The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/124/2/534.full.html
WHAT THIS STUDY ADDS: This study provides the rst objective
measurement of physiological responses in children playing a
new physically active video game, Nintendo Wii. Comparisons with
DDR and treadmill walking show that these games result in signicant
increases in energy expenditure.
ABBREVIATIONS
DDRDance Dance Revolution
HR heart rate
DDR1DDR beginner level
DDR2DDR basic level
RPErating of perceived exertion
KEY WORDS
indirect calorimetry, video games, physical activity
abstract
www.pediatrics.org/cgi/doi/10.1542/peds.2008-2851
doi:10.1542/peds.2008-2851
Accepted for publication Nov 25, 2008
Address correspondence to Kevin R. Short, PhD, CMRI Diabetes
and Metabolic Research Program, 1122 NE 13th St, Suite 1400,
Oklahoma City, OK 73117. E-mail: kevin-short@ouhsc.edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2009 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no nancial relationships relevant to this article to disclose.
534
GRAF et al
ARTICLES
METHODS
Subjects
Twenty-three healthy children (14
boys, 9 girls) aged 10 to 13 years were
recruited from the local community.
Informed written consent and assent
from the parent and child were obtained. The study was conducted under
the approval of the University of Oklahomas institutional review board. A
brief medical screening was performed before data collection. Body
mass and body fat content were measured by using bioelectrical impedance (model BC-418 [Tanita, Arlington
Heights, IL]), and height was measured
to the nearest 0.5 cm. BMI (kg/m2) and
age-adjusted percentile were calculated by using Centers for Disease Control and Prevention charts.14
Protocol and Procedures
Each child completed 2 visits to the laboratory within 4 weeks. Testing order
535
Throughout the study energy expenditure was measured by indirect calorimetry by using an expired breath analyzer (Ultima CardiO2 [Medgraphics,
St Paul, MN]). A neoprene mask was
worn over the mouth and nose with
an open pneumotach for breath-bybreath analysis of expired ventilation
and oxygen and carbon dioxide concentration. Certied gases were used
for calibration before every test. HR
was measured by using a surface electrode chest strap (Polar [PolarElectro
Oy, Helsinki, Finland]) interfaced by telemetry with the metabolic measurement software. Footstep rate was recorded by using an accelerometer
worn above the right ankle (StepWatch
3 [OrthoCare Innovations, Mountlake
Terrace, WA]). During the gaming and
walking phases the participants were
asked to subjectively gauge their level
of effort by using a standard Borg
scale15 for rating of perceived exertion
(RPE) (eg, 6 very easy; 20 very
difcult). During the rest phases before and at 10 minutes after the gaming activities, blood pressure and arterial elasticity were measured in
triplicate by using diastolic pulse
waveform analysis (HDI/Pulsewave
CR-2000 [Hypertension Diagnostics,
Eagan, MN]). Arterial pulse waves
were acquired by using a surface
pressure transducer placed over the
radial artery.
536
GRAF et al
Age, y
Height, cm
Weight, kg
BMI, kg/m2
BMI percentile
Total body fat, %
Systolic blood pressure, mm Hg
Diastolic blood pressure, mm Hg
Large-artery elasticity, mL/mm Hg 10
Small-artery elasticity, mL/mm Hg 10
a
All (n 23),
Mean (SD)
Boys (n 14),
Mean (SD)
Girls (n 9),
Mean (SD)
11.9 (1.2)
150.5 (8.9)
43.4 (8.8)
19.1 (3.1)
54 (31)
20.6 (6.2)
110 (8)
56 (6)
11.8 (2.7)
7.9 (2.2)
11.9 (1.0)
150.9 (9.2)
42.4 (9.6)
18.5 (3.4)
49 (35)
18.1 (6.1)
110 (5)
57 (5)
11.9 (2.9)
8.4 (2.4)
11.8 (1.5)
149.8 (8.9)
44.8 (7.8)
19.9 (2.5)
62 (21)
24.5 (4.0)a
111 (11)
55 (7)
11.5 (2.6)
7.2 (2.0)
Statistical Analysis
RESULTS
6
5
kcal/h per kg
Boys
Girls
a
a
a
3
2
1
0
FIGURE 1
Energy expenditure at rest and during treadmill walking, DDR, and Wii bowling and boxing games.
Treadmill (TM) walking velocities were 2.6, 4.2, and 5.7 km/hour, respectively. a Higher in boys than
girls (P .05).
ARTICLES
TABLE 2 HR, Expired Ventilatory Rate, Oxygen Uptake (VO2), and RPE
Rest
HR, bpm
Boys
Girls
Expired ventilatory rate, L/min
Boys
Girls
VO2, mL/kg per min
Boys
Girls
RPE
Boys
Girls
66 (2)
69 (3)
Treadmill,
2.6 km/h
Treadmill,
4.2 km/h
Treadmill,
5.7 km/h
98 (3)
101 (4)
102 (2)
105 (3)
111 (2)
113 (3)
DDR1
111 (3)
106 (5)
DDR2
Bowl
121 (4)
124 (6)
101 (4)
98 (3)
Boxing
127 (5)
140 (8)
6.3 (0.3)
5.8 (0.3)
11.3 (0.7)
11.7 (0.7)
12.9 (0.7)
13.2 (0.9)
16.0 (0.7)
16.3 (0.9)
15.9 (0.8)
13.0 (0.8)a
18.9 (1.0)
17.6 (1.5)
11.9 (0.9)
9.6 (0.5)a
17.9 (1.4)
18.7 (1.9)
4.8 (0.3)
4.1 (0.3)
9.8 (0.5)
9.3 (0.5)
11.2 (0.4)
10.5 (0.6)
14.0 (0.4)
13.0 (0.5)
13.7 (0.6)
10.2 (0.4)a
15.8 (0.9)
13.2 (0.7)a
10.0 (0.7)
7.7 (0.6)a
13.8 (1.1)
13.5 (1.4)
10 (1)
13 (1)
12 (1)
15 (1)
9 (1)
12 (1)a
13 (1)
16 (1)a
9 (1)
11 (1)
12 (1)
15 (1)a
8 (1)
11 (1)a
80
Steps per min
pattern was evident for energy expenditure expressed in kJ/min (data not
shown). We opted to present energy
expenditure relative to body mass because most activities were weightbearing; therefore, body weight and
energy expenditure were strongly associated (r 0.71 0.86 for walking,
r 0.51 0.57 for DDR). The association between body weight and energy
expenditure during bowling and boxing games was lower (r 0.37 0.42),
reecting greater reliance on upperbody movement. Walking and exergaming resulted in signicant elevations in
energy expenditure (Fig 1), expired
ventilation, VO2, and HR (Table 2) compared with these measures for children watching television at rest. The
highest rate of energy expenditure
was recorded for DDR2 (3.3-fold increase above rest), although energy
expenditure when playing the boxing
game was nearly as high (2.9- and 3.3fold increase above rest for boys and
girls, respectively) and not different
from DDR2. Walking at 5.7 km/hour elevated energy expenditure 3-fold on
average, which was less than that for
DDR2 (P .05) but not boxing. For VO2,
the highest value was recorded during
DDR2 (3.3-fold increase above rest on
average), with lower values during
boxing and walking at 5.7 km/hour
(both 3.0-fold higher than rest). Venti-
Boys
Girls
60
40
20
a
0
TM 2.6 TM 4.6 TM 5.7 DDR1 DDR2 Bowl Boxing
FIGURE 2
Step rate during treadmill walking, DDR, and Wii bowling and boxing games. Treadmill (TM) walking
velocities were 2.6, 4.2, and 5.7 km/hour, respectively. a Higher in boys than girls (P .05).
537
DDR
Wii
DDR
Wii
mL/mm Hg x10
0
-1
-2
-3
-4
Boys
-5
Girls
FIGURE 3
Change in arterial elasticity after DDR and Wii
game play. Left, Large-artery elasticity declined
in boys after playing both games, but only after
Wii gaming for girls. Right, There was a trend for
lower small-arterial elasticity in boys after DDR
(P .052). a Greater decline in boys versus girls
after playing DDR (P .02). b Postexercise value
lower than baseline (P .02).
DISCUSSION
The goal of this study was to quantify
and compare rates of energy expenditure and related physiologic responses in children while playing 2
new-generation physically active video
games. The primary new ndings were
538
GRAF et al
ARTICLES
CONCLUSIONS
Activity-promoting video games increase energy expenditure equivalent to
ACKNOWLEDGMENTS
This project was supported by National
Center for Research Resources grant
P20RR024215 (to Dr Short). Additional
support was provided by the Childrens Medical Research Institute
Brann Summer Scholar program (to
Dr Graf) and the Harold Hamm Oklahoma Diabetes Center.
REFERENCES
1. Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent
fatness. Int J Obes Relat Metab Disord. 1997;21(7):507526
2. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and
adolescents: an epidemiologic review and a public health perspective. J Pediatr. 2000;136(5):664 672
3. Ekelund U, Sjostrom M, Yngve A, et al. Physical activity assessed by activity monitor and doubly
labeled water in children. Med Sci Sports Exerc. 2001;33(2):275281
4. Bouten CV, Verboeket-van de Venne WP, Westerterp KR, Verduin M, Janssen JD. Daily physical
activity assessment: comparison between movement registration and doubly labeled water.
J Appl Physiol. 1996;81(2):1019 1026
5. Hoos MB, Plasqui G, Gerver WJM, Westerterp KR. Physical activity level measured by doubly labeled
water and accelerometry in children. Eur J Appl Physiol. 2003;89(6):624 626
6. Watts K, Beye P, Siafarikas A, et al. Exercise training normalizes vascular dysfunction and improves central adiposity in obese adolescents. J Am Coll Cardiol. 2004;43(10):18231827
7. Watts K, Beye P, Siafarikas A, et al. Effects of exercise training on vascular function in obese
children. J Pediatr. 2004;144(5):620 625
8. Shaibi GQ, Cruz ML, Ball GD, et al. Effects of resistance training on insulin sensitivity in overweight
Latino adolescent males. Med Sci Sports Exerc. 2006;38(7):1208 1215
9. Schlumpf M, Eiholzer U, Gygax M, et al. A daily comprehensive muscle training programme in-
539
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
540
GRAF et al
creases lean mass and spontaneous activity in children with Prader-Willi syndrome after 6
months. J Pediatr Endocrinol Metab. 2006;19(1):6574
Dowda M, Ainsworth BE, Addy CL, Saunders R, Riner W. Environmental inuences, physical activity,
and weight status in 8- to 16-year-olds. Arch Pediatr Adolesc Med. 2001;155(6):711717
Lanningham-Foster L, Jensen TB, Foster RC, et al. Energy expenditure of sedentary screen time
compared with active screen time for children. Pediatrics. 2006;118(6). Available at:
www.pediatrics.org/cgi/content/full/118/6/e1831
Graves LE, Ridgers ND, Stratton G. The contribution of upper limb and total body movement to
adolescents energy expenditure whilst playing Nintendo Wii. Eur J Appl Physiol. 2008;104(4):
617 623
Graves L, Stratton G, Ridgers ND, Cable NT. Comparison of energy expenditure in adolescents when
playing new generation and sedentary computer games: cross sectional study. BMJ. 2007;
335(7633):12821284
Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and
development. Vital Health Stat 11. 2002;(246):1190
Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14(5):377381
Barlow SE; Expert Committee. Expert Committee recommendations regarding the prevention,
assessment, and treatment of child and adolescent overweight and obesity: summary report.
Pediatrics. 2007;120(suppl 4):S164 S192
National High Blood Pressure Education Program, Working Group on High Blood Pressure in
Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high
blood pressure in children and adolescents. Pediatrics. 2004;114(2):555576
Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, DC: National Academies Press; 2005
Hill JO, Wyatt HR, Reed GW, Peters JC. Obesity and the environment: where do we go from here?
Science. 2003;299(5608):853 855
Unnithan VB, Houser W, Fernhall B. Evaluation of the energy cost of playing a dance simulation
video game in overweight and nonoverweight children and adolescents. Int J Sports Med. 2006;
27(10):804 809
Sell K, Lillie T, Taylor J. Energy expenditure during physically interactive video game playing in
male college students with different playing experience. J Am Coll Health. 2008;56(5):505511
Lydakis C, Momen A, Blaha C, et al. Changes of elastic properties of central arteries during acute
static exercise and lower body negative pressure. Eur J Appl Physiol. 2008;102(6):633 641
Heffernan KS, Collier SR, Kelly EE, Jae SY, Fernhall B. Arterial stiffness and baroreex sensitivity
after bouts of aerobic and resistance exercise. Int J Sports Med. 2007;28(3):197203
Sharman JE, McEniery CM, Campbell RI, et al. The effect of exercise on large artery haemodynamics in healthy young men. Eur J Clin Invest. 2005;35(12):738 744
Reed KE, Warburton DER, Lewanczuk RZ, et al. Arterial compliance in young children: the role of
aerobic tness. Eur J Cardiovasc Prev Rehabil. 2005;12(5):492 497
Schack-Nielsen L, Mlgaard C, Larsen D, Martyn C, Michaelsen KF. Arterial stiffness in 10-year-old
children: current and early determinants. Br J Nutr. 2005;94(6):1004 1011
Cowley AD, Minnaar G. Watch out for Wii shoulder. BMJ. 2008;336(7636):110
Peek AC, Ibrahim T, Abunasra H, Waller D, Natarajan R. White-out from a Wii: traumatic haemothorax sustained playing Nintendo Wii. Ann R Coll Surg Engl. 2008;90(6):W9 10
References
Citations
Subspecialty Collections
Reprints