Sports Med DOI 10.1007/s40279-015-0455-z SYSTEMATIC REVIEW Effects of Exergaming on Physical Activity in Overweight Individuals 1 1 1 Christoph Ho¨chsmann • Michael Schu¨pbach • Arno Schmidt-Trucksa¨ss Ó Springer International Publishing Switzerland 2015 Abstract reviewed journal and analyzing the effects of exergames on Background The majority of patients with overweight objectively measured intensity parameters of PA in over- and type 2 diabetes show insufficient levels of daily weight (body mass index [BMI] C25 kg/m2) adults (mean physical activity (PA) and usually are among the least age C18 years) with and without type 2 diabetes were likely to engage in or adhere to any form of generic PA. included. Study selection, data extraction, and quality Active video games (exergames) may be a solution to assessment were performed independently by two review motivate these individuals to overcome their sedentary authors. Primary outcomes included changes in oxygen lifestyle. uptake (VO2), energy expenditure (EE), heart rate (HR), or Objectives This systematic review was conducted to activity counts. Secondary outcomes were enjoyment of review the current evidence for the effectiveness of treatment, exercise adherence, ratings of perceived exertion exergaming in overweight and type 2 diabetes mellitus and (RPE), changes in body composition, and changes in blood thus to evaluate the suitability of these games to be used as parameters (serum glucose, long-term blood glucose, blood tools for exercise promotion that meet current PA cholesterol, triglycerides, or serum lactate). guidelines. Results Of 2845 records, 14 publications (11 studies) met Methods We searched electronic bibliographic databases the inclusion criteria. All included studies (ten experi- (PubMed, Embase, Web of Science, OpenGrey, and the mental, cross-sectional laboratory studies and one RCT) Cochrane Central Register of Controlled Trials) up to were able to show increases in either VO2, EE, HR, or March 2015. Randomized controlled trials (RCT) and activity counts. However, effects of exergaming in terms of cross-sectional studies published in English in a peer- changes in these intensity parameters varied significantly between game modes and consoles as well as because of the vastly differing durations of exergame activity between studies. One of the included studies had a low risk of bias, and three had a high risk of bias; seven studies had an unclear risk of bias as the study description was insuffi- cient. No studies were found investigating the changes in objectively measured PA intensity parameters in patients with type 2 diabetes. Electronic supplementary material The online version of this Conclusion This review suggests that exergames are able article (doi:10.1007/s40279-015-0455-z) contains supplementary material, which is available to authorized users. to increase PA among overweight individuals. However, the inconsistent results and the overall poor or moderate & Arno Schmidt-Trucksa¨ss methodological quality do not permit judgment on whether [email protected] exergames are suitable to meet PA guidelines in this target group. The lack of research regarding the effects of exer- 1 Division of Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Birsstrasse games in type 2 diabetes indicates a great need for future 320 B, 4052 Basel, Switzerland research. 123 C. Ho¨chsmann et al. death in the world [5]. Physical inactivity has been reported Key Points to be responsible for 9 % of premature mortality, or [5.3 of the 57 million premature deaths in 2008 [9]. Physical This systematic review identified 11 studies, mainly inactivity is furthermore responsible for 7 % of the burden with high or unclear risk of bias, that investigated the of disease from type 2 diabetes [9]. Eliminating physical effects of various exergames on changes in intensity inactivity would lead to an increased life expectancy of the parameters of PA in overweight individuals. world’s population of 0.68 years [9]. This is comparable to the influence obesity has on life expectancy, which would The degree of increase in oxygen uptake, energy increase by 0.5–0.7 years if normal weight was attained at expenditure, heart rate, or activity counts and thus age 50 [10]. A meta-analysis that included 33 studies and the suitability of the exergame to be used as an 102,980 participants showed that individuals with low fit- exercise promotion is highly dependent on the game ness had a 70 % higher risk for all-cause mortality and a mode, the console, and the duration of play. 56 % higher risk for cardiovascular mortality. In addition, Further high-quality studies investigating the it was estimated that an increase in the maximal aerobic effectiveness of exergames in overweight and capacity by one metabolic equivalent (MET) is associated especially in individuals with type 2 diabetes in the with a 13 and 15 % reduction in risk of all-cause mortality long term are needed. and coronary heart disease, respectively [11]. Additionally, it has been shown that participation in regular physical activity (PA) improves blood glucose control [12, 13] and can prevent or delay the onset of type 2 1 Introduction diabetes [14–17] and its comorbidities [18, 19]. Individuals who regularly engage in moderate exercise such as 30 min Over the past decades, overweight and obesity have become of brisk walking 5 days per week, as recommended by the a global public health issue. In 2014, an estimated 39 % (1.9 American College of Sports Medicine (ACSM), have a billion) of all adults worldwide were overweight and at least 30 % lower risk of developing type 2 diabetes compared 13 % (600 million) obese, with the worldwide obesity with sedentary individuals [18, 20]. prevalence having more than doubled since 1980 [1]. As The benefits of regular PA in overweight or obese proposed by the World Health Organization (WHO), subjects as well in those with type 2 diabetes are hence overweight is defined as a body mass index (BMI) of clearly demonstrated. However, for any PA-promoting C25 kg/m2 and obesity as a BMI C30 kg/m2. Both over- program to be effective, motivation to start and adhere to weight and obesity are defined as ‘‘abnormal or excessive the lifestyle changes is of utmost importance [6]. Lack of fat accumulations that may impair health’’ [1]. Excessive motivation, absence of social support, and disease-related energy intake and insufficient energy expenditure (EE) as a implications such as fatigue or pain are the main reasons result of a sedentary, inactive lifestyle can lead to an that patients with type 2 diabetes [21], as well as over- increased risk of obesity and facilitate the development of weight and obese individuals [22], cease participation in several comorbidities such as cardiovascular disease, type 2 PA-promoting programs. diabetes, and various types of cancer [2, 3]. A new and entertaining way to encourage inactive Type 2 diabetes mellitus in particular has also seen a individuals to be more physically active is active video dramatic increase in prevalence in past years, paralleling gaming or ‘exergaming’—the combination of video gam- that of overweight and obesity. According to the National ing and physical exercise. While conventional video games Diabetes Statistics Report [4], in 2012, over 29 million do not involve a lot of PA and even encourage more people or 9.3 % of the US population had diabetes, 27.8 % sedentary behavior, exergames utilize the time spent in of those as yet undiagnosed. Another 86 million Americans front of the television to promote a playful form of PA. The are estimated to have prediabetes, a condition that includes exercise modes offered through the different exergame insulin resistance and insulin secretory dysfunction and systems vary, but usually include aerobic (the focus of this constitutes a precursor of type 2 diabetes [4]. systematic review) and/or strength and/or balance exer- Both obesity and type 2 diabetes are associated with cises. Because exergames are enjoyable and at the same high levels of inactivity [5, 6] that affect the physical and time do not take away time from screen-viewing activities, mental health status negatively and constitute an important they are a promising approach to increase PA in individuals contributor to the development of the abovementioned who are among the least likely to engage in regular PA comorbidities [5, 7]. In 2008, globally, 31 % of all adults [23]. aged C15 years were insufficiently active [8], resulting in Several studies have examined the benefits of physical inactivity now being the fourth leading cause of exergaming in children and adolescents. A review by 123 Effects of Exergaming on Physical Activity in Overweight Sween et al. [24] focused on EE during exergame play in 2.3 Study Selection different healthy populations with various age groups and showed that increases in EE of up to 300 % above resting Articles were included if the intervention was defined as levels can be reached, while the majority of active video exergaming, active video game, serious game, video- or games tested were found to achieve PA levels of moderate computer-based, or a combination of these expressions and intensity. It remains unclear whether overweight or obese objectively measured intensity parameters of PA such as adults and those with type 2 diabetes can reach similar VO2, EE, METs, heart rate (HR), activity counts, or exercise intensities during exergame play, allowing them to assessed steps per