School-related sedentary behaviours and indicators of health and well-being among children and youth: a systematic review

Kuzik, Nicholas; da Costa, Bruno G. G.; Hwang, Yeongho; Verswijveren, Simone J. J. M.; Rollo, Scott; Tremblay, Mark S.; Bélanger, Stacey; Carson, Valerie; Davis, Melanie; Hornby, Susan; Huang, Wendy Yajun; Law, Barbi; Salmon, Jo; Tomasone, Jennifer R.; Wachira, Lucy-Joy; Wijndaele, Katrien; Saunders, Travis J.

doi:10.1186/s12966-022-01258-4

International Journal of Behavioral Nutrition and Physical Activity

Table 3 Summary of results for cognitive indicators organized by study design

No. of participants (No. of studies)	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other	Absolute effect	Quality
3628 (7) [37, 43, 52, 77,78,79]	Clustered RCT	No serious risk of bias	No serious risk of inconsistency	Serious risk of indirectness^a	No serious risk of imprecision	None	Overall: • 4/7 studies reported null findings • 1/7 studies reported mixed findings • 1: More sedentary behaviour null and unfavourable for health • 2/7 studies compared types of sedentary behaviours Active breaks: • 1/1 study reported null findings [78] Active lessons: • 1/1 studies reported null findings [79] Additional PA: • 2/2 studies reported null findings [37, 43] Screen time: • 2/2 studies compared types of sedentary behaviours^b • 2: Tablet was favourable for health compared to usual classroom in both experiments/samples [77]. Standing desk: • 1/1 study reported mixed findings^c • 1: Null and unfavourable [52]	Moderate
615 (3) [80,81,82]	RCT	No serious risk of bias	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 1/3 study reported mixed findings • 1: More sedentary behaviour null and unfavourable for health • 2/3 studies compared types of sedentary behaviours Active breaks: • 1/1 studies reported mixed findings • 1: More sedentary behaviour null and unfavourable for health [Null compared to one activity break, but unfavourable compared to two activity breaks [80]] Screen time: • 2/2 studies compared types of sedentary behaviours^d • 2: Mix of favourable and null associations for educational tablet groups compared to non-educational tablet and typical classroom groups [81, 82]	High
200 (2) [83, 84]	Cross-Over Trial	No serious risk of bias	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Screen Time: • 2/2 studies compared types of sedentary behaviours • 1: Paper-based favourable for health when compared to screen-based [83] • 1: Paper-based favourable and null for health when compared to screen based [84]^e	High
277 (3) [85,86,87]	Non-Randomised Intervention	Serious risk of bias^f	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 2/3 studies reported null findings • 1/3 studies compared types of sedentary behaviours Standing desk: • 2/2 studies reported null findings [85, 86]^g Screen time: • 1/1 studies compared types of sedentary behaviours • 1: Class-based educational video games were favourable for the subject Math but null for Danish [87]	Very Low
13,715 (3) [40, 88, 89]	Longitudinal	Serious risk of bias^h	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	Dose Response	Homework: • 1/3 studies reported more homework favourable for health [88] • 2/3 studies reported mixed findingsⁱ • 2: More homework favourable and null for health • 2: Mixed findings included dose response relationships with favourable associations for “high homework” levels and > 121 min/day, and null associations for “medium homework” levels, 61–90 min/day, and 90–120 min/day [40, 89]	Very Low
270,810 (11) [62, 63, 68, 90,91,92,93,94,95,96,97]	Cross-sectional	Serious risk of bias^j	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 1/11 studies reported null findings • 1/11 studies reported more sedentary behaviour unfavourable for health • 6/11 studies reported more sedentary behaviour favourable for health • 3/11 studies reported mixed findings • 2: More sedentary behaviour favourable and null for health • 1: More sedentary behaviour favourable and unfavourable for health Homework: • 5/9 studies reported more homework favourable for health [62, 63, 92,93,94]^k • 1/9 studies reported more sedentary behaviour unfavourable for health [91] • 3/9 studies reported mixed findings^l • 2: More sedentary behaviour favourable and null for health [95, 96] • 1: More sedentary behaviour favourable and unfavourable for health [97] Recess/PE: • 1/1 studies reported null findings [90] Sedentary time: • 1/1 studies reported more sedentary time favourable for health [68]	Very Low

Mean age at baseline ranged from 7.0 to 14.9 years; when mean age was not reported age or grade range minimums were 10.0 years and grade 3 and range maximums were 18.0 years and grade 12. Study designs included clustered RCT, RCT, cross-over trials, non-randomised interventions, and longitudinal with up to 4 years follow-up, and cross-sectional. Cognitive indicators were assessed objectively by academic achievement (grade point average for Japanese, Mathematics, Social Studies, Sciences, English, Music, Arts, and Home Economics/Vocational Technology; Norwegian standardized national tests; General Certificate of Secondary Education exams scores (GCSEs); Grade point average; Language grade; Math grade; Math & language grade; Citizenship grade; Math grade; Spanish grade; Sciences grade; Average of Chinese, mathematics, English, and science standardized test scores; National Assessment Program - Literacy and Numeracy (NAPLAN); and Norwegian standardized national tests -Reading, English, and Numeracy), cognitive flexibility (Trail Making Test part B, Verbal Fluency, Dimensional Change Card Sort Test [NIH Toolbox]), episodic memory (Picture Sequence Test [NIH Toolbox], Wechsler Memory Scale [WMS-R] Logical Memory subtest], executive functions (mean of standardized scores for Trail Making Test part B, Verbal Fluency test, Stroop Color Word test, and Digit Span test), inhibitory control (Stroop test, Eriksen Flanker reaction time, Flanker Test [NIH Toolbox]), manual processing speed (Single-Finger-Tapping task), math abilities (study specific quiz, Early Grade Mathematics Assessment [EGMA], Heidelberger Rechen Test 1–4 [HRT]), mathematics conceptual understanding (study specific quiz), math curriculum knowledge (quiz items based on educational app), maths curriculum knowledge generalization (quiz items based on educational app), memory (study specific quiz), non-verbal reasoning (Matrix Reasoning test [Wechsler Intelligence Scale for Children fourth edition]), processing speed (Pattern Comparison Test [NIH Toolbox]), reading abilities (Early Grade Reading Assessment [EGRA]-Chichewa), selective attention (Sky Search’ subtest of the ‘Test of Selective Attention in Children’ [TEA-Ch]), short-term memory (Forward Spatial Span task, and Forward Digit Span task), verbal reasoning and verbal knowledge (British Abilities Scale Verbal Similarities), visual attention (Speeded Search task), and working memory (Digit Span test [Wechsler Intelligence Scale for Children fourth edition], Backward Digit Span task, Corsi Block Tapping test, and Figural Intersections task). Cognitive indicators were assessed subjectively through self-report of academic achievement (letter grades, percent scores, number of failed subjects, or relative to peers for English, Math, and across all subjects) and academic performance (ability to understand school lessons) or number of failed subjects overall), as well as teacher-report of academic achievement (general performance in Math and Danish)
^a Only 3/7 studies demonstrated an intervention effect for decreasing school-related sedentary behaviours
^b 1 study, but included 2 experiments that were treated as 2 separate studies
^c 1: Null & unfavourable [unfavourable for working memory, but null for non-verbal reasoning [52]]
^d 1: No difference for younger children or when split by gender, but educational tablet group was generally more favourable compared to non-educational tablet and typical classroom groups [81]; 1: educational tablet group favourable for math test score and visual attention when compared to non-educational tablet and typical classroom groups, but no differences between groups for short-term memory and manual processing speed [82]
^e 1: Paper-based favourable for most outcomes, but no difference for younger children and when compared to mobile screens [84]
^f 3/3 studies had high risk of reporting bias based on insufficient details reported for study variables
^g 1: Study reported a favourable finding at 4 months, but null at 8 months [85]
^h 3/3 studies had high risk for attrition bias with included participants differing from excluded participants for key variables
ⁱ 2: Favourable when comparing highest levels of homework (i.e., High homework levels and > 121 min/day) [1: only for English not Math [40]], but null when comparing lower levels of homework (i.e., medium homework levels, 90–120 min/day, and 61–90 min/day) [89]
^j 8/11 studies had high risk of performance bias, with no evidence of psychometric testing for subjective exposure measures
^k 1: favourable overall, but null relationships were seen for boys weekdays and girls weekend days [92]
^l 2: Favourable & null [1: Favourable when doing homework without computer, null when doing homework with computer [95], 1: Favourable for homework, null for cram school attendance [96]]; 1: Favourable & unfavourable [1: Favourable when looking at student time on homework, unfavourable when looking at mean school time on homework [97]]

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ISSN: 1479-5868

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