Digital game interventions for hypertension and diabetes in Latin America: a systematic review

INTRODUCTION

Hypertension and diabetes make up a large share of the cardiometabolic burden of Latin America. Brant et al.(1) described cardiovascular diseases as the main cause of death in Latin America and the Caribbean and traced a rapid rise in obesity and diabetes over four decades. Joseph et al.(2) reported that the burden of cardiovascular disease is moving from the high-income countries of North America towards the middle-income countries of the region. Ilic et al.(3) estimated about 2.3 million new cases of type 2 diabetes and about 214,000 deaths in Latin America in 2019, and Vera-Ponce et al.(4) pooled a prehypertension prevalence of 27.98% (95% CI 21.17 to 35.34) across 17 studies from seven countries.

The first contact with these conditions usually happens in primary care. The NCD Risk Factor Collaboration (5) pointed out that diabetes can be detected at the primary health care level and that effective treatment lowers the risk of complications. Mbuthia et al.(6) reviewed 14 interventions led by community health workers to control blood pressure in low-income and middle-income countries, of which 12 were cluster randomised trials, and found reductions in blood pressure and better linkage to care. Araya et al.(7) showed that a smartphone intervention supported by nurse assistants could be delivered to patients with hypertension or diabetes in primary care in São Paulo and Lima, with a larger proportion of participants reaching a 50% fall in depressive symptoms than with enhanced usual care (40.7% versus 28.6% in São Paulo). Marcolino et al.(8) reviewed 23 systematic reviews of mobile health, 17 of which included studies from low-income and middle-income countries, and identified text messaging was the most frequent intervention. Technology therefore reaches primary care in the region, although not without friction: León Altamirano and Correa (9) reported that 68% of 300 adults with diabetes in Buenos Aires had used telemedicine, and that preference for in-person visits, poor connectivity and difficulty using technology were the main barriers.

Three terms recur in this field and are used here with fixed meanings. A serious game is a game designed for a purpose other than entertainment, such as teaching insulin therapy. Gamification is the use of game design elements in a non-game context, as in an exercise application that awards points. An active video game, or exergame, is a game controlled by body movement. Asadzandi et al.( 10) reviewed gamification in diabetes and observed that physical activity and nutrition were its most frequent targets and that every program aimed to educate, teach skills or improve behaviour. Höchsmann et al.( 11) reviewed 11 studies of exergaming in overweight adults, with and without type 2 diabetes, and noted that all of them showed increases in oxygen uptake, energy expenditure, heart rate or activity counts, although the size of the increase varied between games and consoles.

Games and gamified applications have also been proposed as a way to keep people engaged with self-management. Ossenbrink et al.(12) identified 10 randomised trials of digital health interventions with game components in type 2 diabetes, with glycated haemoglobin improving in 2 of 6 trials and a high risk of bias in nearly all of them. Kaihara et al.(13) pooled three trials and obtained a mean difference of -0.21 in glycated haemoglobin (95% CI -0.37 to -0.05) in favour of gamification, whereas Yao et al.(14) pooled nine studies of electronic games and obtained -0.09% (95% CI -0.29 to 0.10), which was not significant. For blood pressure, Lim et al.(15) reported large effect sizes of game-based exercise in type 2 diabetes, while Davis et al.(16) saw no benefit above usual care in gamified applications for secondary prevention in people at high cardiovascular risk.

These syntheses pooled studies from many regions and did not ask what has been tested in Latin America. De Sá et al.,( 17) from Brazil, mapped 17 studies of mobile games for patients with chronic diseases without synthesising effects on blood pressure or glycaemia, and Reinders et al.( 18) noted that most of the 23 diabetes games they identified were inaccessible outside research settings. Neither review asked whether a digital game improves blood pressure or glycaemic control in Latin American primary care, which is where most people with these conditions are treated and where unequal access to connectivity and devices may change the answer.

The objective of this systematic review was to identify the studies conducted in Latin America on digital game-based interventions for people with hypertension or diabetes, to describe them, to synthesise the blood pressure and glycaemic outcomes they reported compared with usual care, and to appraise the risk of bias and certainty of that evidence.

METHODS

This systematic review followed the PRISMA 2020 statement( 19) and the PRISMA-S extension for reporting searches.( 20) No protocol was registered before the searches. The question was framed with the PICOS structure. Participants were people with hypertension or diabetes of any type and age, or the primary care professionals who manage them. The intervention was a digital game-based intervention, defined as a serious game, a gamified application or web program, an active video game or exergame, or a virtual reality game. The comparator was usual care, a non-game control or no comparator. The outcomes of interest were blood pressure and glycaemic control as primary outcomes, and knowledge, behaviour, usability and engagement as secondary outcomes.

Studies were eligible when they were empirical reports conducted in Latin America, published between 2013 and 2025 in English, Spanish or Portuguese. Latin American setting was judged from the author affiliations and the place of recruitment. Randomised and non-randomised trials, comparative and cross-sectional evaluations, and development and usability studies were accepted, because a restriction to controlled trials would have left no evidence to synthesise. Reviews, protocols without results, non-digital games such as board games and card games, interventions in which a game appeared only in the control arm, and studies of participants without hypertension or diabetes were excluded. The primary care setting was not required, since too few reports described their setting, and it was recorded when available.

Five sources were searched: Scopus, PubMed, OpenAlex, Crossref and Semantic Scholar. Scopus was queried first. The main Scopus string was TITLE-ABS-KEY(("serious game" OR gamif OR "video game" OR "digital game" OR exergam* OR "game-based" OR "mobile game*") AND (hypertension OR "blood pressure" OR diabetes OR glycemic OR glycaemic OR HbA1c) AND ("Latin America" OR Brazil OR Mexico OR Argentina OR Chile OR Colombia OR Peru OR Ecuador OR Guatemala OR Cuba)) AND PUBYEAR > 2012 AND PUBYEAR < 2026. Five further Scopus strings combined game, exergame and virtual reality terms with diabetes and hypertension terms, and with country names either in the text or in the affiliation field, and one of them added the primary care terms in English, Spanish and Portuguese. Equivalent queries with controlled vocabulary and affiliation filters were run in PubMed. To reach the regional literature indexed in SciELO and similar repositories, queries in Spanish (for example juego serio, gamificación, videojuego, hipertensión, atención primaria) and Portuguese (jogo sério, gamificação, jogo digital, hipertensão, atenção primária) were run in OpenAlex and Crossref, and Spanish and Portuguese terms were also included in Scopus. The searches covered publications from 2013 to 2025.

For each study the design, country, participants, game intervention, comparator, outcomes and main result were extracted, each with its source in the report. Randomised trials were appraised with RoB 2,( 21) with the crossover considerations that apply to period and carry-over effects, and non-randomised comparisons with ROBINS-I.( 22) Development and usability studies produce no comparative effect estimate and were not given a risk-of-bias rating. A rating of low risk was never assigned when information was missing.

When several reports described the same programme, they were treated as separate studies if they had distinct participants and answered different questions, as happened with the usability, pilot and randomised trial reports of the InsuOnline game, and as duplicate reports if they described the same trial. A design paper of the InsuOnline trial was excluded on that basis. Reasons for exclusion at the eligibility stage were coded as population, intervention, design, setting or duplicate report. Blood pressure was recorded as the change from the pre-exercise value or against a control session, and glycaemic outcomes were to be recorded as glycated haemoglobin, fasting glucose or post-exercise glucose. Effect estimates were taken as reported, and no values were converted or recalculated.

Studies were synthesised narratively by outcome domain because designs, populations, comparators and outcomes were too heterogeneous for pooling, and no meta-analysis was attempted. Certainty of the evidence was judged qualitatively and not with a formal GRADE assessment. As a measure of regional coverage, the country of the authors and the language and journal of each included report were tabulated. Of the included reports, 20 came from Brazilian institutions and 2 from Mexican institutions, 4 were written in Portuguese or Spanish, and 3 appeared in journals hosted on SciELO. No included study came from the Andean region, the Southern Cone outside Brazil, Central America or the Caribbean.

RESULTS

Study selection

The searches retrieved 2,186 records: 387 from Scopus, 196 from PubMed, 900 from OpenAlex, 600 from Crossref and 103 from Semantic Scholar. After 360 duplicates were removed, 1,826 records were screened and 1,776 were excluded on title and abstract. Of the 50 reports sought, 6 could not be verified and 44 were assessed for eligibility (Figure 1).

At the eligibility stage, 22 reports were excluded for population (8), intervention (8), design (5) and duplicate report (1). The population exclusions covered health students, healthcare workers, adults without hypertension or diabetes, adolescents with overweight, and patients in cardiac rehabilitation. The intervention exclusions included board and card games, an educational application without game elements, a digital game used only as an assessment tool and a cognitive training program in which games appeared only in the control arm. Three reviews and two protocols made up the design exclusions. The six reports not retrieved were a conference paper, three book chapters and two journal articles whose abstracts or full texts could not be reached through open sources. By their titles some of them may have been eligible, so they are a possible source of bias.

DISCUSSION

The evidence from Latin America on digital games for hypertension and diabetes consists mainly of small laboratory studies and development work, and it does not answer the question posed in primary care. Of the 22 studies, three measured blood pressure after a single session, none reported glycated haemoglobin, and the only trial with a usual care comparator among patients measured foot pain and function. Brazilian groups produced 20 of the 22 studies, so the findings describe one country more than a region. This pattern complements the mapping of De Sá et al.,( 17) who identified 17 studies of mobile games for patients with chronic diseases, because the present review narrows the question to hypertension and diabetes in the region and shows that clinical outcomes remain almost unreported.

The acute blood pressure findings agree with work done elsewhere. Vorwerg-Gall et al.( 45) observed that systolic pressure fell after two virtual reality exergame sessions in 22 hypertensive adults older than 65 years, and Silva et al.( 25) recorded falls of similar size after an active video game and treadmill walking. Brasil et al.( 46) reviewed the mechanisms of post-exercise hypotension and related it to autonomic changes that reduce cardiac output or to sustained vasodilatation, although they noted that local vasodilator factors have been proposed in place of autonomic control. Halliwill et al.( 47) described the sustained vasodilatation that follows a single aerobic bout. Not every observation favours the game as such: in the trial by Silva et al.( 25) the sedentary video game lowered systolic pressure by 10.0 mmHg, so a share of the fall may reflect rest and the laboratory setting and not the active component. Silva et al.( 27) added that heart rate during the active game stayed below the range recommended for antihypertensive training, although energy expenditure was adequate.

Several of the laboratory studies compared the active game with an exercise arm and described the responses as similar, which is a claim of equivalence and not of superiority. Silva et al.( 26) based their sample size on an effect size of 1.41 for a pre-post difference, with one-sided testing, which is adequate to detect a fall in pressure but not to show that a game and a walk produce the same fall. With 14 or 15 participants and no confidence intervals in the abstracts, the data cannot exclude a clinically relevant difference between the game and walking. Similarity should therefore be read as compatibility with equivalence, and later trials should state a margin of equivalence in millimetres of mercury before data collection.

The T1DM trial by de Brito Gomes et al.,( 28) in which no post-exercise hypotension appeared, differs from the hypertensive samples because those participants were young adults with a mean age of 24.9 years and presumably normal pressure. This reading is an inference, since the report gives no baseline pressure categories. Unlike the findings of the Latin American laboratory studies, Hou et al.( 48) randomised 128 older adults with hypertension to 16 weeks of exergame, bicycle training or control and found no significant difference in systolic or diastolic pressure. None of the Latin American studies tested repeated exposure. Acute falls and sustained control are different outcomes, and the first cannot be used to support the second. Hernández-Martínez et al.( 49) pooled six trials in children with overweight or obesity and showed that exergaming lowered systolic pressure, which agrees with the acute direction but concerns another population. A recommendation that follows from these comparisons is to measure ambulatory pressure after at least eight weeks of exposure in hypertensive adults, with a walking or usual care arm.

For glycaemic control the review found no regional evidence to set against global estimates. Kaihara et al.( 13) reported a fall of 0.21 in glycated haemoglobin with gamification in three trials, whereas Yao et al.( 14) obtained a non-significant -0.09% in nine studies of electronic games, and Martos-Cabrera et al.( 50) obtained a difference of 0.12 that was also not significant. Ossenbrink et al.( 12) counted improvements in glycated haemoglobin in only 2 of 6 trials. Along the same lines, Reinders et al.( 18) noted that the positive effects reported for diabetes games in research settings rarely extend to games that patients can actually download. The Latin American work on type 1 diabetes reached the stage of prototypes and acute physiology, as shown by de Brito-Gomes et al.,( 31) who reported a rise in HDL cholesterol but similar values on the remaining biochemical measures. A pragmatic trial in adults with type 2 diabetes, the group most represented in the global reviews and without specific results in the Latin American studies, would close this gap if it took glycated haemoglobin at 3 and 6 months as the primary outcome.

The strongest Latin American evidence in primary care concerns professionals, not patients. Diehl et al.( 23) found a larger gain in insulin-prescribing competence with the game than with a session of the same duration (40% versus 34%), and both groups remained above baseline at three months (80% and 76%). Just as Burgon et al.( 51) used a gamified web platform to align primary care physicians in the United States with evidence-based decisions, the Brazilian trial treated clinical inertia as a problem of competence that a game can address. The limitation is that competence was self-assessed and that the study did not follow patients, so it cannot show that better insulin prescribing reached glycated haemoglobin. A follow-up that links physicians who played the game to the glycaemic control of their patients would test that step directly.

Primary care in the region has hosted digital trials that were not game-based, and their scale sets a benchmark. Araya et al.( 7) randomised 880 patients in São Paulo and 432 in Lima, while the largest Latin American game trial among patients enrolled 62 participants. Debon et al.( 52) ran a three-month controlled pilot of an m-Health application in the Family Health Strategy with 39 patients with hypertension and observed that systolic and diastolic pressure moved towards more adequate levels only in the intervention group. Their report does not describe the application as game-based, so it cannot be counted as evidence for games. Silveira et al.( 53) judged a mobile decision support system feasible for 10 family physicians who registered 535 patients with hypertension. Mbuthia et al.( 6) concluded that community health worker interventions reduced blood pressure in low-income and middle-income countries. A game that is to be recommended for primary care should therefore be compared with these established options and not only with no intervention.

The weight of type 1 diabetes in the Latin American studies departs from the global reviews. Ossenbrink et al.( 12) and Kaihara et al.( 13) restricted their reviews to type 2 diabetes, whereas nine of the 22 included studies enrolled people with type 1 diabetes, mainly children and young adults in Brazil. Charlier et al.( 54) pooled randomised trials of serious games in young people with chronic conditions and obtained an effect of 0.361 on knowledge, a type of trial that the Brazilian prototypes have not yet reached. Pairing the prototypes of Sparapani et al.( 39) with a randomised comparison on knowledge and glycated haemoglobin would extend the user-centred design work to outcomes.

Engagement is the argument most often used for games, and the evidence here is thin. Cechetti et al.( 34) found that game elements favoured engagement in 14 patients with hypertension, but the groups were small and unequal in support, so the result cannot separate the effect of the elements from the effect of professional contact. Nishi et al.( 55) pooled 36 trials of apps with and without gamification and detected trivial increases in steps and small reductions in adiposity, with no differences in other outcomes, which indicates modest clinical gains from gamification features. Charlier et al.( 54) obtained a pooled effect of 0.361 on knowledge for serious games in young people with chronic conditions, a result that resembles the knowledge gains reported by Diehl et al.( 32) in trainees. Knowledge is nevertheless a step before behaviour and physiology, and no Latin American study followed children with type 1 diabetes to glycaemic outcomes.

For primary care teams the practical reading is conservative. Active video games raised energy expenditure above that of a sedentary game, as in the women studied by Silva et al.,( 26) although oxygen consumption stayed below that of treadmill walking, and the two studies that measured enjoyment found it high. They may therefore serve patients who do not tolerate or enjoy walking, but the available data do not support prescribing them in place of exercise guidance. The economic data come from a single study: Cruvinel-Júnior et al.( 24) reported low incremental cost-effectiveness ratios per unit of clinical improvement but no cost-effectiveness per quality-adjusted life year, and their program bundled exercise with gamification components, so the contribution of the game cannot be isolated. Future trials of games should therefore record costs from the health system perspective and include an arm without game elements.

Several aspects of the evidence limit its use in practice, and each has a recommendation. Connectivity and device access, which León Altamirano and Correa( 9) identified as barriers to telemedicine in Buenos Aires, were not reported in the included reports available to this review, so trials should record the proportion of eligible patients who could not take part for technological reasons. The evidence is concentrated in Brazil and Mexico, which restricts generalisation to Andean, Central American and Caribbean health systems, and calls for registered trials in at least two additional countries. Most studies had fewer than 20 participants and several lacked a comparator, so future trials should state a minimum sample size for the primary outcome and use usual care as the control.

The strengths of this review are a search that combined five sources and three languages, coded eligibility criteria, an explicit count of the reports that could not be retrieved, and a refusal to read the absence of glycaemic data as an absence of effect.

No included study described delivering a game to patients within a primary care unit, in the reports available here. The only studies tied to primary care concerned its professionals, and the patient studies took place in laboratories, outpatient services or unspecified settings. This matters because the review question refers to usual care in primary care, a comparator that exists in the Family Health Strategy of Brazil and in the primary care networks of other countries, yet none of the games has been tried there against it. A feasible next study is a cluster randomised trial in which primary care units are assigned to a game-supported programme or to usual care, with glycated haemoglobin at 3 and 6 months, office and ambulatory blood pressure, attendance and cost as outcomes, and with reporting of the share of invited patients who own a suitable device. Such a design answers the question that the 22 studies leave open.

CONCLUSIONS

Digital game interventions for hypertension and diabetes in Latin America have been described in a small body of studies, mostly Brazilian, that are dominated by development work and single-session laboratory trials. Blood pressure falls after one session of an active video game in hypertensive adults, but no study has tested repeated exposure, and no study has reported glycated haemoglobin or compared a game with usual care for blood pressure or glycaemic control in primary care. Evidence on knowledge, usability and engagement is encouraging yet limited to small or early-stage studies, and the largest trial improved the insulin-prescribing competence of primary care physicians without following patients. The risk of bias was some concerns or high in every study that could be rated, and the certainty that games improve blood pressure or glycaemic control in Latin American primary care is very low.

References

1. 1 Brant LCC, Miranda JJ, Carrillo-Larco RM, Flood D, Irazola V, Ribeiro ALP. Epidemiology of cardiometabolic health in Latin America and strategies to address disparities. Nat Rev Cardiol. 2024;21(12):849-864. doi: 10.1038/s41569-024-01058-2
2. 2 Joseph P, Lanas F, Roth G, Lopez-Jaramillo P, Lonn E, Miller V, et al. Cardiovascular disease in the Americas: the epidemiology of cardiovascular disease and its risk factors. The Lancet Regional Health - Americas. 2025;42:100960. doi: 10.1016/j.lana.2024.100960
3. 3 Ilic I, Ilic M. The burden of type 2 diabetes mellitus in Latin America, 1990–2019: findings from the Global Burden of Disease study. Public Health. 2024;233:74-82. doi: 10.1016/j.puhe.2024.05.009
4. 4 Vera-Ponce VJ, Loayza-Castro JA, Zuzunaga-Montoya FE, Vásquez-Romero LEM, Sanchez-Tamay NM, Bustamante-Rodríguez JC, et al. Prevalence of prehypertension and high normal blood pressure in Latin America: A systematic review with meta-analysis. Hipertensión y Riesgo Vascular. 2025;42(3):180-194. doi: 10.1016/j.hipert.2025.02.001
5. 5 Zhou B, Rayner AW, Gregg EW, Sheffer KE, Carrillo-Larco RM, Bennett JE, et al. Worldwide trends in diabetes prevalence and treatment from 1990 to 2022: a pooled analysis of 1108 population-representative studies with 141 million participants. The Lancet. 2024;404(10467):2077-2093. doi: 10.1016/s0140-6736(24)02317-1
6. 6 Mbuthia GW, Magutah K, Pellowski J. Approaches and outcomes of community health worker’s interventions for hypertension management and control in low-income and middle-income countries: systematic review. BMJ Open. 2022;12(4):e053455. doi: 10.1136/bmjopen-2021-053455
7. 7 Araya R, Menezes PR, Claro HG, Brandt LR, Daley KL, Quayle J, et al. Effect of a Digital Intervention on Depressive Symptoms in Patients With Comorbid Hypertension or Diabetes in Brazil and Peru. JAMA. 2021;325(18):1852. doi: 10.1001/jama.2021.4348
8. 8 Marcolino MS, Oliveira JAQ, D'Agostino M, Ribeiro AL, Alkmim MBM, Novillo-Ortiz D. The Impact of mHealth Interventions: Systematic Review of Systematic Reviews. JMIR Mhealth Uhealth. 2018;6(1):e23. doi: 10.2196/mhealth.8873
9. 9 Leon Altamirano CF, Manuel Correa FJ. Analysis of the Acceptability of Telemedicine in patients with Diabetes Mellitus. SAP Primary Care. 2025;1:24. doi: 10.62486/pc202524
10. 10 Asadzandi S, Sedghi S, Bigdeli S, Sanjari M. A systematized review on diabetes gamification. mjiri. 2020;34:168. doi: 10.47176/mjiri.34.168
11. 11 Höchsmann C, Schüpbach M, Schmidt-Trucksäss A. Effects of Exergaming on Physical Activity in Overweight Individuals. Sports Med. 2016;46(6):845-860. doi: 10.1007/s40279-015-0455-z
12. 12 Ossenbrink L, Haase T, Timpel P, Schoffer O, Scheibe M, Schmitt J, et al. Effectiveness of Digital Health Interventions Containing Game Components for the Self-management of Type 2 Diabetes: Systematic Review. JMIR Serious Games. 2023;11:e44132. doi: 10.2196/44132
13. 13 Kaihara T, Intan-Goey V, Scherrenberg M, Falter M, Frederix I, Akashi Y, et al. Impact of gamification on glycaemic control among patients with type 2 diabetes mellitus: a systematic review and meta-analysis of randomized controlled trials. Eur Heart J Open. 2021;1(3):oeab030. doi: 10.1093/ehjopen/oeab030
14. 14 Yao W, Han Y, Yang L, Chen Y, Yan S, Cheng Y. Electronic Interactive Games for Glycemic Control in Individuals With Diabetes: Systematic Review and Meta-Analysis. JMIR Serious Games. 2024;12:e43574. doi: 10.2196/43574
15. 15 Lim YS, Ho B, Goh Y. Effectiveness of game‐based exercise interventions on modifiable cardiovascular risk factors of individuals with type two diabetes mellitus: A systematic review and meta‐analysis. Worldviews Ev Based Nurs. 2023;20(4):377-400. doi: 10.1111/wvn.12615
16. 16 Davis AJ, Parker HM, Gallagher R. Gamified applications for secondary prevention in patients with high cardiovascular disease risk: A systematic review of effectiveness and acceptability. Journal of Clinical Nursing. 2021;30(19-20):3001-3010. doi: 10.1111/jocn.15808
17. 17 de Sá KC, Martins MG, da Costa CA, Barbosa JLV, da Rosa Righi R. A Mapping Study on Mobile Games for Patients of Chronic Diseases. J Med Syst. 2017;41(9):138. doi: 10.1007/s10916-017-0781-9
18. 18 Reinders EFH, de Vries R, Wouters – van Poppel PCM, Van Riel NAW, Haak HR. Serious digital games for diabetes Mellitus: A scoping review of its current State, Accessibility, and functionality for patients and healthcare providers. Diabetes Research and Clinical Practice. 2024;216:111833. doi: 10.1016/j.diabres.2024.111833
19. 19 Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi: 10.1136/bmj.n71
20. 20 Rethlefsen ML, Kirtley S, Waffenschmidt S, Ayala AP, Moher D, Page MJ, et al. PRISMA-S: an extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews. Syst Rev. 2021;10(1):39. doi: 10.1186/s13643-020-01542-z
21. 21 Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019:l4898. doi: 10.1136/bmj.l4898
22. 22 Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016:i4919. doi: 10.1136/bmj.i4919
23. 23 Diehl LA, Souza RM, Gordan PA, Esteves RZ, Coelho ICM. InsuOnline, an Electronic Game for Medical Education on Insulin Therapy: A Randomized Controlled Trial With Primary Care Physicians. J Med Internet Res. 2017;19(3):e72. doi: 10.2196/jmir.6944
24. 24 Cruvinel-Júnior RH, Ferreira JSSP, Veríssimo JL, Monteiro RL, Silva ÉQ, Suda EY, et al. Affordable web-based foot–ankle exercise program proves effective for diabetic foot care in a randomized controlled trial with economic evaluation. Sci Rep. 2024;14(1):16094. doi: 10.1038/s41598-024-67176-6
25. 25 Silva TFD, França ACLD, Souza MFD, Silva AS. A single session of active video game play promotes post-exercise hypotension in hypertensive middle-aged subjects. Hum Mov. 2018;19(2):82-89. doi: 10.5114/hm.2018.74063
26. 26 da Silva TF, Cirilo-Souza MDS, de Souza MF, Veloso Neto G, dos Santos MAP, Silva AS. Energy demand in an active videogame session and the potential to promote hypotension after exercise in hypertensive women. PLoS ONE. 2018;13(12):e0207505. doi: 10.1371/journal.pone.0207505
27. 27 SILVA T, SOUSA M, SOUZA M, BASTOS V, VELOSO NETO G, SILVA A. Dispendio Energético do Video Game Ativo pode ser suficiente como Exercício Físico para o Tratamento da Hipertensão Arterial: Estudo Piloto. Rev bras ciênc Saúde. 2015;19(Supl.2):59-66. doi: 10.4034/rbcs.2015.19.s2.09
28. 28 Gomes JLDB, Vancea DMM, Cappato de Araújo R, Soltani P, Guimarães FJDSP, Costa MDC. Cardiovascular and Enjoyment Comparisons after Active Videogame and Running in Type-1 Diabetics: A Randomized Crossover Trial. Games for Health Journal. 2021;10(5):g4h.2020.0209. doi: 10.1089/g4h.2020.0209
29. 29 Luiz de Brito Gomes J, Soltani P, Barbosa RR, Gomes JAF, Costa MDC. Is rating of perceived exertion a valid method for monitoring exergaming intensity in type-1 diabetics? A cross-sectional randomized trial. Journal of Bodywork and Movement Therapies. 2023;36:432-437. doi: 10.1016/j.jbmt.2023.05.018
30. 30 Brito-Gomes JLD, Barbosa RR, Nunes SMS, Ferreira GBS, Costa MDC. Do estimated metabolic equivalent and energy expenditure verify the physical effort of type-1 diabetics in resting and exercise situations? A randomized crossover trial. Rev Bras Ciênc Esporte. 2022;44:e000222. doi: 10.1590/rbce.44.e000222
31. 31 de Brito-Gomes JL, Vancea DMM, Soltani P, Reis ARR, Costa MC. 24-hour blood response comparison between exergaming and aerobic exercise in type-1 diabetes: A randomised study. Science & Sports. 2025;40(8):661-669. doi: 10.1016/j.scispo.2025.07.009
32. 32 Diehl LA, Gordan PA, Esteves RZ, Coelho ICMM. Effectiveness of a serious game for medical education on insulin therapy: a pilot study. Arch Endocrinol Metab. 2015;59(5):470-473. doi: 10.1590/2359-3997000000118
33. 33 Diehl LA, de Souza RM, Gordan PA, Esteves RZ, Coelho ICM. User Assessment of “InsuOnLine,” a Game to Fight Clinical Inertia in Diabetes: A Pilot Study. Games for Health Journal. 2015;4(5):335-343. doi: 10.1089/g4h.2014.0111
34. 34 Cechetti NP, Bellei EA, Biduski D, Rodriguez JPM, Roman MK, De Marchi ACB. Developing and implementing a gamification method to improve user engagement: A case study with an m-Health application for hypertension monitoring. Telematics and Informatics. 2019;41:126-138. doi: 10.1016/j.tele.2019.04.007
35. 35 Ferreira JSSP, Sacco ICN, Siqueira AA, Almeida MHM, Sartor CD. Rehabilitation technology for self-care: Customised foot and ankle exercise software for people with diabetes. PLoS ONE. 2019;14(6):e0218560. doi: 10.1371/journal.pone.0218560
36. 36 Sparapani VDC, Fels S, Nascimento LC. The Value of Children's Voices for a Video Game Development in the Context of Type 1 Diabetes: Focus Group Study. JMIR Diabetes. 2017;2(2):e17. doi: 10.2196/diabetes.7652
37. 37 Sparapani VDC, Fels S, Kamal N, Nascimento LC. Conceptual framework for designing video games for children with type 1 diabetes. Rev Latino-Am Enfermagem. 2019;27:e3090. doi: 10.1590/1518-8345.2764.3090
38. 38 Sparapani VDC, Fels S, Kamal N, Ortiz La Banca R, Nascimento LC. A Video Game for Brazilian T1D Children about Knowledge of Disease and Self-care: A Methodological Study. J Diabetes Sci Technol. 2022;16(6):1444-1450. doi: 10.1177/19322968211017555
39. 39 Sparapani VC, Petry ADS, Barber ROLB, Nascimento LC. Prototyping Process and Usability Testing of a Serious Game for Brazilian Children With Type 1 Diabetes. Comput Inform Nurs. 2023;41(12):941-948. doi: 10.1097/cin.0000000000001030
40. 40 Serafim ARRDM, Silva ANS, Alcântara CMD, Queiroz MVO. Construção de serious games para adolescentes com diabetes mellitus tipo 1. Acta paul enferm. 2019;32(4):374-381. doi: 10.1590/1982-0194201900052
41. 41 Jiménez ASA, Ramírez NAB, Santana-Mancilla PC, Romero JCM, Acosta-Díaz R. Heuristic Evaluation of a Gamified Application for Education in Patients with Diabetes. Proceedings of the 7th Mexican Conference on Human-Computer Interaction. 2018:1-4. doi: 10.1145/3293578.3293593
42. 42 Arce-Jiménez AS, Barón-Ramírez N, Contreras-Castillo JJ. Aplicación gamificada para apoyo en la educación de personas con diabetes. Avances en IHC. 2018;3(1):83-87. doi: 10.47756/aihc.y3i1.54
43. 43 Ribeiro K, De Oliveira Silva EJ, De Souza Filho RP, Vilela Cerqueira T, Gomes de Siqueira E, Sebba Tosta de Souza DM. Educação em saúde sobre pé diabético: jogo educativo. rsc. 2024;7(1):136-167. doi: 10.61411/rsc202410117
44. 44 Riva G, Dores W, Damasio A, Cacione DG, Jorge J, Zorzal E. Virtual Reality applied to medical education and training on Diabetic Foot. 2023 IEEE Conference on Virtual Reality and 3D User Interfaces Abstracts and Workshops (VRW). 2023:174-177. doi: 10.1109/vrw58643.2023.00043
45. 45 Vorwerg-Gall S, Stamm O, Haink M. Virtual reality exergame in older patients with hypertension: a preliminary study to determine load intensity and blood pressure. BMC Geriatr. 2023;23(1):527. doi: 10.1186/s12877-023-04245-x
46. 46 Brasil IA, Silva JCPL, Pescatello LS, Farinatti P. Central and peripheral mechanisms underlying postexercise hypotension: a scoping review. J Hypertens. 2024;42(5):751-763. doi: 10.1097/hjh.0000000000003702
47. 47 Halliwill JR, Buck TM, Lacewell AN, Romero SA. Postexercise hypotension and sustained postexercise vasodilatation: what happens after we exercise?. Experimental Physiology. 2013;98(1):7-18. doi: 10.1113/expphysiol.2011.058065
48. 48 Hou HY, Chen J, Hai L, Wang P, Zhang JX, Li HJ. Effects of exergame and bicycle exercise intervention on blood pressure and executive function in older adults with hypertension: A three-group randomized controlled study. Experimental Gerontology. 2023;173:112099. doi: 10.1016/j.exger.2023.112099
49. 49 Hernandez-Martinez J, Perez-Carcamo J, Melki H, Cid-Calfucura I, Vasquez-Carrasco E, Delgado-Floody P, et al. Effects of Exergaming on Morphological Variables, Biochemical Parameters, and Blood Pressure in Children and Adolescents with Overweight/Obesity: A Systematic Review with Meta-Analysis of Randomized Controlled Trials. Children. 2024;12(1):29. doi: 10.3390/children12010029
50. 50 Martos-Cabrera MB, Membrive-Jiménez MJ, Suleiman-Martos N, Mota-Romero E, Cañadas-De la Fuente GA, Gómez-Urquiza JL, et al. Games and Health Education for Diabetes Control: A Systematic Review with Meta-Analysis. Healthcare. 2020;8(4):399. doi: 10.3390/healthcare8040399
51. 51 Burgon T, Casebeer L, Aasen H, Valdenor C, Tamondong-Lachica D, de Belen E, et al. Measuring and Improving Evidence-Based Patient Care Using a Web-Based Gamified Approach in Primary Care (QualityIQ): Randomized Controlled Trial. J Med Internet Res. 2021;23(12):e31042. doi: 10.2196/31042
52. 52 Debon R, Bellei EA, Biduski D, Volpi SS, Alves ALS, Portella MR, et al. Effects of using a mobile health application on the health conditions of patients with arterial hypertension: A pilot trial in the context of Brazil’s Family Health Strategy. Sci Rep. 2020;10(1):6009. doi: 10.1038/s41598-020-63057-w
53. 53 Silveira DV, Marcolino MS, Machado EL, Ferreira CG, Alkmim MBM, Resende ES, et al. Development and Evaluation of a Mobile Decision Support System for Hypertension Management in the Primary Care Setting in Brazil: Mixed-Methods Field Study on Usability, Feasibility, and Utility. JMIR Mhealth Uhealth. 2019;7(3):e9869. doi: 10.2196/mhealth.9869
54. 54 Charlier N, Zupancic N, Fieuws S, Denhaerynck K, Zaman B, Moons P. Serious games for improving knowledge and self-management in young people with chronic conditions: a systematic review and meta-analysis. J Am Med Inform Assoc. 2016;23(1):230-239. doi: 10.1093/jamia/ocv100
55. 55 Nishi SK, Kavanagh ME, Ramboanga K, Ayoub-Charette S, Modol S, Dias GM, et al. Effect of digital health applications with or without gamification on physical activity and cardiometabolic risk factors: a systematic review and meta-analysis of randomized controlled trials. eClinicalMedicine. 2024;76:102798. doi: 10.1016/j.eclinm.2024.102798