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Dynamic Chiropractic Canada – September 1, 2012, Vol. 05, Issue 09
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Is Exer-Gaming a Viable Public Health Strategy?

By Michelle Laframboise, BKin (Hons), DC, FRCCSS(C)

The World Health Organization states that physical inactivity is the fourth leading risk factor for overall global mortality, due to the devastating effects of sedentariness on the human body.1 It is well-known that increasing physical activity to increase total energy expenditure and reducing caloric intake may form the theoretical basis for the management of obesity.1-4 This is of importance since obesity is on the rise in Canada, with approximately 26 percent of Canadian children and youth between the ages of 2 and 17 over the 90th percentile for body-weight.3 Increasing physical activity and decreasing sedentariness may be the foundation for decreasing childhood obesity and the first step to lasting behavioural change.

What Current Guidelines Say

The Public Health Agency of Canada and the Canadian Society for Exercise Physiology first set physical activity guidelines for children and youth in 2002 to promote healthy, active living in the Canadian population.5 These guidelines recommended children and youth increase the time spent being physically active by 30 minutes per day and progress over time to at least 90 minutes per day of moderate- to vigorous-intensity activity.5

However, in 2011 the Public Health Agency of Canada, in conjunction with the Canadian Society for Exercise Physiology, updated physical activity guidelines for children and youth.6 The new guidelines recommend children and youth accumulate at least 60 minutes of moderate- to vigorous-intensity physical activity daily. Moderate physical activity is defined as 3.0-6.9 metabolic equivalents (METS) and includes activities such as brisk walking and bicycle riding. Vigorous physical activity is defined as >7 METS and includes activities such as running, playing tennis and performing jumping jacks. Vigorous physical activity is recommended at least three days per week and resistance training three days per week for advantageous health benefits.6

Exer-Gaming - Copyright – Stock Photo / Register Mark It appears from the update in the guidelines that as our Canadian society increases in weight, there has been an overall decline in the recommended amount of physical activity. Interestingly, this guideline change came on the heels of the Canadian Society for Exercise Physiology's announcement of the "Canadian Sedentary Behaviour Guidelines" recommending that children and youth minimize the time spent being sedentary each day by limiting recreational screen time (television, computer, video games, etc.) to no more than two hours per day.

So, there has been a decrease in the overall amount of physical activity recommended to children and youth in Canada, as well as an overall increase in the amount of recommended sedentary screen time. This change may be reflective of the rise in obesity within North America.7-9

Paying the Price of Inactivity

The Canadian Public Health Association (CPHA) published the new guidelines for physical activity and sedentariness in the Spring 2011 Health Digest to advise readers of the new change. CPHA is an advocacy group that promotes health in Canadians. According to a recent issue of Health Digest, Canadian children are, on average, larger and weaker compared to 1981. Further, 31 percent of Canadian boys and 25 percent of Canadian girls are now classified as overweight or obese. Thus, there is a need for CPHA and the American Public Health Association (APHA) to promote physical activity to parents, teachers and health care practitioners, all of whom are responsible for the health of our younger generations.

The Canadian Fitness and Lifestyle Research Institute looked at the proportion of Canadian children meeting the current recommended guidelines of 60 minutes of physical activity per day. Only 45 percent of boys and 30 percent of girls 5-10 years of age; 38 percent of boys and 21 percent of girls 11-14 years of age; and 24 percent of boys and 16 percent of girls 15-19 years of age achieve the recommended daily levels of physical activity.10

When the guidelines recommended at least 90 minutes of physical activity daily, none of the Canadian provinces or territories met the guidelines, and only 12 percent of Canadian children and youth overall.10 Therefore, as primary health care practitioners it is our responsibility to educate children and youth about the recommended level of physical activity needed for health benefits and how to achieve it.

Can Exer-Gaming Help Increase Physical Activity Levels?

boy roller skating - Copyright – Stock Photo / Register Mark According to the new Canadian Sedentary Behaviour Guidelines and the guidelines set by the Canadian Pediatric Society, children should limit recreational screen time to no more than two hours per day.7,9 An increase in screen time can lead to a sustained positive energy balance, leading to an increase in adiposity.11 However, as physical inactivity and obesity levels continue to rise, it has been proposed that playing new-generation active computer and video games can increase energy expenditure.12 If sedentary screen time could be converted to active screen time, then this could be an effective approach to promoting physical activity.13

Exer-gaming can increase energy expenditure above and beyond resting basal metabolic rate.12 Lanningham-Foster, et al., measured energy expenditure while 25 children 8-12 years of age watched television, played video games seated, and played active video games. Results showed that playing video games with a hand-held controller while seated increases energy expenditure above basal metabolic rate by 22 percent. Incorporating only upper-body movements during play can increase energy expenditure more than 108 percent, and full-body gaming can increase energy expenditure above basal metabolic rate by 172 percent.12

However, the key question remains whether such activities provide children with the opportunity to expend sufficient energy to meet current public health guidelines. Active gaming uses less energy than authentic sporting activities and intensity is highly variable. Most active video games only engage children in low levels of physical activity, thus not meeting the current guidelines.13-14 The Canadian physical activity guidelines recommend that children should engage in moderate to vigorous physical activity on a daily basis. Therefore, low-level physical activity created by exer-gaming does not reach the recommended requirements.13-14

Weighing the Pros and Cons

There are pros and cons when deciding whether to use new-generation active video games for physical activity. The pros are that children can participate in active gaming in the comfort of their own home under parental supervision, and even in adverse weather conditions.13 It may provide the opportunity for children to develop motor control in a non-threatening environment.

Additionally, low-level activity is better than no activity and may increase motivation for children to get more involved in real-life physical activities or sports.13 Exer-gaming may also be useful in some rehabilitation and therapeutic settings to help individuals overcome injury, disability, disease or aging-related issues.13,15

There are also cons associated with using exer-gaming as a way to meet physical activity guidelines. Real-world sports increase energy expenditure more than active video games.14 Also, there may be a displacement effect with exer-gaming. The time spent playing active video games displaces the time that could be spent on authentic physical activity; thus there is no net gain of energy expenditure.

Moreover, anecdotal reports from many parents confirm that children are extremely savvy and learn quickly that they can lie on the couch and continue to play active video games with small flicks of the wrist. Thus, exer-gaming may provide low levels of physical activity for children, but should not be used as a supplement for authentic indoor or outdoor physical activity.

Take-Home Points

Childhood physical inactivity is on the rise in Canada and globally, increasing the prevalence of obesity.1-2 Parents and children need to be familiar with national physical activity and sedentary behaviour guidelines for healthy, active living. Exer-gaming is not a replacement for authentic physical activity.

As chiropractors, we can be influential in encouraging an increase in physical activity by promoting active, healthy lifestyles within their practice; teaching by example in the community; educational presentations to parents and children; and by educating our patients and ourselves on the health benefits of physical activity.16 The CPHA has provided health care practitioners with the information needed to educate their patients on the benefits of starting physical activity at a young age to avoid obesity in the future. This information has given me the resources needed to complement my expertise as a chiropractor and provide patients, parents and my community with the help they need to become more physically active.


  1. World Health Organization. Global recommendations on physical activity for health. WHO, 2010.
  2. Tremblay MS, Willms JD. Is the Canadian childhood obesity epidemic related to physical inactivity? Int J Obes, 2003;27:1100-1105.
  3. Lau DCW, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E. Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. Canadian Med Assoc J, 2006;176(8):1-13.
  4. Guo S, Huang C, Maynard L, Demereth E, Towne B, Chumlea W, et al. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study. Int J Obes Relat Metab Disord, 2000;24:1628-1635.
  5. Health Canada, Canadian Society for Exercise Physiology: Canada's Physical Activity Guide for Children and Youth. Ottawa: Minister of Public Works and Government Services Canada; 2002.
  6. Health Canada, Canadian Society for Exercise Physiology: Canadian Physical Activity Guidelines for Children and Youth. Ottawa: Minister of Public Works and Government Services Canada; 2011.
  7. Health Canada, Canadian Society for Exercise Physiology: Canadian Sedentary Behaviour Guidelines for Children and Youth. Ottawa: Minister of Public Works and Government Services Canada; 2011.
  8. World Health Organization. Global strategy on diet, physical activity and health. World Health Organization, 2010.
  9. Canadian Paediatric Society. Impact of media on children and youth. Paediatr Child Health, 2003;8:301-306.
  10. Canadian Fitness and Lifestyle Research Institute. Kids CANPLAY! Physical activity levels of Canadian children and youth. Bulletin Number 2. Resources and Services. Ottawa, ON; 2010.
  11. Anderson SE, Whitaker RC. Household routines and obesity in US preschool-aged children. Pediatrics, 2010;125:420-428.
  12. Lanningham-Foster L, Jensen TB, Foster RC, Redmond AB, Walker BA, Heinz D, Levine JA. Energy expenditure of sedentary screen time compared with active screen time for children. Pediatrics, 2006;118:1831-1835.
  13. Daley AJ. Can exer-gaming contribute to improving physical activity levels and health outcomes in children? Pediatrics, 2009;124:763-771.
  14. Graves L, Stratton G, Ridgers ND et al. Energy expenditure in adolescents playing new generation computer games. Br J Sports Med, 2008;42:592-594.
  15. Levac D, Pierrynowski MR, Canestraro M, Gurr L, Leonard L, Neeley C. Exploring children's movement characteristics during virtual reality video game play. Hum Move Sci, 2010;29(6):1023-1038.
  16. Petrella R, Lattanzio C, Overend T. Physical activity counseling and prescription among Canadian primary care physicians. Arch Intern Med, 2007;167:1774-1781.

Dr. Michelle Laframboise is a sports fellow with the Royal College of Chiropractic Sports Sciences and is currently serving as chair of the public health committee. In addition to treating professional, Olympic and recreational athletes in practice at Back to Function in Orillia, Ontario, she has served as medical staff for provincial and national soccer clubs, figure-skating competitions, mountain bike competitions, wrestling and Taekwondo competitions. She has served as medical manager for the Ontario winter and summer games, as well as currently serving as team doctor for a junior 'A' hockey team.

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