary behaviour are less clear. Although AVGs may elicit some health benefits in special populations, there is not sufficient evidence to recommend AVGs as a means of increasing daily physical activity.
Healthy lifestyle habits during adolescence can prevent many of the diseases and disabilities in adulthood and later. The aim of the study was to examine the role of education in improving lifestyles among Iranian adolescents.
This group randomized controlled trial was conducted during October 2010 until January 2011 in Tehran. Participants for this study were selected through a random sampling method and divided into intervention and control groups. The intervention group received a six session course on healthy lifestyles and the control group received no intervention. The Adolescent Lifestyle Questionnaire (ALQ) was used for collecting data. Data were collected before the intervention, at a two week after participation time point, and a three month follow-up was conducted.
Overall, 365 (male: 173, female: 192) adolescents participated in the study. There were significant differences between boys and girls in terms of physical activity and social support (P<0.001). The boys had higher levels of physical activity than girls. Girls received more social support than boys. There were significant differences in the lifestyle scores between the intervention and control groups at follow-up (P<0.001). The educational intervention indicated an improved total lifestyle score (from 123.7(SD.16.1) at baseline to 131.8 (SD.16.7) at two weeks and to 130.5(16.5) at 3 months after education) among the intervention group.
Adolescents' behaviors may be different in some dimensions among boys and girls. Unhealthy lifestyle habits are prevalent among adolescents. Therefore sex-specified lifestyle education can bring promising results. Further research in the field can reveal the importance of lifestyle intervention programs.
Funnel plots, and tests for funnel plot asymmetry, have been widely used to examine bias in the results of meta-analyses. Funnel plot asymmetry should not be equated with publication bias, because it has a number of other possible causes. This article describes how to interpret funnel plot asymmetry, recommends appropriate tests, and explains the implications for choice of meta-analysis modelThe 1997 paper describing the test for funnel plot asymmetry proposed by Egger et al 1 is one of the most cited articles in the history of BMJ.1 Despite the recommendations contained in this and subsequent papers,2 3 funnel plot asymmetry is often, wrongly, equated with publication or other reporting biases. The use and appropriate interpretation of funnel plots and tests for funnel plot asymmetry have been controversial because of questions about statistical validity,4 disputes over appropriate interpretation,3 5 6 and low power of the tests.2This article recommends how to examine and interpret funnel plot asymmetry (also known as small study effects2) in meta-analyses of randomised controlled trials. The recommendations are based on a detailed MEDLINE review of literature published up to 2007 and discussions among methodologists, who extended and adapted guidance previously summarised in the Cochrane Handbook for Systematic Reviews of Interventions.7What is a funnel plot?A funnel plot is a scatter plot of the effect estimates from individual studies against some measure of each study’s size or precision. The standard error of the effect estimate is often chosen as the measure of study size and plotted on the vertical axis8 with a reversed scale that places the larger, most powerful studies towards the top. The effect estimates from smaller studies should scatter more widely at the bottom, with the spread narrowing among larger studies.9 In the absence of bias and between study heterogeneity, the scatter will be due to sampling variation alone and the plot will resemble a symmetrical inverted funnel (fig 1⇓). A triangle centred on a fixed effect summary estimate and extending 1.96 standard errors either side will include about 95% of studies if no bias is present and the fixed effect assumption (that the true treatment effect is the same in each study) is valid. The appendix on bmj.com discusses choice of axis in funnel plots.View larger version:In a new windowDownload as PowerPoint SlideFig 1 Example of symmetrical funnel plot. The outer dashed lines indicate the triangular region within which 95% of studies are expected to lie in the absence of both biases and heterogeneity (fixed effect summary log odds ratio±1.96×standard error of summary log odds ratio). The solid vertical line corresponds to no intervention effectImplications of heterogeneity, reporting bias, and chance Heterogeneity, reporting bias, and chance may all lead to asymmetry or other shapes in funnel plots (box). Funnel plot asymmetry may also be an artefact of the choice of statistics being plotted (see appendix). The presence of any shape in a funnel plot is contingent on the studies having a range of standard errors, since otherwise they would lie on a horizontal line.Box 1: Possible sources of asymmetry in funnel plots (adapted from Egger et al1)Reporting biasesPublication bias: Delayed publication (also known as time lag or pipeline) bias Location biases (eg, language bias, citation bias, multiple publication bias)Selective outcome reportingSelective analysis reportingPoor methodological quality leading to spuriously inflated effects in smaller studiesPoor methodological designInadequate analysisFraudTrue heterogeneitySize of effect differs according to study size (eg, because of differences in the intensity of interventions or in underlying risk between studies of different sizes)ArtefactualIn some circumstances, sampling variation can lead to an association between the intervention effect and its standard errorChanceAsymmetry may occur by chance, which motivates the use of asymmetry testsHeterogeneityStatistical heterogeneity refers to differences between study results beyond those attributable to chance. It may arise because of clinical differences between studies (for example, setting, types of participants, or implementation of the intervention) or methodological differences (such as extent of control over bias). A random effects model is often used to incorporate heterogeneity in meta-analyses. If the heterogeneity fits with the assumptions of this model, a funnel plot will be symmetrical but with additional horizontal scatter. If heterogeneity is large it may overwhelm the sampling error, so that the plot appears cylindrical.Heterogeneity will lead to funnel plot asymmetry if it induces a correlation between study sizes and intervention effects.5 For example, substantial benefit may be seen only in high risk patients, and these may be preferentially included in early, small studies.10 Or the intervention may have been implemented less thoroughly in larger studies, resulting in smaller effect estimates compared with smaller studies.11Figure 2⇓ shows funnel plot asymmetry arising from heterogeneity that is due entirely to there being three distinct subgroups of studies, each with a different intervention effect.12 The separate funnels for each subgroup are symmetrical. Unfortunately, in practice, important sources of heterogeneity are often unknown.View larger version:In a new windowDownload as PowerPoint SlideFig 2 Illustration of funnel plot asymmetry due to heterogeneity, in the form of three distinct subgroups of studies. Funnel plot including all studies (top left) shows clear asymmetry (P<0.001 from Egger test for funnel plot asymmetry). P values for each subgroup are all >0.49.Differences in methodological quality may also cause heterogeneity and lead to funnel plot asymmetry. Smaller studies tend to be conducted and analysed with less methodological rigour than larger studies,13 and trials of lower quality also tend to show larger intervention effects.14 15Reporting biasReporting biases arise when the dissemination of research findings is influenced by the nature and direction of results. Statistically significant “positive” results are more likely to be published, published rapidly, published in English, published more than once, published in high impact journals, and cited by others.16 17 18 19 Data that would lead to negative results may be filtered, manipulated, or presented in such a way that they become positive.14 20 Reporting biases can have three types of consequence for a meta-analysis:A systematic review may fail to locate an eligible study because all information about it is suppressed or hard to find (publication bias) A located study may not provide usable data for the outcome of interest because the study authors did not consider the result sufficiently interesting (selective outcome reporting) A located study may provide biased results for some outcome—for example, by presenting the result with the smallest P value or largest effect estimate after trying several analysis methods (selective analysis reporting).These biases may cause funnel plot asymmetry if statistically significant results suggesting a beneficial effect are more likely to be published than non-significant results. Such asymmetry may be exaggerated if there is a further tendency for smaller studies to be more prone to selective suppression of results than larger studies. This is often assumed to be the case for randomised trials. For instance, it is probably more difficult to make a large study disappear without trace, while a small study can easily be lost in a file drawer.21 The same may apply to specific outcomes—for example, it is difficult not to report on mortality or myocardial infarction if these are outcomes of a large study. Smaller studies have more sampling error in their effect estimates. Thus even though the risk of a false positive significant finding is the same, multiple analyses are more likely to yield a large effect estimate that may seem worth publishing. However, biases may not act this way in real life; funnel plots could be symmetrical even in the presence of publication bias or selective outcome reporting19 22—for example, if the published findings point to effects in different directions but unreported results indicate neither direction. Alternatively, bias may have affected few studies and therefore not cause glaring asymmetry.ChanceThe role of chance is critical for interpretation of funnel plots because most meta-analyses of randomised trials in healthcare contain few studies.2 Investigations of relations across studies in a meta-analysis are seriously prone to false positive findings when there is a small number of studies and heterogeneity across studies,23 and this may affect funnel plot symmetry.Interpreting funnel plot asymmetryAuthors of systematic reviews should distinguish between possible reasons for funnel plot asymmetry (box 1). Knowledge of the intervention, and the circumstances in which it was implemented in different studies, can help identify causes of asymmetry in funnel plots, which should also be interpreted in the context of susceptibility to biases of research in the field of interest. Potential conflicts of interest, whether outcomes and analyses have been standardised, and extent of trial registration may need to be considered. For example, studies of antidepressants generate substantial conflicts of interest because the drugs generate vast sales revenues. Furthermore, there are hundreds of outcome scales, analyses can be very flexible, and trial registration was uncommon until recently.24 Conversely, in a prospective meta-analysis where all data are included and all analyses fully standardised and conducted according to a predetermined protocol, publication or reporting biases cannot exist. Reporting bias is therefore more likely to be a cause of an asymmetric plot in the first situation than in the second.Terrin et al found that researchers were poor at identifying publication bias from funnel plots.5 Including contour lines corresponding to perceived milestones of statistical significance (P=0.01, 0.05, 0.1, etc) may aid visual interpretation.25 If studies seem to be missing in areas of non-significance (fig 3⇓, top) then asymmetry may be due to reporting bias, although other explanations should still be considered. If the supposed missing studies are in areas of higher significance or in a direction likely to be considered desirable to their authors (fig 3⇓, bottom), asymmetry is probably due to factors other than reporting bias. View larger version:In a new windowDownload as PowerPoint SlideFig 3 Contour enhanced funnel plots. In the top diagram there is a suggestion of missing studies in the middle and right of the plot, broadly in the white area of non-significance, making publication bias plausible. In the bottom diagram there is a suggestion of missing studies on the bottom left hand side of the plot. Since most of this area contains regions of high significance, publication bias is unlikely to be the underlying cause of asymmetryStatistical tests for funnel plot asymmetryA test for funnel plot asymmetry (sometimes referred to as a test for small study effects) examines whether the association between estimated intervention effects and a measure of study size is greater than might be expected to occur by chance. These tests typically have low power, so even when a test does not provide evidence of asymmetry, bias cannot be excluded. For outcomes measured on a continuous scale a test based on a weighted linear regression of the effect estimates on their standard errors is straightforward.1 When outcomes are dichotomous and intervention effects are expressed as odds ratios, this corresponds to an inverse variance weighted linear regression of the log odds ratio on its standard error.2 Unfortunately, there are statistical problems because the standard error of the log odds ratio is mathematically linked to the size of the odds ratio, even in the absence of small study effects.2 4 Many authors have therefore proposed alternative tests (see appendix on bmj.com).4 26 27 28Because it is impossible to know the precise mechanism(s) leading to funnel plot asymmetry, simulation studies (in which tests are evaluated on large numbers of computer generated datasets) are required to evaluate test characteristics. Most have examined a range of assumptions about the extent of reporting bias by selectively removing studies from simulated datasets.26 27 28 After reviewing the results of these studies, and based on theoretical considerations, we formulated recommendations on testing for funnel plot asymmetry (box 2). The appendix describes the proposed tests, explains the reasons that some were not recommended, and discusses funnel plots for intervention effects measured as risk ratios, risk differences, and standardised mean differences. Our recommendations imply that tests for funnel plot asymmetry should be used in only a minority of meta-analyses.29Box 2: Recommendations on testing for funnel plot asymmetryAll types of outcomeAs a rule of thumb, tests for funnel plot asymmetry should not be used when there are fewer than 10 studies in the meta-analysis because test power is usually too low to distinguish chance from real asymmetry. (The lower the power of a test, the higher the proportion of “statistically significant” results in which there is in reality no association between study size and intervention effects). In some situations—for example, when there is substantial heterogeneity—the minimum number of studies may be substantially more than 10Test results should be interpreted in the context of visual inspection of funnel plots— for example, are there studies with markedly different intervention effect estimates or studies that are highly influential in the asymmetry test? Even if an asymmetry test is statistically significant, publication bias can probably be excluded if small studies tend to lead to lower estimates of benefit than larger studies or if there are no studies with significant resultsWhen there is evidence of funnel plot asymmetry, publication bias is only one possible explanation (see box 1)As far as possible, testing strategy should be specified in advance: choice of test may depend on the degree of heterogeneity observed. Applying and reporting many tests is discouraged: if more than one test is used, all test results should be reported Tests for funnel plot asymmetry should not be used if the standard errors of the intervention effect estimates are all similar (the studies are of similar sizes)Continuous outcomes with intervention effects measured as mean differencesThe test proposed by Egger et al may be used to test for funnel plot asymmetry.1 There is no reason to prefer more recently proposed tests, although their relative advantages and disadvantages have not been formally examined. General considerations suggest that the power will be greater than for dichotomous outcomes but that use of the test with substantially fewer than 10 studies would be unwiseDichotomous outcomes with intervention effects measured as odds ratiosThe tests proposed by Harbord et al26 and Peters et al27 avoid the mathematical association between the log odds ratio and its standard error when there is a substantial intervention effect while retaining power compared with alternative tests. However, false positive results may still occur if there is substantial between study heterogeneityIf there is substantial between study heterogeneity (the estimated heterogeneity variance of log odds ratios, τ2, is >0.1) only the arcsine test including random effects, proposed by Rücker et al, has been shown to work reasonably well.28 However, it is slightly conservative in the absence of heterogeneity and its interpretation is less familiar than for other tests because it is based on an arcsine transformation.When τ2 is <0.1, one of the tests proposed by Harbord et al,26 Peters et al,27 or Rücker et al28 can be used. Test performance generally deteriorates as τ2 increases.Funnel plots and meta-analysis modelsFixed and random effects modelsFunnel plots can help guide choice of meta-analysis method. Random effects meta-analyses weight studies relatively more equally than fixed effect analyses by incorporating the between study variance into the denominator of each weight. If effect estimates are related to standard errors (funnel plot asymmetry), the random effects estimate will be pulled more towards findings from smaller studies than the fixed effect estimate will be. Random effects models can thus have undesirable consequences and are not always conservative.30The trials of intravenous magnesium after myocardial infarction provide an extreme example of the differences between fixed and random effects analyses that can arise in the presence of funnel plot asymmetry.31 Beneficial effects on mortality, found in a meta-analysis of small studies,32 were subsequently contradicted when the very large ISIS-4 study found no evidence of benefit.33 A contour enhanced funnel plot (fig 4⇓) gives a clear visual impression of asymmetry, which is confirmed by small P values from the Harbord and Peters tests (P<0.001 and P=0.002 respectively).View larger version:In a new windowDownload as PowerPoint SlideFig 4 Contour enhanced funnel plot for trials of the effect of intravenous magnesium on mortality after myocardial infarctionFigure 5⇓ shows that in a fixed effect analysis ISIS-4 receives 90% of the weight, and there is no evidence of a beneficial effect. However, there is clear evidence of between study heterogeneity (P<0.001, I2=68%), and in a random effects analysis the small studies dominate so that intervention appears beneficial. To interpret the accumulated evidence, it is necessary to make a judgment about the validity or relevance of the combined evidence from the smaller studies compared with that from ISIS-4. The contour enhanced funnel plot suggests that publication bias does not completely explain the asymmetry, since many of the beneficial effects reported from smaller studies were not significant. Plausible explanations for these results are that methodological flaws in the smaller studies, or changes in the standard of care (widespread adoption of treatments such as aspirin, heparin, and thrombolysis), led to apparent beneficial effects of magnesium. This belief was reinforced by the subsequent publication of the MAGIC trial, in which magnesium added to these treatments which also found no evidence of benefit on mortality (odds ratio 1.0, 95% confidence interval 0.8 to 1.1).34View larger version:In a new windowDownload as PowerPoint SlideFig 5 Comparison of fixed and random effects meta-analytical estimates of the effect of intravenous magnesium on mortality after myocardial infarctionWe recommend that when review authors are concerned about funnel plot asymmetry in a meta-analysis with evidence of between study heterogeneity, they should compare the fixed and random effects estimates of the intervention effect. If the random effects estimate is more beneficial, authors should consider whether it is plausible that the intervention is more effective in smaller studies. Formal investigations of heterogeneity of effects may reveal explanations for funnel plot asymmetry, in which case presentation of results should focus on these. If larger studies tend to be methodologically superior to smaller studies, or were conducted in circumstances more typical of the use of the intervention in practice, it may be appropriate to include only larger studies in the meta-analysis.Extrapolation of a funnel plot regression lineAn assumed relation between susceptibility to bias and study size can be exploited by extrapolating within a funnel plot. When funnel plot asymmetry is due to bias rather than substantive heterogeneity, it is usually assumed that results from larger studies are more believable than those from smaller studies because they are less susceptible to methodological flaws or reporting biases. Extrapolating a regression line on a funnel plot to minimum bias (maximum sample size) produces a meta-analytical estimate that can be regarded as corrected for such biases.35 36 37 However, because it is difficult to distinguish between asymmetry due to bias and asymmetry due to heterogeneity or chance, the broad applicability of such approaches is uncertain. Further approaches to adjusting for publication bias are described and discussed in the appendix.DiscussionReporting biases are one of a number of possible explanations for the associations between study size and effect size that are displayed in asymmetric funnel plots. Examining and testing for funnel plot asymmetry, when appropriate, is an important means of addressing bias in meta-analyses, but the multiple causes of asymmetry and limited power of asymmetry tests mean that other ways to address reporting biases are also of importance. Searches of online trial registries can identify unpublished trials, although they do not currently guarantee access to trial protocols and results. When there are no registered but unpublished trials, and the outcome of interest is reported by all trials, restricting meta-analyses to registered trials should preclude publication bias. Recent comparisons of results of published trials with those submitted for regulatory approval have also provided clear evidence of reporting bias.38 39 Methods for dealing with selective reporting of outcomes have been described elsewhere. 40Our recommendations apply to meta-analyses of randomised trials, and their applicability in other contexts such as meta-analyses of epidemiological or diagnostic test studies is unclear.41 The performance of tests for funnel plot asymmetry in these contexts is likely to differ from that in meta-analyses of randomised trials. Further factors, such as confounding and precision of measurements, may cause a relation between study size and effect estimates in observational studies. For example, large studies based on routinely collected data might not fully control confounding compared with smaller, purpose designed studies that collected a wide range of potential confounding variables. Alternatively, larger studies might use self reported exposure levels, which are more error prone, while smaller studies used precise measuring instruments. However, simulation studies have usually not considered such situations. An exception is for diagnostic studies, where large imbalances in group sizes and substantial odds ratios lead to poor performance of some tests: that proposed by Deeks et al was designed for use in this context.4Summary points Inferences on the presence of bias or heterogeneity should consider different causes of funnel plot asymmetry and should not be based on visual inspection of funnel plots aloneThey should be informed by contextual factors, including the plausibility of publication bias as an explanation for the asymmetryTesting for funnel plot asymmetry should follow the recommendations detailed in this articleThe fixed and random effects estimates of the intervention effect should be compared when funnel plot asymmetry exists in a meta-analysis with between study heterogeneityNotesCite this as: BMJ 2011;342:d4002FootnotesContributors: All authors contributed to the drafting and editing of the manuscript. DA, JC, JD, RMH, JPTH, JPAI, DRJ, DM, JP, GR, JACS, AJS and JT contributed to the chapter in the Cochrane Handbook for Systematic Reviews of Interventions on which our recommendations on testing for funnel plot asymmetry are based. JACS will act as guarantor.Funding: Funded in part by the Cochrane Collaboration Bias Methods Group, which receives infrastructure funding as part of a commitment by the Canadian Institutes of Health Research (CIHR) and the Canadian Agency for Drugs and Technologies in Health (CADTH) to fund Canadian based Cochrane entities. This supports dissemination activities, web hosting, travel, training, workshops and a full time coordinator position. JPTH was funded by MRC Grant U.1052.00.011. DGA is supported by Cancer Research UK. GR was supported by a grant from Deutsche Forschungsgemeinschaft (FOR 534 Schw 821/2-2).Competing interests. JC, JJD, SD, RMH, JPAI, DRJ, PM, JP, GR, GS, JACS and AJS are all authors on papers proposing tests for funnel plot asymmetry, but have no commercial interests in the use of these tests. All authors have completed the ICJME unified disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that they have no financial or non-financial interests that may be relevant to the submitted work.Provenance and peer review: Not commissioned; externally peer reviewed.References↵Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ1997;315:629-34.OpenUrlFREE Full Text↵Sterne JAC, Gavaghan D, Egger M. Publication and related bias in meta-analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol2000;53:1119-29.OpenUrlCrossRefMedlineWeb of Science↵Lau J, Ioannidis JP, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. BMJ2006;333:597-600.OpenUrlFREE Full Text↵Deeks JJ, Macaskill P, Irwig L. The performance of tests of publication bias and other sample size effects in systematic reviews of diagnostic test accuracy was assessed. J Clin Epidemiol2005;58:882-93.OpenUrlCrossRefMedlineWeb of Science↵Terrin N, Schmid CH, Lau J. In an empirical evaluation of the funnel plot, researchers could not visually identify publication bias. J Clin Epidemiol2005;58:894-901.OpenUrlCrossRefMedlineWeb of Science↵Ioannidis JP. Interpretation of tests of heterogeneity and bias in meta-analysis. J Eval Clin Pract 2008;14:951-7.OpenUrlMedlineWeb of Science↵Sterne JAC, Egger M, Moher D. Addressing reporting biases. In: Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of interventions. Wiley, 2008.↵Sterne JAC, Egger M. Funnel plots for detecting bias in meta-analysis: guidelines on choice of axis. J Clin Epidemiol2001;54:1046-55.OpenUrlCrossRefMedlineWeb of Science↵Begg CB, Berlin JA. Publication bias: a problem in interpreting medical data. J R Statist Soc A1988;151:419-63.OpenUrlCrossRef↵Davey Smith G, Egger M. Who benefits from medical interventions? Treating low risk patients can be a high risk strategy. BMJ1994;308:72-4.OpenUrlFREE Full Text↵Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet1993;342:1032-6.OpenUrlCrossRefMedlineWeb of Science↵Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L, Moreno SG. Assessing publication bias in meta-analyses in the presence of between-study heterogeneity. J R Statist Soc A2010;173:575-91.OpenUrlCrossRef↵Egger M, Jüni P, Bartlett C, Holenstein F, Sterne J. How important are comprehensive literature searches and the assessment of trial quality in systematic reviews? Empirical study. Health Technol Assess2003;7:1-68.OpenUrlMedline↵Ioannidis JP. Why most discovered true associations are inflated. Epidemiology2008;19:640-8.OpenUrlCrossRefMedlineWeb of Science↵Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta-epidemiological study. BMJ2008;336:601-5.OpenUrlFREE Full Text↵Hopewell S, Clarke M, Stewart L, Tierney J. Time to publication for results of clinical trials. Cochrane Database Syst Rev2007;2:MR000011.OpenUrlMedline↵Hopewell S, Loudon K, Clarke MJ, Oxman AD, Dickersin K. Publication bias in clinical trials due to statistical significance or direction of trial results. Cochrane Database Syst Rev2009;1:MR000006.OpenUrlMedline↵Song F, Parekh S, Hooper L, Loke YK, Ryder J, Sutton J, et al. Dissemination and publication of research findings: an updated review of related biases. Health Technol Assess2010;14:iii,ix-iii,193.OpenUrlMedlineWeb of Science↵Dwan K, Altman DG, Arnaiz JA, Bloom J, Chan AW, Cronin E, et al. Systematic review of the empirical evidence of study publication bias and outcome reporting bias. PLoS ONE2008;3:e3081.OpenUrlCrossRefMedline↵Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med2008;358:252-60.OpenUrlCrossRefMedline↵Rosenthal R. The “file drawer” problem and tolerance for null results. Psychol Bull1979;86:638-41.OpenUrlCrossRefWeb of Science↵Chan AW, Hrobjartsson A, Haahr MT, Gotzsche PC, Altman DG. Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles. JAMA2004;291:2457-65.OpenUrlFREE Full Text↵Higgins JP, Thompson SG. Controlling the risk of spurious findings from meta-regression. Stat Med2004;23:1663-82.OpenUrlCrossRefMedlineWeb of Science↵Ioannidis JP. Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials? Philos Ethics Humanit Med2008;3:14.OpenUrlCrossRefMedline↵Peters J, Sutton AJ, Jones DR, Abrams KR, Rushton L. Contour-enhanced meta-analysis funnel plots help distinguish publication bias from other causes of asymmetry. J Clin Epidemiol2008;61:991-6.OpenUrlCrossRefMedlineWeb of Science↵Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med2006;25:3443-57.OpenUrlCrossRefMedlineWeb of Science↵Peters JL, Sutton AJ, Jones DR, Abrams KR, Rushton L. Comparison of two methods to detect publication bias in meta-analysis. JAMA2006;295:676-80.OpenUrlFREE Full Text↵Rücker G, Schwarzer G, Carpenter J. Arcsine test for publication bias in meta-analyses with binary outcomes. Stat Med2008;27:746-63.OpenUrlCrossRefMedlineWeb of Science↵Ioannidis JP, Trikalinos TA. The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey. CMAJ2007;176:1091-6.OpenUrlFREE Full Text↵Poole C, Greenland S. Random-effects meta-analyses are not always conservative. Am J Epidemiol1999;150:469-75.OpenUrlFREE Full Text↵Egger M, Davey Smith G. Misleading meta-analysis. Lessons from an “effective, safe, simple” intervention that wasn’t. BMJ1995;310:752-4.OpenUrlFREE Full Text↵Teo KK, Yusuf S, Collins R, Held PH, Peto R. Effects of intravenous magnesium in suspected acute myocardial infarction: overview of randomised trials. BMJ1991;303:1499-503.OpenUrlFREE Full Text↵ISIS-4 (Fourth International Study of Infarct Survival) Collaborative Group. ISIS-4: a randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58,050 patients with suspected acute myocardial infarction. Lancet1995;345:669-85.OpenUrlCrossRefMedlineWeb of Science↵Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial. Lancet2002;360:1189-96.OpenUrlCrossRefMedlineWeb of Science↵Shang A, Huwiler-Muntener K, Nartey L, Jüni P, Dörig S, Stene JA, et al. Are the clinical effects of homoeopathy placebo effects? Comparative study of placebo-controlled trials of homoeopathy and allopathy. Lancet2005;366:726-32.OpenUrlCrossRefMedlineWeb of Science↵Moreno SG, Sutton AJ, Ades AE, Stanley TD, Abrams KR, Peters JL, et al. Assessment of regression-based methods to adjust for publication bias through a comprehensive simulation study. BMC Med Res Methodol2009;9:2.OpenUrlCrossRefMedline↵Rucker G, Schwarzer G, Carpenter JR, Binder H, Schumacher M. Treatment-effect estimates adjusted for small-study effects via a limit meta-analysis. Biostatistics2011;12:122-42.OpenUrlFREE Full Text↵Moreno SG, Sutton AJ, Turner EH, Abrams KR, Cooper NJ, Palmer TM, et al. Novel methods to deal with publication biases: secondary analysis of antidepressant trials in the FDA trial registry database and related journal publications. BMJ2009;339:b2981.OpenUrlFREE Full Text↵Eyding D, Lelgemann M, Grouven U, Härter M, Kromp M, Kaiser T, et al. Reboxetine for acute treatment of major depression: systematic review and meta-analysis of published and unpublished placebo and selective serotonin reuptake inhibitor controlled trials. BMJ2010;341:c4737. OpenUrlFREE Full Text↵Kirkham JJ, Dwan KM, Altman DG, Gamble C, Dodd S, Smyth R, et al. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews. BMJ2010;340:c365. OpenUrlFREE Full Text↵Egger M, Schneider M, Davey Smith G. Spurious precision? Meta-analysis of observational studies. BMJ1998;316:140-4.OpenUrlFREE Full Text
Most children, including lower socioeconomic status and ethnic minority children, play video games, use computers, and have cell phones, and growing numbers have smart phones and electronic tablets. They are comfortable with, even prefer, electronic media. Many expect to be entertained and have a low tolerance for didactic methods. Thus, health promotion with children needs to incorporate more interactive media. Interactive media for weight control and health promotion among children can be broadly classified into web-based educational/therapeutic programs, tailored motivational messaging systems, data monitoring and feedback systems, active video games, and diverse forms of interactive multimedia experiences involving games. This article describes the primary characteristics of these different technological methods; presents the strengths and weaknesses of each in meeting the needs of children of different ages; emphasizes that we are in the earliest stages of knowing how best to design these systems, including selecting the optimal requisite behavioral change theories; and identifies high-priority research issues. Gaming and technology offer many exciting, innovative opportunities for engaging children and promoting diet and physical activity changes that can contribute to obesity prevention and weight loss maintenance. Research needs to clarify optimal procedures for effectively promoting change with each change procedure.
This systematic review evaluates interventions using active video games (AVGs) to increase physical activity and summarizes laboratory studies quantifying intensity of AVG play among children and adults. Databases (Cochrane Library, PsychInfo, PubMed, SPORTDiscus, Web of Science) and forward citation and reference list searches were used to identify peer-reviewed journal articles in English through March 2011. Studies that used off-the-shelf AVGs to increase physical activity with quantitative outcomes or studies that quantified intensity of AVG play were included. Information on sample characteristics, AVGs employed, study design and conditions, outcome measures, results, and conclusions was extracted by two researchers. Intervention studies were ranked on design quality. Thirteen interventions and 28 laboratory studies were identified. All laboratory studies demonstrated that AVGs are capable of providing light-to-moderate intensity physical activity. However, only three interventions supported AVGs as an effective tool to significantly increase physical activity or exercise attendance. As AVGs are becoming more popular, additional research is needed to determine how to capitalize on the potential of AVGs to increase physical activity.
This naturalistic study tests whether children receiving a new (to them) active video game spontaneously engage in more physical activity than those receiving an inactive video game, and whether the effect would be greater among children in unsafe neighborhoods, who might not be allowed to play outside.
Participants were children 9 to 12 years of age, with a BMI >50th percentile, but <99th percentile; none of these children a medical condition that would preclude physical activity or playing video games. A randomized clinical trial assigned children to receiving 2 active or 2 inactive video games, the peripherals necessary to run the games, and a Wii console. Physical activity was monitored by using accelerometers for 5 weeks over the course of a 13-week experiment. Neighborhood safety was assessed with a 12 item validated questionnaire.
There was no evidence that children receiving the active video games were more active in general, or at anytime, than children receiving the inactive video games. The outcomes were not moderated by parent perceived neighborhood safety, child BMI z score, or other demographic characteristics.
These results provide no reason to believe that simply acquiring an active video game under naturalistic circumstances provides a public health benefit to children.
Community-based interventions are needed to reduce the burden of childhood obesity.
To evaluate the impact of a multi-level promotora-based (Community Health Advisor) intervention to promote healthy eating and physical activity and prevent excess weight gain among Latino children.
Thirteen elementary schools were randomized to one of four intervention conditions: individual/family level (Family-only), school/community level (Community-only), combined (Family + Community), or a measurement-only condition. Participants were 808 Latino parents and their children enrolled in kindergarten through 2(nd) grade. Measures included parent and child body mass index (BMI) and a self-administered parent survey that assessed several parent and child behaviors.
There were no significant intervention effects on children's BMI z-score. The family intervention changed several obesity-related child behaviors (e.g., fruit/vegetable consumption) and these were mediated by changes in parenting variables (e.g., parent monitoring).
A promotora-based behavioral intervention was efficacious at changing parental factors and child obesity-related health behaviors.
Increasing epidemic proportions of overweight children in the United States presents formidable challenges for education and healthcare. Given the popularity and pervasiveness of video gaming culture in North American children, the perfect opportunity arises to investigate the potential of video games to promote healthful behaviour. Our objective was to systematically review the literature for possible benefits of active and educational video games targeting diet and physical activity in children. A review of English-language journal articles from 1998 to 2011 using EMBASE and PubMed was conducted. Thirty-four studies concerned with children, video games, physical, and/or nutritional outcomes were included. Results of these studies that showed some benefit (increased physical activity and nutritional knowledge as a result of gaming) demonstrate the possibility of video games to combat childhood obesity-looking beyond the stigma attached to gaming.
Sedentary activities such as video gaming are independently associated with obesity. Active video games, in which players physically interact with images on screen, may help increase physical activity and improve body composition.
The aim of this study was to evaluate the effect of active video games over a 6-mo period on weight, body composition, physical activity, and physical fitness.
We conducted a 2-arm, parallel, randomized controlled trial in Auckland, New Zealand. A total of 322 overweight and obese children aged 10-14 y, who were current users of sedentary video games, were randomly assigned at a 1:1 ratio to receive either an active video game upgrade package (intervention, n = 160) or to have no change (control group, n = 162). The primary outcome was the change from baseline in body mass index (BMI; in kg/m(2)). Secondary outcomes were changes in percentage body fat, physical activity, cardiorespiratory fitness, video game play, and food snacking.
At 24 wk, the treatment effect on BMI (-0.24; 95% CI: -0.44, -0.05; P = 0.02) favored the intervention group. The change (±SE) in BMI from baseline increased in the control group (0.34 ± 0.08) but remained the same in the intervention group (0.09 ± 0.08). There was also evidence of a reduction in body fat in the intervention group (-0.83%; 95% CI: -1.54%, -0.12%; P = 0.02). The change in daily time spent playing active video games at 24 wk increased (10.03 min; 95% CI: 6.26, 13.81 min; P < 0.0001) with the intervention accompanied by a reduction in the change in daily time spent playing nonactive video games (-9.39 min; 95% CI: -19.38, 0.59 min; P = 0.06).
An active video game intervention has a small but definite effect on BMI and body composition in overweight and obese children. This trial was registered in the Australian New Zealand Clinical Trials Registry at http://www.anzctr.org.au/ as ACTRN12607000632493.
The purpose of this study was to examine the efficacy of interactive video game stationary cycling (GameBike) in comparison with stationary cycling to music on adherence, energy expenditure measures, submaximal aerobic fitness, body composition, and cardiovascular disease risk markers in overweight and obese adolescents, using a randomized controlled trial design. Thirty overweight (with at least 1 metabolic complication) or obese adolescents aged 1217years were stratified by gender and randomized to video game or music condition, with 4 participants (2 per group) failing to complete the twice weekly 60min sessions of the 10-week trial. The music group had a higher rate of attendance compared with the video game group (92% vs. 86%, p< 0.05). Time spent in minutes per session at vigorous intensity (80%100% of predicted peak heart rate) (24.9 20 min vs. 13.7 12.8 min, p< 0.05) and average distance (km) pedaled per session (12.5 2.8 km vs. 10.2 2.2 km, p< 0.05) also favoured the music group. However, both interventions produced significant improvements in submaximal indicators of aerobic fitness as measured by a graded cycle ergometer protocol. Also, when collapsed, the exercise modalities reduced body fat percentage and total cholesterol. The present study indicates that cycling to mus