Received: 25 March 2019 

|  Revised: 7 July 2019 

|  Accepted: 7 August 2019

DOI: 10.1111/sms.13539

REVIEW ARTICLE

Effects of active video games on children and adolescents:

A systematic review with meta‐analysis

Crystian B. Oliveira1   | Rafael Z. Pinto1,2  | Bruna T. C. Saraiva3  | William R. Tebar3   |

Leandro D. Delfino   3
| Marcia R. Franco   4
| Claudiele C. M. Silva   5
| Diego G. D. Christofaro 3

1
Department of Physiotherapy, School of
Technology and Sciences, São Paulo State
Objective: To investigate the effectiveness of active video games (AVGs) on obe-
University (UNESP), Presidente Prudente, sity‐related outcomes and physical activity levels in children and adolescents.
Brazil Design: Systematic review with meta‐analysis.
2
Department of Physiotherapy, Universidade
Methods: Literature search was performed in five electronic databases and the main
Federal de Minas Gerais (UFMG), Belo
Horizonte, Brazil clinical trials registries. Randomized controlled trials investigating the effect of
3
Department of Physical Education, School AVGs compared with no/minimal intervention on obesity‐related outcomes (body
of Technology and Sciences, São Paulo mass index [BMI], body weight, body fat, and waist circumference) and physical
State University (UNESP), Presidente
Prudente, Brazil
activity levels of children and adolescents were eligible. Two independent reviewers
4
Centro Universitário UNA, Contagem, extracted the data of each included study. PEDro scale was used to assess risk of bias
Brazil and GRADE approach to evaluate overall quality of evidence. Pooled estimates were
5
Department of Education, School of obtained using random effect models.
Technology and Sciences, São Paulo State
Results: Twelve studies were considered eligible for this review. Included studies
University (UNESP), Presidente Prudente,
Brazil mostly reported outcome data at short‐term (less or equal than three months) and in-
termediate‐term follow‐up (more than 3 months, but <12 months). AVGs were more
Correspondence
Diego G. D. Christofaro, Department
effective than no/minimal intervention in reducing BMI/zBMI at short‐term (SMD
of Physical Education, São Paulo State = −0.34; 95% CI: −0.62 to −0.05) and intermediate‐term follow‐up (SMD = −0.36;
University (UNESP), School of Technology 95% CI: −0.01 to −0.71). In addition, AVGs were more effective in reducing body
and Sciences, Presidente Prudente, Brazil.
Email: diegochristofaro@yahoo.com.br weight compared with no/minimal intervention at intermediate‐term follow‐up
(SMD = −0.25; 95% CI: −0.46 to −0.04). Regarding physical activity levels, AVGs
Funding information
were not more effective compared with minimal intervention at short‐term and inter-
Fundação de Amparo à Pesquisa do Estado
de São Paulo, Grant/Award Number: mediate‐term follow‐up.
2016/03826‐5 Conclusions: Our review identified that AVGs were better than minimal interven-
tion in reducing BMI and body weight, but not for increasing physical activity in
young people.

KEYWORDS
active video game, adolescents, children, obesity, physical activity

1  |   IN TRO D U C T ION with an increased risk of cardiovascular diseases2-5 and

long‐term complications.6,7 According to the World Health
Obesity and overweight in children and adolescents have be- Organization (WHO),8 physical activity promotion is consid-
come a global health burden, reaching a global prevalence of ered an appropriate management strategy to prevent obesity
almost 10%.1 In fact, childhood obesity has been associated among children. Although high physical activity levels are

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wileyonlinelibrary.com/journal/sms
2019 John Wiley & Sons A/S. Scand J Med Sci Sports. 2020;30:4–12.
Published by John Wiley & Sons Ltd
OLIVEIRA et al.
associated with reduced obesity‐related outcomes,9-11 the
vast majority of children do not meet the recommended levels
of physical activity.12
In addition to physical activity, other interventions have
been proposed to reduce weight in children including behav-
ioral, dietary, and drug therapy approaches. However, current
evidence reveals that none of these interventions are effective
for reducing weight in children.13,14 A systematic review15
demonstrated that physical activity interventions have only
a small effect on improving physical activity levels of chil-
dren which may explain, in part, why these interventions
have limited success in reducing weight in this population. A
new generation of video games, known as active video games
(AVGs) or “exergames,” has emerged as an innovative inter-
vention to reduce childhood obesity.16
Several types of AVG are available, such as Nintendo
(Redmond, WA) Wii fit games, “Dance Dance Revolution”
(Konami Digital Entertainment, El Segundo, CA), and
Kinect sports, and they might be considered a possible option
given that 83% of young people have access to at least one
video game console.17 AVGs explore and integrate exercise
and gaming entertainment using a digital interface to pro-
mote physical activity and discourage sedentary behavior18
which may be delivered at home, in schools, and in laborato-
ries. Recently, a growing number of studies have been con-
ducted to estimate the effectiveness of AVGs in children and
adolescents.
Previous systematic reviews19,20 investigated the effective-
ness of AVGs on physical activity levels and obesity‐related
outcomes. The first review19 conducted in 2014 investigat-
ing the effectiveness of AVGs on obesity‐related outcomes
was unable to perform a meta‐analysis. The second review20
conducted in 2015 reported a meta‐analysis showing favor-
able results for the AVG group over sedentary behaviors (eg,
sedentary video games, TV viewing) among young people.20
However, this review also included non‐randomized con-
trolled trials in the meta‐analyses which may overestimate
the results.21,22 Furthermore, AVGs delivered out of school
environment are more feasible due to the nature of the inter-
vention and may increase the practice of physical activity in
order to reduce weight and promote health improvement.23
Therefore, the aim of this systematic review of randomized
controlled trials was to investigate the effectiveness of AVGs
performed out of school (ie, home‐based and laboratory‐
based) compared with minimal intervention on obesity‐re-
lated outcomes and physical activity levels in children and
adolescents.
2  |   M ET H OD S
This review followed the Preferred Reported Items
for Systematic review and Meta‐analyses (PRISMA)
  
|
   5
recommendations,24 and it was prospectively registered at
PROSPERO (CRD42017058483).
A comprehensive literature search was performed from
their inception to October/2018 in the following databases:
MEDLINE, EMBASE, CINAHL, SPORT Discus, and
PEDro. The search strategy was conducted using a combi-
nation of search terms for children (“youth,” “childhood”),
AVGs (“exergame,” “active videogame,” “game‐based”) and
randomized controlled trials. In addition, we searched in
the main trial register databases (ie, ClinicalTrials.gov, the
International Standard Randomized Controlled Trial Number
Register, and the Australian New Zealand Clinical Trials
Registry) to identify ongoing and unpublished trials. The
search was also aided by the World Health Organization—
International Clinical Trials Registry Platform search por-
tal. The searches were restricted to publications in English,
Spanish, and Portuguese. Appendix 1 contains the search
strategy performed in MEDLINE. Citation tracking was
performed to detect relevant studies missed by our search
strategy.
2.1  |  Study selection
Two reviewers independently screened the titles and ab-
stracts retrieved from the search strategy. Records selected
as potentially eligible studies for the review were assessed
through the full texts by two independent reviewers. Any
case of disagreement was resolved in consensus with a third
reviewer.
Randomised Controlled Trials and quasi‐RCTs investi-
gating the efficacy of AVGs compared with minimal inter-
vention (eg, usual care, no intervention, education, advice,
inactive videogames, and waiting list) in children aged
from 2 to 19  years were included in this review. Quasi‐
RCTs were considered eligible in this review because, in
this study design, participants are allocated using a method
which may not be considered strictly random (eg, date of
birth).25 We adopted this approach in accordance with a
previous review instead of including any non‐random-
ized trial.26 AVGs were defined as any computer game
using interaction between body movements and specific
feedback and goals. Therefore, interventions which in-
cluded consoles, such as the Nintendo Wii, Playstation
(Sony Computer Entertainment Inc), and Kinect TM for
Microsoft's Xbox 360TM (Microsoft Inc), and game con-
trollers, such as GameCycle (Three Rivers Holdings) and
Sony EyeToyVR (Sony Computer Entertainment Inc), were
considered eligible. Interventions using AVGs isolated or
in combination with other approaches were required to be
delivered at home or in the laboratory. Therefore, school‐
based interventions were excluded from this review.
Weight‐related outcomes, such as BMI and BMI z‐
score, body weight, body fat, and waist circumference, were
 |
6       OLIVEIRA et al.
considered as primary outcomes for this review. Secondary
outcomes were physical activity level measures, such as mod-
erate‐to‐vigorous activity, sedentary activity, counts per min-
ute, and light physical activity. To be included, studies should
provide data for at least one primary or secondary outcome.
2.2  |  Data extraction and quality assessment
Data extraction was performed by two independent review-
ers using a standardized form. Information extracted in-
cluded sample characteristics (ie, sample source, sample size,
age), interventions (ie, mode of delivery, components, type
of comparator, type of game), outcomes, and follow‐up as-
sessment. In case of disagreement, a consensus was reached.
Means, standard deviation, and sample sizes were extracted
from the studies. In case of insufficient data provided by the
studies, the Cochrane Handbook for Systematic Reviews of
Interventions was used for data estimation.25
Risk of bias of the included studies was assessed using the
Physiotherapy Evidence Database (PEDro) scale. The PEDro
scale is a reliable27 and valid tool28 consisting of 10 yes or no
questions for measuring internal and statistical validity of trials.
The scores range from 0 to 10, and higher scores indicate greater
methodological quality. Two independent reviewers assessed
the risk of bias of the included studies, and a third reviewer
was available to resolve any disagreement. Trials indexed in the
PEDro database with scores available were extracted.
The Grading of Recommendations Assessment,
Development, and Evaluation (GRADE) approach was used
to evaluate the overall quality of the evidence for the inter-
vention.29 The overall quality of evidence was downgraded
one level for each of the following criteria: limitation of study
design (more than 25% of the participants from studies with
low methodological quality [PEDro score < 6]30); inconsis-
tent results (25% or more of the trials did not have the same
direction or substantial heterogeneity with an I2 higher than
50%); and imprecision (<300 participants for each outcome).
Indirectness was not considered due to the inclusion of a
specific population, intervention, and outcomes measures.
Publication bias of the studies was assessed using a funnel
plot as there were insufficient studies (ie, <10 studies) in
each meta‐analysis.
The overall quality of evidence was defined as: high qual-
ity (ie, all domains were satisfied, and further research is very
unlikely to change our confidence in the estimate of effect);
moderate quality (ie, one domain was not met, and further re-
search is likely to have an important impact on our confidence
in the estimate of effect and may change the estimate); low
quality (ie, two domains were not met, and further research
is very likely to have an important impact on our confidence
in the estimate of effect and is likely to change the estimate);
and very low quality (ie, three domains were not met, and any
estimate of effect is very uncertain).
2.3  |  Data synthesis and data analysis
Time points of the follow‐up assessments were summarized
for short term (≤3 months), intermediate term (between 3 and
12 months), and long term (>12 months). Standardized mean
difference (SMD) was calculated for the outcome measures.
We interpreted the magnitude of treatment effects as small
(SMD = 0.20), medium (SMD = 0.50), and large effect size
(SMD = 0.80). For the meta‐analysis, we combined the BMI
and zBMI in the forest plot, based on previous studies.13,31
When studies reported both measures, BMI and zBMI, we
considered the non‐standardized BMI32 (ie, without standard-
ize BMI for any variable). Heterogeneity between the stud-
ies was investigated using I2 statistics and the chi‐squared
test. Considering that multiple outcomes measures regarding
physical activity measures are often reported (eg, light physi-
cal activity, moderate‐to‐vigorous physical activity, number
of steps, counts per minute), we used a least and most con-
servative approaches to combine our treatment effects on
physical activity. In the least conservative analysis, we con-
sidered the physical activity measure with the largest effect
(ie, highest effect favoring the AVGs), while in the most con-
servative analysis we included the smallest effect (ie, lowest
effect favoring the control group). We reported both analyses
in the manuscript. All meta‐analysis calculations were ob-
tained through the Comprehensive Meta‐Analysis software,
version 2.2.04 (Biostat) and using random effect models to
account to the heterogeneity across the individual effects of
the studies.
3  |  RESULTS
Figure 1 describes the study selection steps of the review.
The search processes retrieved 3327 records after removing
duplicate studies. After title and abstract screening, 27 ar-
ticles were considered potentially eligible and the full texts
were reviewed. Finally, 12 randomized controlled trials met
the eligibility criteria and were included in this review33-44
(Appendix 2 provides a list of reasons for exclusion of each
study).
The total sample size of the studies included in the review
was 1016 children and adolescents with mean ages ranging
from 7 to 19 years. The proportion of boys (55.8%) was higher
than girls. Furthermore, three studies (23%) reported an aver-
age age below 10 years. Dance games (n = 6)37-39,42-44 were
the most commonly used type of game in the included studies,
followed by sports games (n = 2),34,41 a gaming package with
a combination of dance and sport games (n = 3),33,36,40 and
a peripheral device (n = 1).35 Maintaining normal activities
was the most frequently used comparator (n = 10) followed
by inactive video games (n = 2). Appendix 3 summarizes the
characteristics of the included studies.
OLIVEIRA et al.
F I G U R E 1   Flowchart of study selection. Abbreviations: RCT, randomized controlled trial
Regarding the risk of bias, one study (7.7%) had a PEDro
score of 7 out of 10, four studies (30.7%) scored 6 out of
10, and six studies scored 5 out of 10 (46.1%) (Appendix
4). Two studies (15.4%) blinded the assessors, five (38.5%)
performed intention‐to‐treat analysis, and ten (76.9%) studies
presented adequate follow‐up (ie, <15% of loss to follow‐up).
After performing the search in the base of records of ran-
domized clinical trials, three ongoing studies were found.
The estimated sample sizes of the studies ranged from 60
to 116 children and adolescents with two trials investigating
exercise and one sports games. Two trials planned reporting
obesity‐related outcomes, and two trials report physical ac-
tivity levels. Appendix 5 describes the characteristics of on-
going trials.
3.1  |  Weight‐related outcomes
Appendix 6 summarizes the overall quality evidence
using the GRADE approach for primary and secondary
outcomes. A total of 11 trials reported weight‐related
outcomes. For BMI/zBMI data, there was high‐quality
evidence that AVGs were more effective than no/mini-
mal intervention at short‐term (6 trials, SMD = −0.34;
95% CI: −0.62 to −0.05) and intermediate‐term fol-
low‐up (2 trials, SMD  =  −0.36; 95% CI: −0.71 to
−0.01) (Figure 2). In fact, the effect sizes were small
at short‐term and intermediate‐term follow‐ups. For
  
|
   7
body weight, there was moderate‐quality evidence
(downgraded for risk of bias) that AVGs were not more
effective than no/minimal intervention at short‐term
follow‐up (5 trials, SMD  =  −0.12; 95% CI: −0.30 to
0.06) (Appendix 7). Nevertheless, there was high‐qual-
ity evidence that AVGs were more effective in reducing
body weight compared with no/minimal intervention at
intermediate‐term follow‐up (2 trials, SMD  =  −0.25;
95% CI: −0.46 to −0.04) (Figure 3). For body fat and
waist circumference (Appendix 8), there was high‐
quality evidence demonstrating non‐significant ef-
fects for AVGs compared with minimal intervention at
short‐term follow‐up (3 trials, SMD = −0.31; 95% CI:
−0.72 to 0.10/ 2 trials, SMD  =  −0.64; 95% CI −1.46
to 0.17).
3.2  |  Physical activity levels
Figure 3 shows pooled effects for physical activity levels
using the less conservative analysis. There was moder-
ate‐quality evidence (downgraded for risk of bias) that the
AVGs were not more effective than the control group for
increasing physical activity levels at the short‐term fol-
low‐up (6 trials, SMD  =  0.06; 95% CI: −0.19 to 0.31).
There was moderate‐quality evidence that AVGs were
not more effective compared with minimal intervention
at intermediate‐term follow‐up (4 trials, SMD  =  0.22;
 |
8       OLIVEIRA et al.
95% CI: −0.09 to 0.52) (Figure 3). Considering the most
conservative analysis (Appendix 9), there was a signifi-
cant difference favoring the minimal intervention group
at short‐term follow‐up (6 trials, SMD  =  −0.35; 95%
CI: −0.64 to −0.05) and non‐significant differences be-
tween groups at intermediate‐term follow‐up (4 trials,
SMD = −0.04; 95% CI: −0.19 to 0.11).
4  |   D IS C U S S ION
The main findings of this review are that we found moder-
ate‐quality evidence that AVGs are more effective in reduc-
ing BMI and weight compared with no/minimal intervention.
Considering the physical activity levels, AVGS were not bet-
ter compared with minimal intervention at short‐term and
F I G U R E 2   Effectiveness of
active video game compared to minimal
intervention on BMI and zBMI in children
and adolescents. Abbreviations: AVGs,
active video game; CI, confidence interval;
SMD, standardized mean difference
F I G U R E 3   Effectiveness of
active video game compared to minimal
intervention on physical activity levels (ie,
less conservative analysis) in children and
adolescents. Abbreviations: AVGs, active
video game; CI, confidence interval; SMD,
standardized mean difference
intermediate‐term follow‐up. Of note, our search identified
that at least three studies have already been recorded in the
clinical trials database which could change the results for
the outcomes with moderate‐quality evidence, according to
GRADE.
Considering the objectives of this review, three other re-
views were detected with a similar objective.19,20,45 Our find-
ings conflict with Bochner, Sorensen 45 which detected no
significant differences favoring the AVGs in a meta‐analysis
including seven studies. One of the possible differences be-
tween the reviews might be attributable to the data analysis.
Bochner, Sorensen45 used a combination of weight‐related
outcomes to compare the intervention group and control
group, while we analyzed the outcomes separately in the cur-
rent review. Another factor is that two new RCTs were added
in the current review.42,46 Meanwhile, the findings of the
OLIVEIRA et al.
current review align to those found by Gao, Chen 20 which
also observed a small effect size on body composition in
young people favoring the AVGs.
Our review showed that AVGs may reduce BMI and body
weight of children and adolescents. Similarly, a previous re-
view demonstrated that exercise can effectively reduce BMI
in obese and overweight children.47 Indeed, this review also
explored whether changes in exercise and/or physical activity
levels beyond the exercise intervention influenced between‐
group changes in BMI. However, they did not detect any sig-
nificant association between these variables. One explanation
is that the substitution of a sedentary activity (ie, inactive
videogame) to the practice of AVGs may stimulate children
and adolescents to adopt a healthier lifestyle regardless of the
increase in physical activity levels. For example, previous
studies have shown that an increased time spent in sedentary
activities is associated with food intake and poor eating hab-
its.48,49 Therefore, we could argue that the practice of AVGs
may generate additional changes toward a healthy lifestyle
in this population (eg, healthy eating habits) which, conse-
quently, would reduce BMI and body weight. Nevertheless,
future studies should test the effects of including AVGs as
part of a multidisciplinary intervention in order to improve
weight‐related outcomes in children and adolescents.
In contrast, AVGs were not effective in reducing body
fat and waist circumference of children and adolescents.
Considering there was a significant reduction in body mass
index and body weight, it might have been a reduction in lean
mass of children and adolescents after the AVGs. However,
the pooled estimates of body fat and waist circumference
showed very low quality of evidence which indicates high
uncertainty in these estimates, and therefore, further studies
are required to reach a definitive conclusion.
Considering the effects of AVG use on physical activity,
this meta‐analysis found no significant differences in increas-
ing the physical activity levels in the AVGs group compared
with the control group. This finding aligns to the results of
the Gao et al which also detected no significant differences
in promoting the physical activity levels favoring the AVGs.
In fact, these findings show that despite AVGs contributing
to a reduction in BMI and body weight they do not replace
the physical activity of traditional sports.50-52 Considering
that most studies (7 out of 8) reported objectively measured
physical activity, one explanation for these findings is that
the varied amount of movements performed in the interven-
tion could not be entirely captured by the objective methods
due to the limited sensibility in specific activities (eg, arms
movements). Future studies investigating the effects of AVGs
on physical activity levels should be conducted using the ob-
jective measures with different choices of data collection (eg,
multiple accelerometers) to clarify this issue.
The strength of this review may be considered the litera-
ture searches conducted in five databases which identified the
  
   9
|
included studies in this review; however, we could not exclude
the possibility of missing studies. It is noteworthy that another
aspect to be highlighted is the three unpublished articles found
in the clinical trials database, which might increase the overall
quality of evidence in the near future. Another strength is that
we also investigated the effectiveness of AVGs on promoting
additional benefits in addition to improving weight‐related
outcomes including to increase physical activity levels of
young people. One of the limitations of this review was the
heterogeneity across individual studies of weight‐related out-
come measurements and physical activity levels. To reduce the
possible heterogeneity in the comparisons, we conducted the
meta‐analyses were performed grouping the measures, for ex-
ample, weight‐related outcome was stratified by the variables
weight, BMI, body fat, and waist circumference. Furthermore,
the included studies reported the outcome measures only at
short‐term and intermediate‐term follow‐up. Thus, further
studies should be conducted to assess the long‐term effective-
ness of AVGs in young individuals.
In summary, there was high‐quality evidence to support
the use of AVGs among young people to reduce BMI and
body weight, but there is limited evidence to support the ra-
tionale that AVGs can increase physical activity levels and re-
duce body fat and waist circumference. Nevertheless, AVGs
should be performed in combination with sports activities,
but especially when adolescents are spending time on screen
activities. Indeed, the practice of this type of intervention
could be further implemented to promote a behavior change
toward a healthy lifestyle, since a large proportion of these
young people spend a high number of hours per day playing
inactive video game.53
This review demonstrated that AVGs can contribute to re-
duce BMI and body weight, but should not replace traditional
sports because they did not increase the physical activity levels
of children and adolescents. However, some questions remain
to be answered by future studies: (a) if the AVG is performed
together with traditional sports activities, could it cause bet-
ter effects on weight‐related outcomes and levels of physical
activity intensity of young people; (b) does the type of game
adopted in these interventions (usually dance and sports)
have the same effects on the health of these young people; (c)
long‐term interventions (minimum 12 months) could provide
changes in the lifestyle of young people; and (d) what types of
games could be played in the competitions or cooperatively.
5  |  CONCLUSION
The findings of the current review demonstrated that AVGs
were more effective in reducing BMI and body weight com-
pared with minimal intervention of young people at short‐
term and intermediate follow‐up. In contrast, AVGs were not
better than minimal intervention for increasing the physical
 |
10       OLIVEIRA et al.
activity levels of young people. Further studies investigating
the long‐term effects of the AVGs are still warranted.
6  |   P E R S P E C T IV E S
An increasingly number of studies have been conducted in
order to investigate the effectiveness of AVGs in children
and adolescents. We found moderate‐ to high‐quality evi-
dence that active video games were slightly effective when
compared to no/minimal intervention in reducing BMI and
body weight in children and adolescents. The evidence in
this review supports the practice of physical activity using
active video games as a strategy for reducing BMI and body
weight in children and adolescents. Although we identified
additional trials compared with previous systematic reviews,
further researches are still needed to better understand the
effectiveness of active video game on physical activity lev-
els and the long‐term effects in children and adolescents.
ACKNOWLEDGEMENTS
We thank the support of Sao Paulo Research Foundation
(FAPESP) for the PhD scholarship of Mr Oliveira
(FAPESP/grant number: 2016/03826‐5). In addition, the
authors have no financial relationships relevant to this ar-
ticle to disclose.
CONFLICT OF INTEREST
The authors have no conflicts of interest relevant to this arti-
cle to disclose.
AUTHOR CONTRIBUTION
Mr Oliveira, Drs Christofaro, and Pinto conceptualized and de-
signed the study, drafted the initial manuscript, and reviewed
and revised the manuscript. Mrs Bruna Saraiva, Mr William
Tebar, and Mr Leandro Delfino designed the data collection
instruments, collected data, carried out the initial analyses,
and reviewed and revised the manuscript. Drs Marcia Franco
and Claudiele Silva conceptualized and designed the study,
coordinated and supervised data collection, and critically re-
viewed the manuscript for important intellectual content. All
authors approved the final manuscript as submitted and agree
to be accountable for all aspects of the work.
ORCID
Crystian B. Oliveira  https://orcid.org/0000-0002-6911-7018
William R. Tebar  https://orcid.org/0000-0002-6192-4667
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Brazilian adolescents, mainly among girls. Eur J Sport Sci.

2016;16(4):498‐506. How to cite this article: Oliveira CB, Pinto RZ,
Saraiva BTC, et al. Effects of active video games on
children and adolescents: A systematic review with
SUPPORTING INFORMATION
meta‐analysis. Scand J Med Sci Sports. 2020;30:4–12.
Additional supporting information may be found online https​://doi.org/10.1111/sms.13539​
in the Supporting Information section at the end of the
article.