Association of Physical Education With Improvement of Health-Related Physical Fitness Outcomes and Fundamental Motor Skills Among Youths: A Systematic Review and Meta-analysis | Adolescent Medicine | JAMA Pediatrics | JAMA Network
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Figure.  PRISMA Flow Diagram
PRISMA Flow Diagram
Table 1.  Summary of Included Studies
Summary of Included Studies
Table 2.  Synthesis of Pooled Results
Synthesis of Pooled Results
Table 3.  Subgroup Analysis According to Nature of the Intervention for Quality-Based Physical Education
Subgroup Analysis According to Nature of the Intervention for Quality-Based Physical Education
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

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    Original Investigation
    April 6, 2020

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

    Author Affiliations
    • 1Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain
    • 2Laboratorio de Ciencias de la Actividad Física, el Deporte y la Salud, Universidad de Santiago de Chile, Santiago, Chile
    • 3Department of Health Sciences, Public University of Navarra, CIBER of Frailty and Healthy Aging, Instituto de Salud Carlos III, Pamplona, Navarra, Spain
    • 4Faculty of Sport Sciences, University of Huelva, Huelva, Spain
    • 5Laboratory of Human Performance, Quality of Life and Wellness Research Group, Department of Physical Activity Sciences, Universidad de Los Lagos, Osorno, Chile
    JAMA Pediatr. 2020;174(6):e200223. doi:10.1001/jamapediatrics.2020.0223
    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.

    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 studies2,3 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 studies5,6 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 PE17-50 and 22 for quantity-based PE.50-71 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 studies18,22,43 included overweight and/or obese children. All studies included boys and girls with the exception of 6 studies27,28,30,38,44,49 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).

    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).

    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).

    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

    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.

    Back to top
    Article Information

    Accepted for Publication: December 30, 2019.

    Corresponding Author: Antonio García-Hermoso, PhD, Navarrabiomed, Complejo Hospitalario de Navarra, Universidad Pública de Navarra, Instituto de Investigación Sanitaria de Navarra, Calle Irunlarrea 3, 31008 Pamplona, Spain (antonio.garciah@unavarra.es).

    Published Online: April 6, 2020. doi:10.1001/jamapediatrics.2020.0223

    Author Contributions: Dr García-Hermoso had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: All authors.

    Acquisition, analysis, or interpretation of data: García Hermoso, Alonso-Martínez, Ramírez-Vélez, Ramirez-Campillo.

    Drafting of the manuscript: García Hermoso, Ramirez-Campillo, Pérez-Sousa, Izquierdo.

    Critical revision of the manuscript for important intellectual content: García Hermoso, Alonso-Martínez, Ramírez-Vélez, Ramirez-Campillo, Izquierdo.

    Statistical analysis: García Hermoso, Ramirez-Campillo, Pérez-Sousa.

    Obtained funding: Izquierdo.

    Administrative, technical, or material support: Alonso-Martínez, Izquierdo.

    Supervision: Ramírez-Vélez, Izquierdo.

    Conflict of Interest Disclosures: None reported.

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