Association of Physical Education With Improvement of Health-Related Physical Fitness Outcomes and Fundamental Motor Skills Among Youths: A Systematic Review and Meta-analysis

Antonio García-Hermoso; Alicia M Alonso-Martínez; Robinson Ramírez-Vélez; Miguel Ángel Pérez-Sousa; Rodrigo Ramírez-Campillo; Mikel Izquierdo

doi:10.1001/jamapediatrics.2020.0223

. 2020 Apr 6;174(6):e200223. doi: 10.1001/jamapediatrics.2020.0223

Association of Physical Education With Improvement of Health-Related Physical Fitness Outcomes and Fundamental Motor Skills Among Youths

A Systematic Review and Meta-analysis

Antonio García-Hermoso ^1,^2,^✉, Alicia M Alonso-Martínez ³, Robinson Ramírez-Vélez ^1,³, Miguel Ángel Pérez-Sousa ⁴, Rodrigo Ramírez-Campillo ⁵, Mikel Izquierdo ^1,³

PMCID: PMC7136862 PMID: 32250414

Key Points

Question

Is there an association between quality- or quantity-based physical education interventions and improvement in health-related physical fitness and fundamental motor skills in youth?

Findings

In this systematic review and meta-analysis of 48 185 youths, quality-based physical education interventions were associated with small increases in fitness components and fundamental motor skills regardless of frequency or duration of physical education lessons. By contrast, quantity-based interventions were associated with small increases in only fitness components.

Meaning

The study suggests that quality-based physical education strategies are associated with improved class efficiency assuming typical school constraints (eg, reduced practice time per session).

Abstract

Importance

Whether quality- or quantity-based physical education (PE) interventions are associated with improvement of health-related physical fitness outcomes and fundamental motor skills (FMSs) in children and adolescents is unknown.

Objective

To examine the association of interventions aimed at optimizing PE in terms of quality (teaching strategies or fitness infusion) or quantity (lessons per week) with health-related physical fitness and FMSs in children and adolescents.

Data Sources

For this systematic review and meta-analysis, studies were identified through a systematic search of Ovid MEDLINE, Embase, Cochrane Controlled Trials Registry, and SPORTDiscus databases (from inception to October 10, 2019) with the keywords physical education OR PE OR P.E. AND fitness AND motor ability OR skills. Manual examination of references in selected articles was also performed.

Study Selection

Studies that assessed the association of quality- or quantity-based PE interventions with improvement in physical fitness and/or FMSs in youths (aged 3-18 years) were included.

Data Extraction and Synthesis

Data were processed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Random-effects models were used to estimate the pooled effect size (Hedges g).

Main Outcomes and Measures

Health-related physical fitness outcomes and FMSs.

Results

Fifty-six trials composed of 48 185 youths (48% girls) were included in the meta-analysis. Quality-based PE interventions were associated with small increases in health-related physical fitness (cardiorespiratory fitness [Hedges g = 0.24; 95% CI, 0.16-0.32] and muscular strength [Hedges g = 0.19; 95% CI, 0.09-0.29]) and FMSs (Hedges g = 0.38; 95% CI, 0.27-0.49). Subgroup analyses found stronger associations for quality-based PE interventions on body mass index (Hedges g = −0.18; 95% CI, −0.26 to −0.09), body fat (Hedges g = −0.28; 95% CI, −0.37 to −0.18), cardiorespiratory fitness (Hedges g = 0.31; 95% CI, 0.23-0.39), and muscular strength (Hedges g = 0.29; 95% CI, 0.18-0.39). Quantity-based PE interventions were associated with small increases in only cardiorespiratory fitness (Hedges g = 0.42; 95% CI, 0.30-0.55), muscular strength (Hedges g = 0.20; 95% CI, 0.08-0.31), and speed agility (Hedges g = 0.29; 95% CI, 0.07-0.51).

Conclusions and Relevance

The findings suggest that quality-based PE interventions are associated with small increases in both student health-related physical fitness components and FMSs regardless of frequency or duration of PE lessons. Because PE aims to improve more than health, high levels of active learning time may need to be balanced with opportunities for instruction, feedback, and reflection.

This systematic review and meta-analysis examines the association of quality- and quantity-based physical education interventions with health-related physical fitness and fundamental motor skills in children and adolescents.

Introduction

Schools are ideal settings for the promotion of physical activity and exercise among children and adolescents, and physical education (PE) is the primary vehicle to achieve these objectives.¹ Numerous studies^2,3 on moderate to vigorous physical activity (MVPA) in school PE lessons have found that the proportion of PE lesson time during which children and adolescents are engaged in MVPA is typically less than 50% of the target set by international recommendations.

To overcome this problem, some school programs include additional PE lessons⁴; however, given the competitive requirements of the curriculum, increasing the frequency and duration of PE classes is not always possible. Other programs are based on curriculum changes, developing strategies for more efficient use of PE classes. Several studies^5,6 have suggested that the most effective strategies to increase youths’ levels of physical activity and improve fundamental motor skills (FMSs) in PE are direct instruction teaching methods and sufficient and ongoing professional development for teachers in how to use these PE instruction methods.⁵ In this regard, Lonsdale et al⁶ reported that fitness infusion interventions (ie, PE lessons that combine sport activities with vigorous fitness activities, such as high-intensity interval training [HIIT], jump training, and circuit training) have a stronger association with increasing MVPA than the teaching strategies interventions (ie, teachers learning strategies to encourage physical activity through effective activity selection, class organization and management, and instruction).

Despite the abundance of studies on this topic, to our knowledge, no systematic review and meta-analysis has been conducted to examine the association of interventions aimed at optimizing PE in terms of quality or quantity (lessons per week) with health-related outcomes, such as physical fitness and FMSs, which are both associated with health outcomes later in life.^7,8 Therefore, the aim of this study was to examine the association of quality- and quantity-based PE interventions with health-related physical fitness and FMSs in children and adolescents.

Methods

Protocol and Registration

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline⁹ and is awaiting registration in the PROSPERO International Prospective Register of Systematic Reviews.

Information Sources and Search

The electronic search of Ovid MEDLINE, Embase, Cochrane Controlled Trials Registry, and SPORTDiscus was combined with manual searches of the existing literature, performed from inception to October 10, 2019. The search strategy combined the following relevant terms: physical education OR PE OR P.E. AND fitness AND motor ability OR skills. In addition, the reference lists of the included studies were checked to find potential studies that could also be used in the review.

Eligibility Criteria and Study Selection

The criteria for study inclusion were as follows: (1) apparently healthy (ie, general population, including samples of children and adolescents with overweight or obesity but not samples of children exclusively with a diagnosed medical condition) children and adolescents (mean age, 3-18 years); (2) experimental pilot studies (if they included a control group), controlled trials, randomized clinical trials (RCTs), and cluster RCTs in which the control group received no structured type of physical exercise or dietary restriction intervention (ie, usual care or regular school curriculum); (3) intervention characteristics that only included studies that increased the proportion of curriculum time allocated to PE (ie, quantity-based PE interventions) or enhanced the quality of the PE (ie, quality-based PE interventions); and (4) an assessment of at least one of the following variables: health-related physical fitness (ie, body mass index [BMI; calculated as weight in kilograms divided by height in meters squared], waist circumference, skinfold thickness, fat mass and body lean mass, cardiorespiratory fitness [CRF], muscular strength, and speed agility) and/or FMSs (locomotor and object control skills). Titles, abstracts, and full texts were assessed for eligibility independently by 2 of us (A.G-.H. and R.R.-V.) for potential inclusion. If necessary, a third researcher (M.I.) was consulted.

Data Collection Process

For each study, data were extracted for characteristics of the study population, including (1) first author’s last name; (2) year of publication; (3) characteristics of participants, sample size, and age; (4) characteristics of PE intervention (type, frequency, and duration) and the nature of the intervention (teaching strategies in which teachers learned strategies to encourage physical activity by effective activity selection, class organization and management, and instruction or “fitness infusion” in which teachers supplemented students’ participation in sport activities [eg, basketball] with vigorous fitness activities [eg, running and jumping]); (5) outcomes; and (6) differences in the means of 2 time points or postintervention mean values with corresponding SDs. When there was insufficient information, the respective corresponding author was contacted.

Risk of Bias of Individual Studies

The risk of bias was evaluated using the Physiotherapy Evidence Database criteria,¹⁰ an 11-item scale designed for measuring the methodologic quality of studies.

Statistical Analysis

All analyses were performed using Comprehensive Meta-analysis Software, second version (Biostat) to calculate the standardized mean difference, which was expressed as Hedges g to correct for possible small sample bias.¹¹ Hedges g of each variable from baseline to follow-up between groups was calculated and pooled using a random-effects model (DerSimonian-Laird approach¹²). Data were pooled if outcomes were reported by at least 3 studies. The pooled effect size for Hedges g was classified as small (0-0.50), moderate (>0.50 to 0.80), or large (>0.80).¹³ The percentage of total variation across the studies owing to heterogeneity (Cochran Q statistic) was used to calculate the I² statistic¹⁴; I² values less than 25% were considered as small heterogeneity, 25% to 75% as moderate heterogeneity, and greater than 75% as high heterogeneity.¹⁵

Each study was deleted from the model once to analyze the influence of each study on the overall results. Egger regression tests were performed to detect small study effects and possible publication bias.¹⁶

In addition, whenever possible, a subgroup analysis was conducted by removing the non-RCT studies according to the nature of the intervention for quality-based PE (teaching strategies or fitness infusion) and education level (primary or secondary). In addition, random-effects meta-regression analyses were used to evaluate whether the results might vary according to the differences in sessions per week (ie, PE lessons) between the intervention and control groups.

Results

Study Selection

The electronic search strategy retrieved 3810 records. After removal of duplicate references and screening of titles and abstracts, 2965 articles were excluded. Of the remaining 845 articles and after full-text screening and checking the reference lists of included studies and previous reviews for additional relevant articles, 110 studies were read in full. The reasons for exclusion based on full text were (1) inappropriate study design (11 articles), (2) inappropriate intervention (7 articles), (3) secondary study (5 articles), and (4) inappropriate outcome measurement (31 articles). Therefore, 56 studies were included in the final meta-analysis: 34 for quality-based PE^{17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50} and 22 for quantity-based PE.^{50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71} The PRISMA flow diagram is shown in the Figure.

Study Characteristics

Table 1 summarizes the study characteristics. Publication dates ranged from 1991 to 2019. The final analysis included a total of 48 185 children and adolescents (48% girls). Most studies included apparently healthy children and/or adolescents, but 3 studies^18,22,43 included overweight and/or obese children. All studies included boys and girls with the exception of 6 studies^{27,28,30,38,44,49} that included only girls. Sample sizes across studies ranged from 26²⁹ to 10 206 (mean, 873.2).⁶³ Participants enrolled in the different studies were predominantly from the US (12 articles), with other studies from Albania (1), Australia (4), Belgium (1), Canada (6), Chile (1), Denmark (6), France (1), Italy (5), the Netherlands (1), Portugal (1), Spain (6), Serbia (1), Slovenia (1), Sweden (3), Switzerland (3), or the UK (1).

Table 1. Summary of Included Studies.

Source, location	Design	Sample, No. (%)	Age, range or mean, y	Intervention length	Intervention characteristics and duration per session	Outcomes
Quality-based PE
Alonso-Fernández et al,²⁹ 2019, Spain	RCT	26 (50% female)	15-16	7 wk	Fitness infusion; HIIT protocol intervention based on the Tabata method	BMI, body fat, lean body mass, CRF
Baquet et al,⁴¹ 2001, France	CT	551 (48% female)	11-16	10 wk	Fitness infusion; HIIT protocol intervention	BMI, SKT, CRF, muscular strength, speed agility
Boyle-Holmes et al,⁴⁰ 2010, US	CT	1464 (49% female)	8-12	1 y	Teaching strategies; Michigan’s Exemplary Physical Education Curriculum: PE curriculum that focuses on developing knowledge, attitudes, skills, and behaviors that are associated with lifelong physical activity through teaching and motor skills learning progressions	CRF, muscular strength, fundamental motor skills
Carrel et al,⁴³ 2005, US	RCT	50 (48% female)	12^a	9 mo	Fitness infusion; fitness-oriented gym classes	BMI, body fat, CRF
Chavarro et al,⁴⁴ 2005, US	RCT	508 (100% female)	10-13	2 School years	Teaching strategies; Planet Health curriculum: this approach is designed to enhance efficiency by using classroom teachers with minimal health education training to implement the materials	BMI, SKT
Cohen et al,⁴⁵ 2015, Australia	cRCT	460 (54% female)	7-10	1 y	Teaching strategies; PE lesson structure recommendations	CRF, fundamental motor skills
Costigan et al,⁴² 2015, Australia	RCT	65 (31% female)	15.8	8 wk	Fitness infusion; participants completed HIIT sessions with or without strength training	BMI, zBMI, WC, CRF, muscular strength
Cvejić et al,²⁰ 2017, Serbia	RCT	178 (48% female)	9.0	8 wk	Fitness infusion; FITT program: primarily teaching contents, methods, forms, and other teaching instruments of work are used so that the planned physical activity or exercise by frequency, intensity, duration, and type leads to the improvement of aerobic fitness, muscular fitness, and flexibility and indirectly to the improvement of body composition	BMI, SKT, CRF, muscular strength
Daly et al,⁴⁶ 2016, Australia	cRCT	727 (50% female)	8.1	4 School years	Teaching strategies; specialized PE by teachers who emphasized more vigorous exercise and games combined with static and dynamic postural activities that involve muscle strength	Body fat, lean body mass
Dalziell et al,⁴⁷ 2019, UK	RCT	143 (NR)	10-11	16 wk	Teaching strategies; Better Movers and Thinkers: a novel approach to PE that directly targets the development of physical competence, cognitive skills, and personal qualities	Fundamental motor skills
Delgado-Floody et al,¹⁸ 2018, Chile	CT	197 (55% female)	6-11	28 wk	Fitness infusion; HIIT	BMI, WC, body fat, CRF
Faigenbaum and Mediate,³⁹ 2006, US	CT	118 (35% female)	15-16	6 wk	Fitness infusion; Medicine Ball Training Program	Muscular strength, speed agility
Gallotta et al,⁴⁸ 2017, Italy	RCT	230 (43% female)	8-11	5 mo	Fitness infusion; the experimental 1 intervention was designed to promote health, fitness, sensory-motor, social, and communicative development and the experimental 2 intervention was focused on improving the coordination and dexterity of the participants	CRF, muscular strength, fundamental motor skills
Jarani et al,¹⁹ 2016, Albania	RCT	760 (47% female)	8.3	5 mo	Fitness infusion; ABC 5 on 5 PE program: the exercise group intervention program emphasized physical activity exercises (eg, gait exercises to improve speed), whereas the games group intervention program was focused on fun games (eg, tag games to improve speed)	BMI, body fat, CRF, muscular strength, speed agility, fundamental motor skills
Lucertini et al,²¹ 2013, Italy	RCT	101 (45% female)	9.5	6 mo	Fitness infusion; group A trained strength and endurance with specifically designed cardiovascular and resistance devices (the Kid’s System), whereas group B by means of traditional or nonconventional devices (eg, light dumbbells, elastic bands, plastic water bottles, etc)	BMI, body fat, CRF, muscular strength, speed agility, fundamental motor skills
Marshall and Bouffard,²² 1997, Canada	RCT	406 (48% female)	5-10	NR	Teaching strategies; quality daily PE: the program facilitates the development of movement skill in obese children	SKT, CRF, fundamental motor skills
Mayorga-Vega et al,²³ 2012, Spain	CT	75 (47% female)	11.1	8 wk	Fitness infusion; the fitness program included 2 circuits with 8 stages performed for 15 to 35 s each with 45 to 25 s of rest between them	CRF, muscular strength
Mayorga-Vega et al,²⁴ 2016, Spain	cRCT	111 (37% female)	12-14	9 wk	Fitness infusion; students performed commonly used PE-based physical fitness sessions (eg, strength games, running games, circuit training, multijumps, or multithrows) followed by some team games	CRF, muscular strength
McKay et al,²⁵ 2000, Canada	RCT	145 (51% female)	6.9-10.2	8 mo	Fitness infusion; exercise groups did 10 tuck jumps 3 times weekly and incorporated jumping, hopping, and skipping into twice weekly PE classes	Body fat, lean body mass
McKenzie et al,²⁶ 1996, US	RCT	5106 (48% female)	8-9	2.5 y	Teaching strategies: CATCH: the goals of CATCH PE were to promote children’s enjoyment of and participation in moderate to vigorous during PE classes and to provide skills to be used out of school and throughout life	CRF
Neumark-Sztainer et al,²⁷ 2003, US	RCT	201 (100% female)	15.4	8 mo	Teaching strategies: New Moves program: offered as a girls-only alternative PE program that high school girls took for credit in Social Cognitive Theory	BMI
Nogueira et al,²⁸ 2014, Australia	RCT	151 (100% female)	10.6	9 mo	Fitness infusion; the intervention group participated in instructor-led exercise bouts comprising 10 min of continuous high-intensity movements intended to improve musculoskeletal and metabolic health	WC, CRF, muscular strength
Pate et al,⁴⁹ 2005, US	RCT	2744 (100% female)	13-15	1 y	Teaching strategies; Lifestyle Education for Activity Program (LEAP PE): designed (1) to enhance physical activity self-efficacy and enjoyment, (2) to teach the physical and behavioral skills needed to adopt and maintain an active lifestyle, and (3) to involve girls in moderate to vigorous physical activity during ≥50% of PE class time	Obesity
Pesce et al,³¹ 2013, Italy	CT	125 (NR)	10-11	8 mo	Teaching strategies; the intervention, centered on experiences joining multiple sports in varied ways, was structured in 4 didactic modules lasting 8 wk each	CRF, muscular strength
Pesce et al,³² 2016, Italy	RCT	920 (48% female)	5-10	6 mo	Teaching strategies; the enriched PE was centered on deliberate play and cognitively challenging variability of practice, on motor coordination and cognitive processing	Fundamental motor skills
Ramírez et al,⁵⁰ 2012, Spain	RCT	84 (39% female)	15-18	8 wk	Fitness infusion; aerobic training	CRF
Sallis et al,³³ 1997, US	RCT	955 (49% female)	9.5-9.6	2 y	Teaching strategies; Sport, Play, Activity, and Recreation for Kids PE intervention: PE specialist-led: PE teachers taught PE and self-management while receiving ongoing professional development and supervision from investigators	SKT, CRF, muscular strength
Schmidt et al,³⁴ 2015, Switzerland	RCT	181 (55% female)	10-12	6 wk	Fitness infusion; children were assigned to either a PE program with a high level of physical exertion and high cognitive engagement (team games), a PE program with high physical exertion but low cognitive engagement (aerobic exercise)	CRF
Telford et al,³⁵ 2012, Canada	RCT	620 (NR)	7-8	2 y	Teaching strategies; Lifestyle of Our Kids study: the specialist-taught intervention was conducted in 13 schools by 1 of 3 visiting PE teaching specialists and involved 2 classes of 45 to 50 min/wk for 75 of the 80 wk of school during the 2-y period	BMI, body fat, CRF
Ten Hoor et al,¹⁷ 2018, the Netherlands	cRCT	695 (50% female)	11-15	1 y	Fitness infusion; adolescents spend at least 30% of the PE lessons on strength exercises (approximately 15-30 min per lesson)	Body fat, lean body mass
van Beurden et al,³⁶ 2003, Australia	RCT	1045 (47% female)	7-10	18 mo	Teaching strategies; Move It project intervention: consisted of school project teams to have a whole school approach, buddy program that involved classroom teachers partnered with preservice PE teachers	Fundamental motor skills
Webber et al,³⁰ 2008, US	RCT	1712 (100% female)	11-12	2 y	Teaching strategies; Trial of Activity for Adolescent Girls PE: intervention promoted MVPA for at least 50% of class time and encouraged teachers to promote physical activity outside of class; PE teachers were trained in class management strategies, skill-building activities, the importance of engaging girls in MVPA during class, and the provision of appropriate equipment and choices of physical activity	BMI, body fat, SKT
Weeks et al,³⁷ 2008, Australia	RCT	99 (53% female)	13.8	8 mo	Fitness infusion; the POWER PE Study: intervention subjects performed 10 min of jumping activity in place of regular PE	BMI, body fat, lean body mass, muscular strength
Young et al,³⁸ 2006, US	RCT	221 (100% female)	13.8	1 y	Teaching strategies; the intervention was also designed to maximize physical activity during PE class; classes were optimized for physical activity by teaching units that were active in nature (eg, soccer instead of softball [personal fitness unit]), breaking skills training into small-group activities, and playing games in small groups (eg, 3-on-3 basketball); skills training was limited to that needed for competency rather than proficiency	BMI, WC
Quantity-based PE
Ardoy et al,⁵¹ 2011, Spain	RCT	67 (36% female)	12-14	16 wk	4 Sessions per week vs 2 sessions per week; 55 min	CRF, muscular strength, speed-agility
Bugge et al,⁵² 2012, Denmark	CT	696 (41% female)	6-7	3 y	4 Sessions per week vs 2 sessions per week; 45 min	BMI, zBMI, WC, SKT, CRF
Erfle and Gamble,⁶³ 2015, US	CT	10 206 (50% female)	11-14	1 y	5 Sessions per week vs 2 sessions per week; 30 min	BMI, CRF, muscular strength
Ericsson and Karlsson,⁶⁵ 2014, Sweden	CT	220 (46% female)	7-9	9 y	5 Sessions per week vs 2 sessions per week; 45 min	Fundamental motor skills
Hansen et al,⁶⁶ 1991, Denmark	RCT	132 (48% female)	9-11	8 mo	3 Sessions per week vs 2 sessions per week; 50 min	BMI, SKT, CRF
Heidemann et al,⁶⁷ 2013, Denmark	CT	717 (52% female)	8-12	2 y	6 Sessions per week vs 2 sessions per week; 45 min	BMI, body fat, lean body mass
Jurak et al,⁶⁸ 2008, Slovenia	CT	328 (49% female)	7-10	4 y	4 Sessions per week vs 3 sessions per week; 60 min	SKT, CRF, muscular strength, speed-agility
Klakk et al,⁶⁹ 2013, Denmark	CT	632 (50% female)	8-13	2 y	6 sessions per week vs 2 sessions per week; 45 min	BMI, body fat, obesity
Kriemler et al,⁷⁰ 2010, Switzerland	cRCT	540 (51% female)	5-11	1 y	5 Sessions per week vs 3 sessions per week; 45 min	BMI, WC, SKT, CRF
Learmonth et al,⁷¹ 2019, Denmark	CT	1009 (53% female)	5-12	2 y	6 Sessions per week vs 2 sessions per week; 45 min	Obesity
Löfgren et al,⁵³ 2013, Sweden	CT	232 (43% female)	7-9	2 y	5 Sessions per week (40 min) vs 1 session per week of 60 min	BMI, body fat, lean body mass, muscular strength
Lopes et al,⁵⁴ 2017, Portugal	RCT	60 (37% female)	9.0	1 y	3 Sessions per week vs 2 sessions per week; 45-50 min	BMI, SKT, fundamental motor skills
Meyer et al,⁵⁵ 2014, Switzerland	cRCT	502 (57% female)	6-12	3 y	5 Sessions per week vs 3 sessions per week; 45 min	BMI, zBMI, WC, SKT, CRF
Piéron et al,⁵⁶ 1996, Belgium	CT	7721 (NR)	5-12	1 y	5 Sessions per week vs NR; NR	Fundamental motor skills
Ramírez et al,⁵⁰ 2012, Spain	RCT	84 (39% female)	15-18	8 wk	3 Sessions per week vs 2 sessions per week; 60 min	CRF
Reed et al,⁵⁷ 2013, US	CT	470 (50% female)	10.2	1 y	5 Sessions per week (45 min) vs 1 session per week of 30-45 min	CRF, muscular strength
Rexen et al,⁵⁸ 2015, Denmark	CT	1247 (47% female)	8.4	2.5 y	3 Sessions per week vs 1 session per week; 90 min	CRF, muscular strength, fundamental motor skills
Sacchetti et al,⁵⁹ 2013, Italy	RCT	438 (47% female)	8-9	2 y	5 Sessions per week vs 2 sessions per week; 50 min	BMI, obesity, muscular strength, speed-agility
Shephard and Lavallée,^61,62 1993 and 1994,⁶⁰ Canada	CT	546 (47% female)	7-12	6 y	5 Sessions per week vs 1 session per week; NR	SKT, CRF, muscular strength
Sollerhed and Ejlertsson,⁶⁴ 2008, Sweden	CT	132 (45% female)	6-9	3 y	4 Sessions per week vs 1-2 sessions per week; 40 min	BMI, WC, CRF, muscular strength, fundamental motor skills

Open in a new tab

Abbreviations: BMI, body mass index (calculated as weight in kilograms divided by height in meters squared); CATCH, Child and Adolescent Trial for Cardiovascular Health; CRF, cardiorespiratory fitness; cRCT, cluster randomized clinical trial; CT, clinical trial; HIIT, high-intensity interval training; MVPA, moderate to vigorous physical activity; NR, not reported; PE, physical education; RCT, randomized clinical trial; SKT, skinfold thickness; WC, waist circumference; zBMI, BMI for age z score.

^{^a}

Overweight children.

Complete details regarding interventions are given in Table 1. Of the quality-based PE studies, 17 used teaching strategies (eg, enriched PE lessons and PE specialist–led lessons) and 18 used fitness infusion (eg, HIIT, jump training, and circuit training). Of the quantity-based PE studies, each included study increased the proportion of curriculum time allocated to PE compared with PE afforded to the control group. Studies increased the dose of PE by adding 1,^50,54,66,68 2,^{51,52,55,58,64,70} 3,^59,63,65 or 4⁶⁷ additional PE lessons each week for between 8 weeks⁵⁰ and 9 years.⁶⁵

The outcome measures were BMI; BMI z score; waist circumference; skinfold thickness; body fat; lean body mass; CRF (usually assessed with the 20-m shuttle run test); muscular fitness assessed with endurance (eg, push-ups and sit-ups) or strength tests (eg, handgrip and standing long jump); speed agility assessed with the 10-m ×4 shuttle run test,⁵¹ the 10-m ×5 test,^19,21,41 or a 60-m⁶⁸ or a 20-m linear sprint test⁵⁹; and FMSs assessed using standardized tests (eg, Test of Gross Motor Development 2⁴⁵ or Gross Motor Coordination Test⁴⁷).

Risk of Bias Within Studies

The mean total Physiotherapy Evidence Database score was 4.5 (range, 3-8). Low scores corresponded to studies that failed to conceal allocation (3 of 55 [6%]) or to blind participants and professors (0 of 55 [0%]) or had researchers in charge of end point assessment (10 of 55 [18%]) (eTable 1 in the Supplement).

Summary of Evidence

Compared with the control conditions, quality-based PE interventions were associated with significant reductions in BMI (Hedges g = −0.13; 95% CI, −0.19 to −0.06), waist circumference (Hedges g = −0.28; 95% CI, −0.48 to −0.08), and body fat (Hedges g = −0.22; 95% CI, −0.33 to −0.11) and with increases in lean body mass (Hedges g = 0.33; 95% CI, 0.01-0.66), CRF (Hedges g = 0.24; 95% CI, 0.16-0.32), muscular strength (Hedges g = 0.19; 95% CI, 0.09-0.29), and FMSs (Hedges g = 0.38; 95% CI, 0.27-0.49) (eFigures 1-9 in the Supplement). Quantity-based PE interventions were associated with increases in CRF (Hedges g = 0.42; 95% CI, 0.30-0.55), muscular strength (Hedges g = 0.20; 95% CI, 0.08-0.31), and speed agility (Hedges g = 0.29; 95% CI, 0.07-0.51) (Table 2 and eFigures 10-17 in the Supplement).

Table 2. Synthesis of Pooled Results.

Health-related physical fitness	Quality-based physical education					Quantity-based physical education
Health-related physical fitness	No. of studies (No. of participants)	Hedges g (95% CI)	P value	I²	Egger test P value	No. of studies (No. of participants)	Hedges g (95% CI)	P value	I²	Egger vest P value
Body mass index	14 (5289)	−0.13 (−0.19 to −0.06)	<.001	14.58	.06	11 (14 287)	−0.03 (−0.10 to 0.04)	.46	44.26	.19
Waist circumference	4 (634)	−0.28 (−0.48 to −0.08)	.005	21.99	.009	4 (1870)	−0.04 (−0.14 to 0.07)	.48	0	.88
Skinfold thickness	5 (3904)	−0.03 (−0.13 to 0.06)	.48	33.93	.87	4 (2258)	−0.05 (−0.16 to 0.06)	.34	0	.07
Body fat	11 (4556)	−0.22 (−0.33 to −0.11)	<.001	53.71	.02	3 (1581)	0.16 (−0.06 to 0.39)	.16	77.09	.16
Lean body mass	4 (971)	0.33 (0.01 to 0.66)	.04	45.48	.42	NA	NA	NA	NA	NA
Cardiorespiratory fitness	20 (11 276)	0.24 (0.16 to 0.32)	<.001	47.74	.003	11 (13 703)	0.42 (0.30 to 0.55)	<.001	68.79	.17
Muscular strength	13 (4858)	0.19 (0.09 to 0.29)	<.001	52.61	.34	9 (13 180)	0.20 (0.08 to 0.31)	.001	62.23	.14
Speed agility	4 (1530)	0.19 (−0.05 to 0.43)	.12	76.16	.19	4 (2080)	0.29 (0.07 to 0.51)	.009	73.88	.15
Fundamental motor skills	7 (3873)	0.38 (0.27 to 0.49)	<.001	73.43	.002	4 (1659)	0.20 (−0.01 to 0.42)	.06	79.03	.20

Open in a new tab

Abbreviation: NA, not applicable.

For quality-based PE interventions, subgroup analysis revealed that those incorporating fitness infusion interventions were associated with slightly larger reductions in BMI (Hedges g = −0.18; 95% CI, −0.26 to −0.09) and body fat (Hedges g = −0.28; 95% CI, −0.37 to −0.18) and with increased lean body mass (Hedges g = 0.33; 95% CI, 0.11-0.66), CRF (Hedges g = 0.31; 95% CI, 0.23-0.39), and muscular strength (Hedges g = 0.29; 95% CI, 0.18-0.39) compared with overall results (Table 3). For the quality-based PE interventions that incorporated teaching strategies as the main intervention, CRF (Hedges g = 0.19; 95% CI, 0.07-0.32) and FMSs (Hedges g = 0.34; 95% CI, 0.25-0.43) increased (Table 3).

Table 3. Subgroup Analysis According to Nature of the Intervention for Quality-Based Physical Education.

Health-related physical fitness	Teaching strategies					Fitness infusion
Health-related physical fitness	No. of studies (No. of participants)	Hedges g (95% CI)	P value	I²	Egger test P value	No. of studies (No. of participants)	Hedges g (95% CI)	P value	I²	Egger test P value
Body mass index	4 (2553)	−0.10 (−0.21 to −0.01)	.09	57.29	.50	10 (2736)	−0.18 (−0.26 to −0.09)	<.001	0	.80
Skinfold thickness	4 (3353)	−0.05 (−0.19 to 0.09)	.50	65.62	.88	NA	NA	NA	NA	NA
Body fat	3 (2477)	−0.07 (−0.19 to 0.04)	.21	41.63	.73	8 (2079)	−0.28 (−0.37 to −0.18)	<.001	7.27	.32
Lean body mass	NA	NA	NA	NA	NA	4 (971)	0.33 (0.11 to 0.66)	.04	45.58	.42
Cardiorespiratory fitness	6 (8516)	0.19 (0.07 to 0.32)	.002	74.17	.01	14 (2760)	0.31 (0.23 to 0.39)	<.001	0	.08
Muscular strength	NA	NA	NA	NA	NA	11 (2439)	0.29 (0.18 to 0.39)	<.001	23.31	.39
Fundamental motor skills	6 (3634)	0.34 (0.25 to 0.43)	<.001	63.64	.01	NA	NA	NA	NA	NA

Open in a new tab

Abbreviation: NA, not applicable.

For educational level, analyses for primary education found results similar to the overall findings (for quality- and quantity-based PE), with slightly stronger associations. For secondary education, the small number of studies limited the analyses; however, the results for body mass index (Hedges g = −0.04; 95% CI, −0.10 to 0.02) and body fat (Hedges g = −0.13; 95% CI, −0.29 to 0.02) but not CRF (quality-based PE: Hedges g = 0.29; 95% CI, 0.10-0.47; quantity-based PE: Hedges g = 0.37; 95% CI, 0.07-0.67) were no longer statistically significant (eTable 2 in the Supplement).

In addition, meta-regression analyses found that increasing PE exposure might not be associated with changes in the outcomes assessed except for FMSs (β = 0.38; 95% CI, 0.15-0.62) (eFigures 18-24 in the Supplement).

Risk of Bias Across Studies

Egger linear regression tests provided evidence of a potential publication bias for body fat, CRF, and FMSs in quality-based PE interventions. In the sensitivity analysis with each study deleted once from the model, the results remained the same across all deletions.

Discussion

The main findings of this study are that (1) quality-based PE interventions may be associated with small improvements in BMI, body fat, lean body mass, CRF, muscular strength, and FMSs in children and adolescents; (2) the associations with BMI, body fat, CRF, and muscular strength seem to be slightly larger with interventions that used fitness infusion strategies (ie, PE lessons that include HIIT, jump training, and circuit training) and in primary education, although the associations remain small; and (3) quantity-based PE interventions may be associated with small increases in only CRF, muscular strength, and speed agility.

Considering the decline in physical activity typically observed during adolescence,⁷² increasing active learning time in PE should be a public health priority. In this sense, Lonsdale et al⁶ performed a meta-analysis of the evidence related to interventions designed to increase students’ MVPA within PE lessons and found that these interventions were associated with approximately 24% more active learning time compared with usual practice (10% more of total lesson time spent in MVPA). Specifically, effective intervention strategies included teacher professional learning; focusing on class organization, management, and instruction; and supplementing usual PE lessons with fitness infusion. These results are in line with those of the present meta-analysis, which revealed small increases in health-related physical fitness (ie, anthropometric, body composition, CRF, and muscular strength) and FMSs associated with quality-based PE interventions.

Similar to the aforementioned study,⁶ which indicated that fitness infusion interventions had stronger association with increased MVPA than did the teaching strategies interventions, the present subgroup analysis revealed that fitness infusion interventions were associated with slightly larger increases in health-related physical fitness components. Accordingly, this is an appealing strategy for increasing active learning time because it requires minimal organization and planning from teachers. For example, school-based HIIT interventions appear to be a promising approach for improving health-related physical fitness outcomes among children and adolescents,^29,41,42 even in overweight or obese youths.⁷³ In addition, medium and long-term intervention programs (≤5 months)^{19,21,25,28,37,43,48} have similar associations with health-related physical fitness, showing the potential effectiveness and sustainability of this approach. Fitness infusion and gamelike elements, used according to self-determination theory principles, are associated with enhanced student physical activity and motivation toward PE.⁷⁴ Similarly, teaching strategies (ie, specialist PE teachers and highly trained classroom teachers) appear to have potential long-term benefits for teachers and students⁷⁵ and can also be a good alternative to promote health. In addition, a previous study⁵ suggested that direct and explicit teaching strategies may be associated with increasing fundamental movement skill proficiency in children and adolescents, which was corroborated in the present study.

The question of how much extra PE is needed to document beneficial associations with health-related outcome is not easily answered. Overall, our meta-analysis suggests that quantity-based PE interventions are associated with small increases in CRF, muscular strength, and speed agility. However, meta-regression analyses revealed that incorporation of more PE lessons per week was not associated with larger changes in health-related physical fitness outcomes but greater differences in PE sessions per week between the intervention and control groups were associated with greater FMS performance. Therefore, our results indicate that an increase of PE exposure might not be associated with major changes in these health-related outcomes in apparently healthy youths (eg, body composition), whereas it may be a good strategy to improve FMSs among children and adolescents.^64,65

Overall, the present findings would contradict expectations regarding the more-is-better theory, which may indicate the need to structure and plan conscientiously the PE lessons to encourage healthy improvements.⁶ Ensuring that PE teachers are highly qualified and accountable for establishing and maintaining consistent routines appears to be necessary. However, not all PE lessons are conducive to high levels of physical activity but might still be valuable, for example, by providing students with the knowledge of movements, skills, and abilities; improving social and emotional outcomes and confidence to be active (key elements for long-term health-related fitness development); creating an appropriate setting for learning self-management strategies (eg, goal setting, self-assessment, and monitoring); and teaching the rules, tactics, and objectives of various games.

It seems reasonable to hypothesize that, ideally, an increase in quantity (ie, frequency) and quality of PE lessons would be required to maximize health-related benefits.⁵¹ However, assuming various school constraints (ie, reduced practice time per session, number of weekly sessions, or lack of material resources and facilities) to increase the PE class efficiency, our analysis suggests that fitness infusion strategies should be considered in school-based programs. Notwithstanding current results suggesting possible improvements in several future health-related outcomes,^7,8 although the absolute effects were limited (small associations), PE alone may not provide young people with all the exercise they need.

Strengths and Limitations

To our knowledge, this was the first study to examine the associations of interventions aimed at improving PE in terms of quality or quantity (lessons per week) with health-related physical fitness and FMSs among children and adolescents, including a total of 48 185 youths in the analyses.

This study has limitations. These limitations include (1) the variety of strategies used during PE lessons; (2) the heterogeneity in the number of PE lessons per week in the intervention and control groups and their duration; (3) the outcome measures; (4) the follow-up time (from 6 weeks to 9 years); (5) the age of the participants; (6) the role of potential confounders (eg, total physical activity); and (7) the inclusion of non-RCTs (ie, controlled trials), which introduce some risk of bias. However, subgroup analyses confirmed the overall results when only RCTs were analyzed.

Conclusions

Supplement.

eTable 1. Risk of Bias Within Studies

eTable 2. Synthesis of Pooled Results According to Education Level

eFigure 1. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Body Mass Index Between Intervention and Control Groups for Each Study

eFigure 2. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Waist Circumference Between Intervention and Control Groups for Each Study

eFigure 3. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Skinfolds Thickness Between Intervention and Control Groups for Each Study

eFigure 4. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Body Fat Between Intervention and Control Groups for Each Study

eFigure 5. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Lean Body Mass Between Intervention and Control Groups for Each Study

eFigure 6. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Cardiorespiratory Fitness Between Intervention and Control Groups for Each Study

eFigure 7. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Muscular Strength Between Intervention and Control Groups for Each Study

eFigure 8. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Speed Agility Between Intervention and Control Groups for Each Study

eFigure 9. Forest Plot Showing the Effect Size (Hedges g) of Quality-Based Physical Education Interventions on Fundamental Motor Skills Between Intervention and Control Groups for Each Study

eFigure 10. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Body Mass Index Between Intervention and Control Groups for Each Study

eFigure 11. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Waist Circumference Between Intervention and Control Groups for Each Study

eFigure 12. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Skinfolds Thickness Between Intervention and Control Groups for Each Study

eFigure 13. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Body Fat Between Intervention and Control Groups for Each Study

eFigure 14. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Cardiorespiratory Fitness Between Intervention and Control Groups for Each Study

eFigure 15. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Muscular Strength Between Intervention and Control Groups for Each Study

eFigure 16. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Speed Agility Between Intervention and Control Groups for Each Study

eFigure 17. Forest Plot Showing the Effect Size (Hedges g) of Quantity-Based Physical Education Interventions on Fundamental Motor Skills Between Intervention and Control Groups for Each Study

eFigure 18. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Body Mass Index Changes

eFigure 19. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week o Intervention Group vs Control Group With Waist Circumference Changes

eFigure 20. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Skinfolds Thickness Changes

eFigure 21. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Cardiorespiratory Fitness Changes

eFigure 22. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Muscular Strength Changes

eFigure 23. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Speed Agility Changes

eFigure 24. Meta-Regression Analysis of the Association Between Difference in Hours of Physical Education per Week of Intervention Group vs Control Group With Fundamental Motor Skills Changes

eReferences

Click here for additional data file.^{(402.4KB, pdf)}

References

1.van Sluijs EMF, McMinn AM, Griffin SJ. Effectiveness of interventions to promote physical activity in children and adolescents: systematic review of controlled trials. Br J Sports Med. 2008;42(8):653-657. [PubMed] [Google Scholar]
2.Hollis JL, Williams AJ, Sutherland R, et al. . A systematic review and meta-analysis of moderate-to-vigorous physical activity levels in elementary school physical education lessons. Prev Med. 2016;86:34-54. doi: 10.1016/j.ypmed.2015.11.018 [DOI] [PubMed] [Google Scholar]
3.Hollis JL, Sutherland R, Williams AJ, et al. . A systematic review and meta-analysis of moderate-to-vigorous physical activity levels in secondary school physical education lessons. Int J Behav Nutr Phys Act. 2017;14(1):52. doi: 10.1186/s12966-017-0504-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
4.Dudley D, Burden R. What effect on learning does increasing the proportion of curriculum time allocated to physical education have? a systematic review and meta-analysis.Published online February 17, 2020. Eur Phys Educ Rev. doi: 10.1177/1356336X19830113 [DOI] [Google Scholar]
5.Lander N, Eather N, Morgan PJ, Salmon J, Barnett LM. Characteristics of teacher training in school-based physical education interventions to improve fundamental movement skills and/or physical activity: a systematic review. Sports Med. 2017;47(1):135-161. doi: 10.1007/s40279-016-0561-6 [DOI] [PubMed] [Google Scholar]
6.Lonsdale C, Rosenkranz RR, Peralta LR, Bennie A, Fahey P, Lubans DR. A systematic review and meta-analysis of interventions designed to increase moderate-to-vigorous physical activity in school physical education lessons. Prev Med. 2013;56(2):152-161. doi: 10.1016/j.ypmed.2012.12.004 [DOI] [PubMed] [Google Scholar]
7.Mintjens S, Menting MD, Daams JG, van Poppel MNM, Roseboom TJ, Gemke RJBJ. Cardiorespiratory fitness in childhood and adolescence affects future cardiovascular risk factors: a systematic review of longitudinal studies. Sports Med. 2018;48(11):2577-2605. doi: 10.1007/s40279-018-0974-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
8.García-Hermoso A, Ramírez-Campillo R, Izquierdo M. Is muscular fitness associated with future health benefits in children and adolescents? a systematic review and meta-analysis of longitudinal studies. Sports Med. 2019;49(7):1079-1094. doi: 10.1007/s40279-019-01098-6 [DOI] [PubMed] [Google Scholar]
9.Liberati A, Altman DG, Tetzlaff J, et al. . The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100. doi: 10.1371/journal.pmed.1000100 [DOI] [PMC free article] [PubMed] [Google Scholar]
10.Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713-721. doi: 10.1093/ptj/83.8.713 [DOI] [PubMed] [Google Scholar]
11.Higgins JP, Green S, eds. Cochrane Handbook for Systematic Reviews of Interventions. John Wiley & Sons, Ltd; 2008. doi: 10.1002/9780470712184 [DOI] [Google Scholar]
12.Jackson D, White IR, Thompson SG. Extending DerSimonian and Laird’s methodology to perform multivariate random effects meta-analyses. Stat Med. 2010;29(12):1282-1297. doi: 10.1002/sim.3602 [DOI] [PubMed] [Google Scholar]
13.Cohen J. Statistical Power Calculations for the Behavioral Sciences. Lawrence Erlbaum Associates; 1988:2. [Google Scholar]
14.Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558. doi: 10.1002/sim.1186 [DOI] [PubMed] [Google Scholar]
15.Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta-analyses. BMJ. 2003;327(7414):557-560. doi: 10.1136/bmj.327.7414.557 [DOI] [PMC free article] [PubMed] [Google Scholar]
16.Egger M, Davey Smith G, Schneider M, Minder C. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315(7109):629-634. doi: 10.1136/bmj.315.7109.629 [DOI] [PMC free article] [PubMed] [Google Scholar]
17.Ten Hoor GA, Rutten GM, Van Breukelen GJP, et al. . Strength exercises during physical education classes in secondary schools improve body composition: a cluster randomized controlled trial. Int J Behav Nutr Phys Act. 2018;15(1):92. doi: 10.1186/s12966-018-0727-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
18.Delgado-Floody P, Espinoza-Silva M, García-Pinillos F, Latorre-Román P. Effects of 28 weeks of high-intensity interval training during physical education classes on cardiometabolic risk factors in Chilean schoolchildren: a pilot trial. Eur J Pediatr. 2018;177(7):1019-1027. doi: 10.1007/s00431-018-3149-3 [DOI] [PubMed] [Google Scholar]
19.Jarani J, Grøntved A, Muca F, et al. . Effects of two physical education programmes on health- and skill-related physical fitness of Albanian children. J Sports Sci. 2016;34(1):35-46. doi: 10.1080/02640414.2015.1031161 [DOI] [PubMed] [Google Scholar]
20.Cvejić D, Universitatis SO-F, Physical S, et al. . Effects of the FITT program on physical activity and health-related fitness in primary school age children. Facta Univ Phys Educ Sport. 2017;15:437-451. [Google Scholar]
21.Lucertini F, Spazzafumo L, De Lillo F, Centonze D, Valentini M, Federici A. Effectiveness of professionally-guided physical education on fitness outcomes of primary school children. Eur J Sport Sci. 2013;13(5):582-590. doi: 10.1080/17461391.2012.746732 [DOI] [PubMed] [Google Scholar]
22.Marshall J, Bouffard M. The effects of quality daily physical education on movement competency in obese versus nonobese children. Adapt Phys Activ Q. 1997;14(3):222-237. doi: 10.1123/apaq.14.3.222 [DOI] [Google Scholar]
23.Mayorga-Vega D, Viciana J, Cocca A, de Rueda Villén B. Effect of a physical fitness program on physical self-concept and physical fitness elements in primary school students. Percept Mot Skills. 2012;115(3):984-996. doi: 10.2466/06.10.25.PMS.115.6.984-996 [DOI] [PubMed] [Google Scholar]
24.Mayorga-Vega D, Montoro-Escaño J, Merino-Marban R, et al. . Effects of a physical education-based programme on health-related physical fitness and its maintenance in high school students. Eur Phys Educ Rev. 2016;22:243-259. doi: 10.1177/1356336X15599010 [DOI] [Google Scholar]
25.McKay HA, Petit MA, Schutz RW, Prior JC, Barr SI, Khan KM. Augmented trochanteric bone mineral density after modified physical education classes: a randomized school-based exercise intervention study in prepubescent and early pubescent children. J Pediatr. 2000;136(2):156-162. doi: 10.1016/S0022-3476(00)70095-3 [DOI] [PubMed] [Google Scholar]
26.McKenzie TL, Nader PR, Strikmiller PK, et al. . School physical education: effect of the Child and Adolescent Trial for Cardiovascular Health. Prev Med. 1996;25(4):423-431. doi: 10.1006/pmed.1996.0074 [DOI] [PubMed] [Google Scholar]
27.Neumark-Sztainer D, Story M, Hannan PJ, Rex J. New Moves: a school-based obesity prevention program for adolescent girls. Prev Med. 2003;37(1):41-51. doi: 10.1016/S0091-7435(03)00057-4 [DOI] [PubMed] [Google Scholar]
28.Nogueira RC, Weeks BK, Beck BR. An in-school exercise intervention to enhance bone and reduce fat in girls: the CAPO Kids trial. Bone. 2014;68:92-99. doi: 10.1016/j.bone.2014.08.006 [DOI] [PubMed] [Google Scholar]
29.Alonso-Fernández D, Fernández-Rodríguez R, Taboada-Iglesias Y, et al. . Impact of a HIIT protocol on body composition and VO2max in adolescents. Sci Sports. 2019;34:341-347. doi: 10.1016/j.scispo.2019.04.001 [DOI] [Google Scholar]
30.Webber LS, Catellier DJ, Lytle LA, et al. ; TAAG Collaborative Research Group . Promoting physical activity in middle school girls: Trial of Activity for Adolescent Girls. Am J Prev Med. 2008;34(3):173-184. doi: 10.1016/j.amepre.2007.11.018 [DOI] [PMC free article] [PubMed] [Google Scholar]
31.Pesce C, Faigenbaum A, Crova C, Marchetti R, Bellucci M. Benefits of multi-sports physical education in the elementary school context. Health Educ J. 2013;72:326-336. doi: 10.1177/0017896912444176 [DOI] [Google Scholar]
32.Pesce C, Masci I, Marchetti R, Vazou S, Sääkslahti A, Tomporowski PD. Deliberate play and preparation jointly benefit motor and cognitive development: mediated and moderated effects. Front Psychol. 2016;7:349. doi: 10.3389/fpsyg.2016.00349 [DOI] [PMC free article] [PubMed] [Google Scholar]
33.Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Faucette N, Hovell MF. The effects of a 2-year physical education program (SPARK) on physical activity and fitness in elementary school students: Sports, Play and Active Recreation for Kids. Am J Public Health. 1997;87(8):1328-1334. doi: 10.2105/AJPH.87.8.1328 [DOI] [PMC free article] [PubMed] [Google Scholar]
34.Schmidt M, Jäger K, Egger F, Roebers CM, Conzelmann A. Cognitively engaging chronic physical activity, but not aerobic exercise, affects executive functions in primary school children: a group-randomized controlled trial. J Sport Exerc Psychol. 2015;37(6):575-591. doi: 10.1123/jsep.2015-0069 [DOI] [PubMed] [Google Scholar]
35.Telford RD, Cunningham RB, Fitzgerald R, et al. . Physical education, obesity, and academic achievement: a 2-year longitudinal investigation of Australian elementary school children. Am J Public Health. 2012;102(2):368-374. doi: 10.2105/AJPH.2011.300220 [DOI] [PMC free article] [PubMed] [Google Scholar]
36.van Beurden E, Barnett LM, Zask A, Dietrich UC, Brooks LO, Beard J. Can we skill and activate children through primary school physical education lessons? “Move it Groove it”—a collaborative health promotion intervention. Prev Med. 2003;36(4):493-501. doi: 10.1016/S0091-7435(02)00044-0 [DOI] [PubMed] [Google Scholar]
37.Weeks BK, Young CM, Beck BR. Eight months of regular in-school jumping improves indices of bone strength in adolescent boys and girls: the POWER PE study. J Bone Miner Res. 2008;23(7):1002-1011. doi: 10.1359/jbmr.080226 [DOI] [PubMed] [Google Scholar]
38.Young DR, Phillips JA, Yu T, Haythornthwaite JA. Effects of a life skills intervention for increasing physical activity in adolescent girls. Arch Pediatr Adolesc Med. 2006;160(12):1255-1261. doi: 10.1001/archpedi.160.12.1255 [DOI] [PubMed] [Google Scholar]
39.Faigenbaum A, Mediate P. The effects of medicine ball training on physical fitness in high school physical education students. Phys Educator. 2006;63:160-167. [Google Scholar]
40.Boyle-Holmes T, Grost L, Russell L, et al. . Promoting elementary physical education: results of a school-based evaluation study. Health Educ Behav. 2010;37(3):377-389. doi: 10.1177/1090198109343895 [DOI] [PubMed] [Google Scholar]
41.Baquet G, Berthoin S, Gerbeaux M, Van Praagh E. High-intensity aerobic training during a 10 week one-hour physical education cycle: effects on physical fitness of adolescents aged 11 to 16. Int J Sports Med. 2001;22(4):295-300. doi: 10.1055/s-2001-14343 [DOI] [PubMed] [Google Scholar]
42.Costigan SA, Eather N, Plotnikoff RC, et al. . Preliminary efficacy and feasibility of embedding high intensity interval training into the school day: a pilot randomized controlled trial. Prev Med Rep. 2015;2:973-979. doi: 10.1016/j.pmedr.2015.11.001 [DOI] [PMC free article] [PubMed] [Google Scholar]
43.Carrel AL, Clark RR, Peterson SE, Nemeth BA, Sullivan J, Allen DB. Improvement of fitness, body composition, and insulin sensitivity in overweight children in a school-based exercise program: a randomized, controlled study. Arch Pediatr Adolesc Med. 2005;159(10):963-968. doi: 10.1001/archpedi.159.10.963 [DOI] [PubMed] [Google Scholar]
44.Chavarro JE, Peterson KE, Sobol AM, Wiecha JL, Gortmaker SL. Effects of a school-based obesity-prevention intervention on menarche (United States). Cancer Causes Control. 2005;16(10):1245-1252. doi: 10.1007/s10552-005-0404-5 [DOI] [PubMed] [Google Scholar]
45.Cohen KE, Morgan PJ, Plotnikoff RC, Callister R, Lubans DR. Physical activity and skills intervention: SCORES cluster randomized controlled trial. Med Sci Sports Exerc. 2015;47(4):765-774. doi: 10.1249/MSS.0000000000000452 [DOI] [PubMed] [Google Scholar]
46.Daly RM, Ducher G, Hill B, et al. . Effects of a specialist-led, school physical education program on bone mass, structure, and strength in primary school children: a 4-year cluster randomized controlled trial. J Bone Miner Res. 2016;31(2):289-298. doi: 10.1002/jbmr.2688 [DOI] [PubMed] [Google Scholar]
47.Dalziell A, Booth JN, Boyle J, et al. . Better Movers and Thinkers: an evaluation of how a novel approach to teaching physical education can impact children’s physical activity, coordination and cognition. Br Educ Res J. 2019;45:576-591. doi: 10.1002/berj.3514 [DOI] [Google Scholar]
48.Gallotta MC, Emerenziani GP, Iazzoni S, Iasevoli L, Guidetti L, Baldari C. Effects of different physical education programmes on children’s skill- and health-related outcomes: a pilot randomised controlled trial. J Sports Sci. 2017;35(15):1547-1555. doi: 10.1080/02640414.2016.1225969 [DOI] [PubMed] [Google Scholar]
49.Pate RR, Ward DS, Saunders RP, Felton G, Dishman RK, Dowda M. Promotion of physical activity among high-school girls: a randomized controlled trial. Am J Public Health. 2005;95(9):1582-1587. doi: 10.2105/AJPH.2004.045807 [DOI] [PMC free article] [PubMed] [Google Scholar]
50.Ramírez Lechuga J, Muros Molina JJ, Morente Sánchez J, Sánchez Muñoz C, Femia Marzo P, Zabala Díaz M. Effect of an 8-week aerobic training program during physical education lessons on aerobic fitness in adolescents [in Spanish]. Nutr Hosp. 2012;27(3):747-754. [DOI] [PubMed] [Google Scholar]
51.Ardoy DN, Fernández-Rodríguez JM, Ruiz JR, et al. . Improving physical fitness in adolescents through a school-based intervention: the EDUFIT study [in Spanish]. Rev Esp Cardiol. 2011;64(6):484-491. doi: 10.1016/j.recesp.2011.01.009 [DOI] [PubMed] [Google Scholar]
52.Bugge A, El-Naaman B, Dencker M, et al. . Effects of a three-year intervention: the Copenhagen School Child Intervention Study. Med Sci Sports Exerc. 2012;44(7):1310-1317. doi: 10.1249/MSS.0b013e31824bd579 [DOI] [PubMed] [Google Scholar]
53.Löfgren B, Daly RM, Nilsson J-Å, Dencker M, Karlsson MK. An increase in school-based physical education increases muscle strength in children. Med Sci Sports Exerc. 2013;45(5):997-1003. doi: 10.1249/MSS.0b013e31827c0889 [DOI] [PubMed] [Google Scholar]
54.Lopes VP, Stodden DF, Rodrigues LP. Effectiveness of physical education to promote motor competence in primary school children. Phys Educ Sport Pedagogy. 2017;22:589-602. doi: 10.1080/17408989.2017.1341474 [DOI] [Google Scholar]
55.Meyer U, Schindler C, Zahner L, et al. . Long-term effect of a school-based physical activity program (KISS) on fitness and adiposity in children: a cluster-randomized controlled trial. PLoS One. 2014;9(2):e87929. doi: 10.1371/journal.pone.0087929 [DOI] [PMC free article] [PubMed] [Google Scholar]
56.Piéron M, Cloes M, Delfosse C, et al. . An investigation of the effects of daily physical education in kindergarten and elementary schools. Eur Phys Educ Rev. 1996;2:116-132. doi: 10.1177/1356336X9600200204 [DOI] [Google Scholar]
57.Reed JA, Maslow AL, Long S, Hughey M. Examining the impact of 45 minutes of daily physical education on cognitive ability, fitness performance, and body composition of African American youth. J Phys Act Health. 2013;10(2):185-197. doi: 10.1123/jpah.10.2.185 [DOI] [PubMed] [Google Scholar]
58.Rexen CT, Ersbøll AK, Møller NC, Klakk H, Wedderkopp N, Andersen LB. Effects of extra school-based physical education on overall physical fitness development: the CHAMPS study DK. Scand J Med Sci Sports. 2015;25(5):706-715. doi: 10.1111/sms.12293 [DOI] [PubMed] [Google Scholar]
59.Sacchetti R, Ceciliani A, Garulli A, Dallolio L, Beltrami P, Leoni E. Effects of a 2-year school-based intervention of enhanced physical education in the primary school. J Sch Health. 2013;83(9):639-646. doi: 10.1111/josh.12076 [DOI] [PubMed] [Google Scholar]
60.Shephard R, Lavallée H. Impact of enhanced physical education on muscle strength of the prepubescent child. Pediatr Exerc Sci. 1994;6(1):75-87. doi: 10.1123/pes.6.1.75 [DOI] [Google Scholar]
61.Shephard RJ, Lavallée H. Enhanced physical education and body fat in the primary school child. Am J Hum Biol. 1993;5(6):697-704. doi: 10.1002/ajhb.1310050612 [DOI] [PubMed] [Google Scholar]
62.Shephard RJ, Lavallée H. Impact of enhanced physical education in the prepubescent child: Trois Rivie’res revisited. Pediatr Exerc Sci. 1993;5(2):177-189. doi: 10.1123/pes.5.2.177 [DOI] [Google Scholar]
63.Erfle SE, Gamble A. Effects of daily physical education on physical fitness and weight status in middle school adolescents. J Sch Health. 2015;85(1):27-35. doi: 10.1111/josh.12217 [DOI] [PubMed] [Google Scholar]
64.Sollerhed A-C, Ejlertsson G. Physical benefits of expanded physical education in primary school: findings from a 3-year intervention study in Sweden. Scand J Med Sci Sports. 2008;18(1):102-107. doi: 10.1111/j.1600-0838.2007.00636.x [DOI] [PubMed] [Google Scholar]
65.Ericsson I, Karlsson MK. Motor skills and school performance in children with daily physical education in school: a 9-year intervention study. Scand J Med Sci Sports. 2014;24(2):273-278. doi: 10.1111/j.1600-0838.2012.01458.x [DOI] [PubMed] [Google Scholar]
66.Hansen HS, Froberg K, Hyldebrandt N, Nielsen JR. A controlled study of eight months of physical training and reduction of blood pressure in children: the Odense schoolchild study. BMJ. 1991;303(6804):682-685. doi: 10.1136/bmj.303.6804.682 [DOI] [PMC free article] [PubMed] [Google Scholar]
67.Heidemann M, Jespersen E, Holst R, et al. . The impact on children’s bone health of a school-based physical education program and participation in leisure time sports: the Childhood Health, Activity and Motor Performance School (the CHAMPS) study, Denmark. Prev Med. 2013;57(2):87-91. doi: 10.1016/j.ypmed.2013.04.015 [DOI] [PubMed] [Google Scholar]
68.Jurak G, Kovač M, Strel J. Impact of the additional physical education lessons programme on the physical and motor development of 7-to 10-year-old children. Kinesiology. 2008;38(2):105-115. [Google Scholar]
69.Klakk H, Chinapaw M, Heidemann M, Andersen LB, Wedderkopp N. Effect of four additional physical education lessons on body composition in children aged 8-13 years: a prospective study during two school years. BMC Pediatr. 2013;13:170. doi: 10.1186/1471-2431-13-170 [DOI] [PMC free article] [PubMed] [Google Scholar]
70.Kriemler S, Zahner L, Schindler C, et al. . Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised controlled trial. BMJ. 2010;340:c785. doi: 10.1136/bmj.c785 [DOI] [PMC free article] [PubMed] [Google Scholar]
71.Learmonth YC, Hebert JJ, Fairchild TJ, Møller NC, Klakk H, Wedderkopp N. Physical education and leisure-time sport reduce overweight and obesity: a number needed to treat analysis. Int J Obes (Lond). 2019;43(10):2076-2084. doi: 10.1038/s41366-018-0300-1 [DOI] [PubMed] [Google Scholar]
72.Aubert S, Barnes JD, Abdeta C, et al. . Global Matrix 3.0 physical activity report card grades for children and youth: results and analysis from 49 countries. J Phys Act Health. 2018;15(S2):S251-S273. doi: 10.1123/jpah.2018-0472 [DOI] [PubMed] [Google Scholar]
73.García-Hermoso A, Cerrillo-Urbina AJ, Herrera-Valenzuela T, Cristi-Montero C, Saavedra JM, Martínez-Vizcaíno V. Is high-intensity interval training more effective on improving cardiometabolic risk and aerobic capacity than other forms of exercise in overweight and obese youth? a meta-analysis. Obes Rev. 2016;17(6):531-540. doi: 10.1111/obr.12395 [DOI] [PubMed] [Google Scholar]
74.Ha AS, Lonsdale C, Lubans DR, Ng JYY Increasing students’ activity in physical education. Med Sci Sport Exerc 2020;52(3):696-704. . [DOI] [PubMed]
75.McKenzie TL, Sallis JF, Prochaska JJ, Conway TL, Marshall SJ, Rosengard P. Evaluation of a two-year middle-school physical education intervention: M-SPAN. Med Sci Sports Exerc. 2004;36(8):1382-1388. doi: 10.1249/01.MSS.0000135792.20358.4D [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials