Research

JAMA Pediatrics | Original Investigation

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, PhD; Alicia M. Alonso-Martínez, PhD; Robinson Ramírez-Vélez, PhD;
Miguel Ángel Pérez-Sousa, PhD; Rodrigo Ramírez-Campillo, PhD; Mikel Izquierdo, PhD

Supplemental content
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.

Author Affiliations: Author

affiliations are listed at the end of this
article.
Corresponding Author: Antonio
García-Hermoso, PhD,
Navarrabiomed, Complejo
Hospitalario de Navarra, Universidad
Pública de Navarra, Instituto de
Investigación Sanitaria de Navarra,
JAMA Pediatr. doi:10.1001/jamapediatrics.2020.0223 Calle Irunlarrea 3, 31008 Pamplona,
Published online April 6, 2020. Spain (antonio.garciah@unavarra.es).

(Reprinted) E1
© 2020 American Medical Association. All rights reserved.

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 Research Original Investigation Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths
S
chools 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 lessons 4 ; however, given the com-
petitive 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 fun-
damental 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 learn-
ing 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 exam-
ine the association of quality- and quantity-based PE in-
terventions with health-related physical fitness and FMSs in
children and adolescents.
Methods
Protocol and Registration
This study followed the Preferred Reporting Items for System-
atic 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 ref-
erence lists of the included studies were checked to find
potential studies that could also be used in the review.
E2 JAMA Pediatrics Published online April 6, 2020 (Reprinted)
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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).
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, fre-
quency, and duration) and the nature of the intervention
(teaching strategies in which teachers learned strategies to en-
courage physical activity by effective activity selection, class
organization and management, and instruction or “fitness in-
fusion” in which teachers supplemented students’ participa-
tion in sport activities [eg, basketball] with vigorous fitness ac-
tivities [eg, running and jumping]); (5) outcomes; and (6)
differences in the means of 2 time points or postintervention
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 Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths
mean values with corresponding SDs. When there was insuf-
ficient information, the respective corresponding author was
contacted.
Risk of Bias of Individual Studies
The risk of bias was evaluated using the Physiotherapy Evi-
dence Database criteria,10 an 11-item scale designed for mea-
suring 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 cal-
culated and pooled using a random-effects model (DerSimo-
nian-Laird approach12). Data were pooled if outcomes were re-
ported 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 con-
sidered as small heterogeneity, 25% to 75% as moderate hetero-
geneity, 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 re-
gression 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 strat-
egies or fitness infusion) and education level (primary or sec-
ondary). In addition, random-effects meta-regression analy-
ses were used to evaluate whether the results might vary
according to the differences in sessions per week (ie, PE les-
sons) 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 refer-
ence lists of included studies and previous reviews for addi-
tional relevant articles, 110 studies were read in full. The rea-
sons for exclusion based on full text were (1) inappropriate
study design (11 articles), (2) inappropriate intervention (7 ar-
ticles), (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
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Original Investigation Research
Figure. PRISMA Flow Diagram
3810 Records identified through database searching
2965 Records after duplicates removed
845 Records screened
110 Full-text articles assessed for eligibility
54 Excluded
31 Inappropriate outcome
7 Inappropriate intervention
11 Inappropriate design
5 Secondary study
56 Studies included in qualitative synthesis
34 Quality-based physical 22 Quantity-based physical
education (meta-analysis) education (meta-analysis)
of 48 185 children and adolescents (48% girls). Most studies in-
cluded 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 predomi-
nantly 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), Portu-
gal (1), Spain (6), Serbia (1), Slovenia (1), Sweden (3), Switzer-
land (3), or the UK (1).
Complete details regarding interventions are given in
Table 1. Of the quality-based PE studies, 17 used teaching strat-
egies (eg, enriched PE lessons and PE specialist–led lessons)
and 18 used fitness infusion (eg, HIIT, jump training, and cir-
cuit training). Of the quantity-based PE studies, each in-
cluded 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, 50,5 4,66,68
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 cir-
cumference; skinfold thickness; body fat; lean body mass; CRF
(usually assessed with the 20-m shuttle run test); muscular fit-
ness 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 Mo-
tor 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
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 E4
Table 1. Summary of Included Studies
Age, range or Intervention
Source, location Design Sample, No. (%) mean, y length Intervention characteristics and duration per session Outcomes
Quality-based PE
Alonso-Fernández RCT 26 (50% female) 15-16 7 wk Fitness infusion; HIIT protocol intervention based on the Tabata method BMI, body fat, lean body
et al,29 2019, Spain mass, CRF
Baquet et al,41 2001, CT 551 (48% 11-16 10 wk Fitness infusion; HIIT protocol intervention BMI, SKT, CRF, muscular
France female) strength, speed agility
Boyle-Holmes et al,40 CT 1464 (49% 8-12 1y Teaching strategies; Michigan’s Exemplary Physical Education Curriculum: PE curriculum that focuses CRF, muscular strength,
Research Original Investigation

2010, US female) on developing knowledge, attitudes, skills, and behaviors that are associated with lifelong physical fundamental motor skills
activity through teaching and motor skills learning progressions
Carrel et al,43 2005, US RCT 50 (48% female) 12a 9 mo Fitness infusion; fitness-oriented gym classes BMI, body fat, CRF
44
Chavarro et al, 2005, RCT 508 (100% 10-13 2 School Teaching strategies; Planet Health curriculum: this approach is designed to enhance efficiency by using BMI, SKT
US female) years classroom teachers with minimal health education training to implement the materials
45
Cohen et al, 2015, cRCT 460 (54% 7-10 1y Teaching strategies; PE lesson structure recommendations CRF, fundamental motor
Australia female) skills
Costigan et al,42 2015, RCT 65 (31% female) 15.8 8 wk Fitness infusion; participants completed HIIT sessions with or without strength training BMI, zBMI, WC, CRF,
Australia muscular strength
20
Cvejić et al, 2017, RCT 178 (48% 9.0 8 wk Fitness infusion; FITT program: primarily teaching contents, methods, forms, and other teaching BMI, SKT, CRF, muscular

JAMA Pediatrics Published online April 6, 2020 (Reprinted)

Serbia female) instruments of work are used so that the planned physical activity or exercise by frequency, intensity, strength
duration, and type leads to the improvement of aerobic fitness, muscular fitness, and flexibility and
indirectly to the improvement of body composition
Daly et al,46 2016, cRCT 727 (50% 8.1 4 School Teaching strategies; specialized PE by teachers who emphasized more vigorous exercise and games Body fat, lean body mass
Australia female) years combined with static and dynamic postural activities that involve muscle strength
Dalziell et al,47 2019, RCT 143 (NR) 10-11 16 wk Teaching strategies; Better Movers and Thinkers: a novel approach to PE that directly targets the Fundamental motor skills
UK development of physical competence, cognitive skills, and personal qualities
Delgado-Floody et al,18 CT 197 (55% 6-11 28 wk Fitness infusion; HIIT BMI, WC, body fat, CRF
2018, Chile female)
Faigenbaum and CT 118 (35% 15-16 6 wk Fitness infusion; Medicine Ball Training Program Muscular strength, speed
Mediate,39 2006, US female) agility
Gallotta et al,48 2017, RCT 230 (43% 8-11 5 mo Fitness infusion; the experimental 1 intervention was designed to promote health, fitness, CRF, muscular strength,

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Italy female) sensory-motor, social, and communicative development and the experimental 2 intervention was fundamental motor skills
focused on improving the coordination and dexterity of the participants
Jarani et al,19 2016, RCT 760 (47% 8.3 5 mo Fitness infusion; ABC 5 on 5 PE program: the exercise group intervention program emphasized physical BMI, body fat, CRF, muscular
Albania female) activity exercises (eg, gait exercises to improve speed), whereas the games group intervention program strength, speed agility,
was focused on fun games (eg, tag games to improve speed) fundamental motor skills
Lucertini et al,21 2013, RCT 101 (45% 9.5 6 mo Fitness infusion; group A trained strength and endurance with specifically designed cardiovascular and BMI, body fat, CRF, muscular

© 2020 American Medical Association. All rights reserved.

Italy female) resistance devices (the Kid’s System), whereas group B by means of traditional or nonconventional strength, speed agility,
devices (eg, light dumbbells, elastic bands, plastic water bottles, etc) fundamental motor skills
Marshall and RCT 406 (48% 5-10 NR Teaching strategies; quality daily PE: the program facilitates the development of movement skill SKT, CRF, fundamental
Bouffard,22 1997, female) in obese children motor skills
Canada
Mayorga-Vega et al,23 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 CRF, muscular strength
2012, Spain each with 45 to 25 s of rest between them
Mayorga-Vega et al,24 cRCT 111 (37% 12-14 9 wk Fitness infusion; students performed commonly used PE-based physical fitness sessions (eg, strength CRF, muscular strength
2016, Spain female) games, running games, circuit training, multijumps, or multithrows) followed by some team games
McKay et al,25 2000, RCT 145 (51% 6.9-10.2 8 mo Fitness infusion; exercise groups did 10 tuck jumps 3 times weekly and incorporated jumping, hopping, Body fat, lean body mass
Canada female) and skipping into twice weekly PE classes

(continued)

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Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths
 Table 1. Summary of Included Studies (continued)
Age, range or Intervention
Source, location Design Sample, No. (%) mean, y length Intervention characteristics and duration per session Outcomes
McKenzie et al,26 1996, RCT 5106 (48% 8-9 2.5 y Teaching strategies: CATCH: the goals of CATCH PE were to promote children’s enjoyment of and CRF
US female) participation in moderate to vigorous during PE classes and to provide skills to be used out of school

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and throughout life
Neumark-Sztainer RCT 201 (100% 15.4 8 mo Teaching strategies: New Moves program: offered as a girls-only alternative PE program that high school BMI
et al,27 2003, US female) girls took for credit in Social Cognitive Theory
Nogueira et al,28 2014, RCT 151 (100% 10.6 9 mo Fitness infusion; the intervention group participated in instructor-led exercise bouts comprising 10 min WC, CRF, muscular strength
Australia female) of continuous high-intensity movements intended to improve musculoskeletal and metabolic health
Pate et al,49 2005, US RCT 2744 (100% 13-15 1y Teaching strategies; Lifestyle Education for Activity Program (LEAP PE): designed (1) to enhance Obesity
female) 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
Pesce et al,31 2013, CT 125 (NR) 10-11 8 mo Teaching strategies; the intervention, centered on experiences joining multiple sports in varied ways, CRF, muscular strength
Italy was structured in 4 didactic modules lasting 8 wk each
Pesce et al,32 2016, RCT 920 (48% 5-10 6 mo Teaching strategies; the enriched PE was centered on deliberate play and cognitively challenging Fundamental motor skills
Italy female) variability of practice, on motor coordination and cognitive processing
50
Ramírez et al, 2012, RCT 84 (39% female) 15-18 8 wk Fitness infusion; aerobic training CRF
Spain
Sallis et al,33 1997, US RCT 955 (49% 9.5-9.6 2y Teaching strategies; Sport, Play, Activity, and Recreation for Kids PE intervention: PE specialist-led: SKT, CRF, muscular strength
female) PE teachers taught PE and self-management while receiving ongoing professional development and
supervision from investigators
Schmidt et al,34 2015, RCT 181 (55% 10-12 6 wk Fitness infusion; children were assigned to either a PE program with a high level of physical exertion and CRF
Switzerland female) high cognitive engagement (team games), a PE program with high physical exertion but low cognitive
engagement (aerobic exercise)
Telford et al,35 2012, RCT 620 (NR) 7-8 2y Teaching strategies; Lifestyle of Our Kids study: the specialist-taught intervention was conducted in 13 BMI, body fat, CRF
Canada 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
Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths

Ten Hoor et al,17 2018, cRCT 695 (50% 11-15 1y Fitness infusion; adolescents spend at least 30% of the PE lessons on strength exercises (approximately Body fat, lean body mass
the Netherlands female) 15-30 min per lesson)
36
van Beurden et al, RCT 1045 (47% 7-10 18 mo Teaching strategies; Move It project intervention: consisted of school project teams to have a whole Fundamental motor skills

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2003, Australia female) school approach, buddy program that involved classroom teachers partnered with preservice PE teachers
Webber et al,30 2008, RCT 1712 (100% 11-12 2y Teaching strategies; Trial of Activity for Adolescent Girls PE: intervention promoted MVPA for at least BMI, body fat, SKT
US female) 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
Weeks et al,37 2008, RCT 99 (53% female) 13.8 8 mo Fitness infusion; the POWER PE Study: intervention subjects performed 10 min of jumping activity in BMI, body fat, lean body

© 2020 American Medical Association. All rights reserved.

Australia place of regular PE mass, muscular strength
Young et al,38 2006, US RCT 221 (100% 13.8 1y Teaching strategies; the intervention was also designed to maximize physical activity during PE class; BMI, WC
female) 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
Quantity-based PE
Ardoy et al,51 2011, RCT 67 (36% female) 12-14 16 wk 4 Sessions per week vs 2 sessions per week; 55 min CRF, muscular strength,
Spain speed-agility
Bugge et al,52 2012, CT 696 (41% 6-7 3y 4 Sessions per week vs 2 sessions per week; 45 min BMI, zBMI, WC, SKT, CRF
Denmark female)
Erfle and Gamble,63 CT 10 206 (50% 11-14 1y 5 Sessions per week vs 2 sessions per week; 30 min BMI, CRF, muscular strength
2015, US female)

(continued)

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Original Investigation Research

E5
 E6
Table 1. Summary of Included Studies (continued)
Age, range or Intervention
Source, location Design Sample, No. (%) mean, y length Intervention characteristics and duration per session Outcomes
Ericsson and Karlsson,65 CT 220 (46% 7-9 9y 5 Sessions per week vs 2 sessions per week; 45 min Fundamental motor skills
2014, Sweden female)
Hansen et al,66 1991, RCT 132 (48% 9-11 8 mo 3 Sessions per week vs 2 sessions per week; 50 min BMI, SKT, CRF
Denmark female)
Heidemann et al,67 CT 717 (52% 8-12 2y 6 Sessions per week vs 2 sessions per week; 45 min BMI, body fat, lean body mass
2013, Denmark female)
Research Original Investigation

Jurak et al,68 2008, CT 328 (49% 7-10 4y 4 Sessions per week vs 3 sessions per week; 60 min SKT, CRF, muscular strength,
Slovenia female) speed-agility
Klakk et al,69 2013, CT 632 (50% 8-13 2y 6 sessions per week vs 2 sessions per week; 45 min BMI, body fat, obesity
Denmark female)
Kriemler et al,70 2010, cRCT 540 (51% 5-11 1y 5 Sessions per week vs 3 sessions per week; 45 min BMI, WC, SKT, CRF
Switzerland female)
Learmonth et al,71 CT 1009 (53% 5-12 2y 6 Sessions per week vs 2 sessions per week; 45 min Obesity
2019, Denmark female)
Löfgren et al,53 2013, CT 232 (43% 7-9 2y 5 Sessions per week (40 min) vs 1 session per week of 60 min BMI, body fat, lean body
Sweden female) mass, muscular strength

JAMA Pediatrics Published online April 6, 2020 (Reprinted)

Lopes et al,54 2017, RCT 60 (37% female) 9.0 1y 3 Sessions per week vs 2 sessions per week; 45-50 min BMI, SKT, fundamental
Portugal motor skills
Meyer et al,55 2014, cRCT 502 (57% 6-12 3y 5 Sessions per week vs 3 sessions per week; 45 min BMI, zBMI, WC, SKT, CRF
Switzerland female)
Piéron et al,56 1996, CT 7721 (NR) 5-12 1y 5 Sessions per week vs NR; NR Fundamental motor skills
Belgium
Ramírez et al,50 2012, RCT 84 (39% female) 15-18 8 wk 3 Sessions per week vs 2 sessions per week; 60 min CRF
Spain
Reed et al,57 2013, US CT 470 (50% 10.2 1y 5 Sessions per week (45 min) vs 1 session per week of 30-45 min CRF, muscular strength
female)
Rexen et al,58 2015, CT 1247 (47% 8.4 2.5 y 3 Sessions per week vs 1 session per week; 90 min CRF, muscular strength,
Denmark female) fundamental motor skills

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Sacchetti et al,59 2013, RCT 438 (47% 8-9 2y 5 Sessions per week vs 2 sessions per week; 50 min BMI, obesity, muscular
Italy female) strength, speed-agility
Shephard and CT 546 (47% 7-12 6y 5 Sessions per week vs 1 session per week; NR SKT, CRF, muscular strength
Lavallée,61,62 1993 and female)
1994,60 Canada

© 2020 American Medical Association. All rights reserved.

Sollerhed and CT 132 (45% 6-9 3y 4 Sessions per week vs 1-2 sessions per week; 40 min BMI, WC, CRF, muscular
Ejlertsson,64 2008, female) strength, fundamental
Sweden motor skills
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.

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Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths
 Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths Original Investigation Research

Table 2. Synthesis of Pooled Results

Health- Quality-based physical education Quantity-based physical education

related No. of studies Egger Egger
physical (No. of Hedges g test No. of studies (No. Hedges g vest
2 2
fitness participants) (95% CI) P value I P value of participants) (95% CI) P value I P value
Body mass 14 (5289) −0.13 (−0.19 <.001 14.58 .06 11 (14 287) −0.03 (−0.10 .46 44.26 .19
index to −0.06) to 0.04)
Waist 4 (634) −0.28 (−0.48 .005 21.99 .009 4 (1870) −0.04 (−0.14 .48 0 .88
circumference to −0.08) to 0.07)
Skinfold 5 (3904) −0.03 (−0.13 .48 33.93 .87 4 (2258) −0.05 (−0.16 .34 0 .07
thickness to 0.06) to 0.06)
Body fat 11 (4556) −0.22 (−0.33 <.001 53.71 .02 3 (1581) 0.16 (−0.06 .16 77.09 .16
to −0.11) to 0.39)
Lean body 4 (971) 0.33 (0.01 to .04 45.48 .42 NA NA NA NA NA
mass 0.66)
Cardiores- 20 (11 276) 0.24 (0.16 to <.001 47.74 .003 11 (13 703) 0.42 (0.30 <.001 68.79 .17
piratory 0.32) to 0.55)
fitness
Muscular 13 (4858) 0.19 (0.09 to <.001 52.61 .34 9 (13 180) 0.20 (0.08 .001 62.23 .14
strength 0.29) to 0.31)
Speed agility 4 (1530) 0.19 (−0.05 to .12 76.16 .19 4 (2080) 0.29 (0.07 .009 73.88 .15
0.43) to 0.51)
Fundamental 7 (3873) 0.38 (0.27 to <.001 73.43 .002 4 (1659) 0.20 (−0.01 .06 79.03 .20
motor skills 0.49) to 0.42)

Abbreviation: NA, not applicable.

failed to conceal allocation (3 of 55 [6%]) or to blind partici-
pants 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 in-
terventions were associated with significant reductions in BMI
(Hedges g = −0.13; 95% CI, −0.19 to −0.06), waist circumfer-
ence (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 Supple-
ment). Quantity-based PE interventions were associated with
increases in CRF (Hedges g = 0.42; 95% CI, 0.30-0.55), mus-
cular 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 eFig-
ures 10-17 in the Supplement).
For quality-based PE interventions, subgroup analysis re-
vealed that those incorporating fitness infusion interven-
tions 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 in-
creased 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 interven-
tions that incorporated teaching strategies as the main inter-
vention, 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 increas-
ing 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 increases 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

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 Research Original Investigation Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths

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

Teaching strategies Fitness infusion

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

Abbreviation: NA, not applicable.

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 learn-
ing time compared with usual practice (10% more of total
lesson time spent in MVPA). Specifically, effective interven-
tion strategies included teacher professional learning;
focusing on class organization, management, and instruc-
tion; 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 composi-
tion, 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 inter-
ventions, 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 improv-
ing 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 effec-
tiveness 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 cor-
roborated in the present study.
The question of how much extra PE is needed to docu-
ment beneficial associations with health-related outcome is
not easily answered. Overall, our meta-analysis suggests that
quantity-based PE interventions are associated with small in-
creases in CRF, muscular strength, and speed agility. How-
ever, 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 perfor-
mance. 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 expecta-
tions regarding the more-is-better theory, which may indi-
cate the need to structure and plan conscientiously the PE les-
sons to encourage healthy improvements.6 Ensuring that PE
teachers are highly qualified and accountable for establish-
ing and maintaining consistent routines appears to be neces-
sary. 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 in-
crease in quantity (ie, frequency) and quality of PE lessons
would be required to maximize health-related benefits.51 How-
ever, assuming various school constraints (ie, reduced prac-
tice time per session, number of weekly sessions, or lack of ma-
terial resources and facilities) to increase the PE class efficiency,

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 Physical Education and Improvement of Physical Fitness Outcomes and Motor Skills in Youths Original Investigation Research

our analysis suggests that fitness infusion strategies should
be considered in school-based programs. Notwithstanding cur-
rent results suggesting possible improvements in several fu-
ture health-related outcomes,7,8 although the absolute ef-
fects were limited (small associations), PE alone may not
provide young people with all the exercise they need.
measures; (4) the follow-up time (from 6 weeks to 9 years);
(5) the age of the participants; (6) the role of potential con-
founders (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 re-
sults when only RCTs were analyzed.

Strengths and Limitations

To our knowledge, this was the first study to examine the as-
sociations 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, in-
cluding 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 heteroge-
neity in the number of PE lessons per week in the interven-
tion and control groups and their duration; (3) the outcome
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 im-
prove more than health, high levels of active learning time may
need to be balanced with opportunities for instruction, feed-
back, and reflection.

ARTICLE INFORMATION
Accepted for Publication: December 30, 2019.
Published Online: April 6, 2020.
doi:10.1001/jamapediatrics.2020.0223
Author Affiliations: Navarrabiomed, Complejo
Hospitalario de Navarra, Universidad Pública de
Navarra, Instituto de Investigación Sanitaria de
Navarra, Pamplona, Spain (García-Hermoso,
Ramírez-Vélez, Izquierdo); Laboratorio de Ciencias
de la Actividad Física, el Deporte y la Salud,
Universidad de Santiago de Chile, Santiago, Chile
(García-Hermoso); Department of Health Sciences,
Public University of Navarra, CIBER of Frailty and
Healthy Aging, Instituto de Salud Carlos III,
Pamplona, Navarra, Spain (Alonso-Martínez,
Ramírez-Vélez, Izquierdo); Faculty of Sport
Sciences, University of Huelva, Huelva, Spain
(Pérez-Sousa); Laboratory of Human Performance,
Quality of Life and Wellness Research Group,
Department of Physical Activity Sciences,
Universidad de Los Lagos, Osorno, Chile
(Ramírez-Campillo).
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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