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 8 Summary of results for other movement behaviour indicators organized by study design

No. of participants (No. of studies)	Design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other	Absolute effect	Quality
6051 (14) [43, 49,50,51,52, 78, 79, 111, 125, 128,129,130,131,132]	Clustered RCT	No serious risk of bias	No serious risk of inconsistency	Very serious risk of indirectness^a	No serious risk of imprecision	None	Overall: • 4/14 studies reported null findings • 2/14 studies reported more sedentary behaviour unfavourable for health • 8/14 studies reported mixed findings • 7: More sedentary behaviour null and unfavourable for health • 1: More sedentary behaviour favourable, null, and unfavourable for health Active breaks: • 1/1 study reported mixed findings^b • 1: More sedentary behaviour null and unfavourable for health [78] Active lessons: • 1/3 studies reported more sedentary behaviour unfavourable for health [111] • 2/3 studies reported mixed findings^c • 1: More sedentary behaviour favourable, null, and unfavourable for health [79] • 1: More sedentary behaviour null and unfavourable for health [129] Additional PA: • 2/6 studies reported null findings [43, 49] • 1/6 studies reported more sedentary behaviour unfavourable for health [128] • 3/6 studies reported mixed findings^d • 3: More sedentary behaviour null and unfavourable for health [50, 125, 130] Recess/PE: • 1/1 studies reported null findings [51] Standing Desk: • 1/3 studies reported null findings [52, 132] • 2/3 studies reported mixed findings^e • 1: More sedentary behaviour null and unfavourable for health [131]	Low
336 (3) [98, 133, 134]	Cross-Over Trial	Very serious risk of bias^f	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 1/3 studies reported more sedentary behaviour unfavourable for health • 2/3 studies reported mixed findings • 2: More sedentary behaviour null and unfavourable for health Active Lessons: • 1/1 study reported mixed findings^g • 1: More sedentary behaviour null and unfavourable for health [134] Standing Desks: • 1/2 studies reported more sedentary behaviour unfavourable for health [133] • 1/2 studies reported mixed findings^h • 1: More sedentary behaviour null and unfavourable for health [98]	Low
4392 (14) [44, 53,54,55,56, 85, 86, 115, 135,136,137,138,139]	Non-Randomised Intervention	Serious risk of biasⁱ	No serious risk of inconsistency	No serious risk of indirectness	Serious risk of imprecision^j	None	Overall: • 1/14 studies reported null findings • 4/14 studies reported more sedentary behaviour unfavourable for health • 9/14 studies reported mixed findings • 6: More sedentary behaviour null and unfavourable for health • 3: More sedentary behaviour favourable, null, and unfavourable for health Active breaks: • 2/3 studies reported more sedentary behaviour unfavourable for health [56, 115] • 1/3 studies reported mixed findings^k • 1: More sedentary behaviour null and unfavourable for health [136] Active Lessons: • 1/1 studies reported mixed findings^l • 1: More sedentary behaviour null and unfavourable for health [137] Recess/PE: • 2/2 studies reported mixed findings^m • 2: More sedentary behaviour favourable, null, and unfavourable for health [53, 138] Standing desk: • 1/8 studies reported null findings [44, 54, 86, 139] • 2/8 studies reported more sedentary behaviour unfavourable for health [55, 135] • 5/8 studies reported mixed findingsⁿ • 4: More sedentary behaviour null and unfavourable for health [44, 54, 86, 139] • 1: More sedentary behaviour favourable, null, and unfavourable for health [85]	Very Low
35,835 (5) [42, 57, 115, 140, 141]	Longitudinal	Serious risk of bias^o	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 1/5 studies reported null findings • 1/5 studies reported more sedentary behaviour unfavourable for health • 3/5 studies reported mixed findings • 3: More sedentary behaviour null and unfavourable for health Active breaks: • 1/1 studies reported mixed findings^p • 1: More sedentary behaviour null and unfavourable for health [115] Homework: • 1/3 studies reported more sedentary behaviour unfavourable for health [42] • 2/3 studies reported mixed findings^q • 2: More sedentary behaviour null and unfavourable for health [57, 141] Recess/PE: • 1/2 studies reported null findings [140] • 1/2 studies reported mixed findings^r • 1: More sedentary behaviour null and unfavourable for health [115]	Very Low
299,148 (25) [42, 45, 62, 71, 74, 75, 91, 93, 94, 108, 121, 123, 137, 140, 142,143,144,145,146,147,148,149,150,151,152]	Cross-sectional	Serious risk of bias^s	No serious risk of inconsistency	No serious risk of indirectness	No serious risk of imprecision	None	Overall: • 3/25 studies reported null findings • 5/25 studies reported more sedentary behaviour unfavourable for health • 2/25 studies reported more sedentary behaviour favourable for health • 15/25 studies reported mixed findings • 10: More sedentary behaviour null and unfavourable for health • 1: More sedentary behaviour favourable, null and unfavourable for health • 2: More sedentary behaviour favourable and unfavourable for health • 2: More sedentary behaviour favourable and null for health • 4: Mixed findings included dose response relationships Homework: • 2/18 studies reported null findings [123, 142] • 2/18 studies reported more sedentary behaviour unfavourable for health [42, 143] • 2/18 studies reported more sedentary behaviour favourable for health [121, 146] • 12/18 studies reported mixed findings^t • 7: More sedentary behaviour null and unfavourable for health [62, 74, 91, 147,148,149,150] • 2: More sedentary behaviour null and favourable for health [93, 151] • 2: More sedentary behaviour favourable and unfavourable for health [94, 152] • 1: More sedentary behaviour favourable, null, and unfavourable for health [108] • 3: Mixed findings included dose response relationships with unfavourable associations for ≥3 h/day and 2–3 h/day, favourable for 1–3 h/day, and null for 1–2 h/day and 2–3 h/day [149, 150, 152] Recess/PE: • 1/4 studies reported null findings [140] • 1/4 studies reported more sedentary behaviour unfavourable for health [144] • 2/4 studies reported mixed findings^u • 2: More sedentary behaviour null and unfavourable for health [75, 137] Sedentary time: • 2/3 studies reported more sedentary behaviour unfavourable for health [71, 145] • 1/3 studies reported mixed findings^v • 1: More sedentary behaviour null and unfavourable for health [45] • 1: Mixed findings included dose response relationships with unfavourable for all comparisons between not sedentary and most sedentary, null for comparisons with less and more sedentary to most sedentary [45]	Very Low

Mean age at baseline ranged from 6.0 to 17.0 years; when mean age was not reported age or grade range minimums were 9.0 years and grade 1 and range maximums were 19.0 years and grade 12. Study designs included clustered RCT, cross-over trial, non-randomized intervention, and longitudinal with up to 7 years follow-up, and cross-sectional. Other movement behaviour indicators were assessed objectively for physical activity during and outside of school (heart rate 50–59.9% of max, heart rate ≥ 60% of max, light-intensity physical activity, metabolic equivalent(MET)-minutes, METs < 3, METs ≥3, moderate-intensity physical activity, moderate- to vigorous-intensity physical activity, physical activity guideline adherence, sit-to-stand transitions, standing time, stepping time, steps/day guideline adherence, total steps, total accelerometer x counts during field trip, total accelerometer y counts during field trip, total accelerometer counts per minute, total physical activity, and vigorous-intensity physical activity, using ActiGraph GT1M/GT3X/GT3X+/WGT3X-BT/GT9X Link accelerometers, ActivPAL/3/3C/micro accelerometers, Axivity AX3 accelerometers, Sensewear accelerometers, or Yamax Digi-Walker SW-200 pedometers), sedentary behaviours outside of school (sedentary time and sitting time, using ActiGraph GT3X and ActivPAL micro accelerometers), and sleep (sleep duration, using ActivPAL micro visual inspection and logsheets); or subjectively for physical activity during and outside of school (active videogames, activity usually, activity yesterday, days meeting physical activity guideline adherence, exercise habits, Godin Leisure-Time Exercise Questionnaire, leisure activity index, organized leisure physical activity, physical activity guideline adherence, Physical Activity Questionnaire-Children (PAQ-C), physical exercise index, total physical activity), sedentary behaviour outside of school (computer for communicating, computer for playing games, electronic videogames, mobile for communicationg, mobile for playing games, overall sedentary screen media usage, overall screen time, passive videogames, personal computer (PC) use, recreational screen time, screen based social networking, sedentary screen time, talking on the phone, television, texting, and video chatting), and sleep outside of school (bedroom-sharing, bedtime routine, daytime tiredness, daytime sleep, daytime sleepiness, difficulty initiating sleep, difficulty maintaining sleep, insomnia, school day bedtime, sleep duration, sleep guideline adherence, sleep hygiene [cognitive, emotional, physiological, and overall], sleep stability, and wake time)
^a 4/14 studies did not find an intervention effect on sedentary behaviours measures, and 6/14 studies did not report school-related sedentary behaviours
^b Null for sedentary vs light activity conditions, but unfavourable for sedentary vs moderate or vigorous conditions [78]
^c 1: Favourable and null and unfavourable findings [Unfavourable during the intervention, null for whole day (intervention and post-intervention periods), and after the intervention null, unfavourable, and favourable for LPA, MPA, and VPA, respectively [79]]; 1: null and unfavourable findings [1: Unfavourable for objectively assessed MPA and MVPA, null for VPA, LPA, and self-report PA [129]])
^d 3: Null and unfavourable [1: Overall unfavourable when compared to educational PA intervention group, null when compared to recreational PA intervention group [125]; 1: LPA group did not significantly differ, typical day unfavourable compared to MVPA group, restricted PA unfavourable compared to typical day, null effects for post-intervention compensation [130]; 1: Unfavourable for CPM, MVPA and Steps, but null for LPA; for boys null for CPM and LPA, unfavourable for MVPA and steps; for girls unfavourable for CPM, null for LPA, MVPA, and Steps [50]]
^e 2: Null and unfavourable [1: Unfavourable school-time MVPA, standing time and weekday standing time, null for all other context (outside school, school time, whole day weekends, whole day weekdays) and outcome (LPA, MVPA, standing, sitting, steps, sit-to-stand transitions, sleep) comparisons [131]; 1: Null associations for screen time, stepping time in secondary and primary school children, and standing time in secondary school children, but sedentary behaviour unfavourable for standing time in primary school children [132]]
^f No study randomized conditions
^g 1: null & unfavourable [1: unfavourable for all outcomes (MET-minutes, LPA, MPA, and VPA) at school A, B, and D, but school C null for LPA and VPA [134]
^h 1: Null & unfavourable [1: unfavourable for school day standing time, but null for full day sedentary time, LPA, MPA, and VPA [98]]
ⁱ 7/14 studies had control group in the same school/class, 8/14 studies insufficiently reported outcome results (e.g., only post values)
^j 4/14 studies did not report a school-related sedentary measure, 3/14 studies did not demonstrate an intervention effect
^k 1: Null and unfavourable [1: overall null for MVPA and TPA, unfavourable for LPA, all null for just overweight participants, unfavourable for LPA and TPA in normal weight participants, but null for MVPA [136]]
^l 1: Null and unfavourable [1: overall unfavourable when comparing intervention time to class time for LPA and MVPA, and when comparing intervention day to non-intervention day for LPA, but null when comparing intervention day to non-intervention day for MVPA [137]]
^m 2: Favourable, null, and unfavourable findings [1: favourable only occurred for leisure time outcomes, unfavourable only occurred for overall school time outcomes, null occurred across all domains (total, weekend, school-time, leisure time, PE, and recess) [138]; 1: Overall unfavourable for physical activity measure, but null for screen time; favourable for girls screen time, but null for girls PA; unfavourable for boys PA, but null for boys screen time [53]]; 1: Null and unfavourable [1: null for LPA when comparing PE days, unfavourable for all other combinations [137]]
ⁿ 5: null and unfavourable [2: some unfavourable findings for steps, but overall null (1 study, two experiments) [44]; 1: unfavourable for school time sit-to-stand transitions, but null for all other movement behaviours in class, in school and during waking hours [54]; 1: unfavourable for MVPA, but null for LPA [139]; 1: unfavourable for standing time, but null for steps [86]]; 1: Favourable, null, and unfavourable [1: favourable for after school stepping time, unfavourable for class time standing and stepping, but null for after school standing, and class time standing and stepping [85]])
^o Subjective measures of outcomes in 4/5 studies and exposures in 5/5 studies, with no evidence of psychometric testing
^p 1: Null and unfavourable [1: unfavourable for “ever” held active breaks and time spent in active breaks, but null for held active breaks in the past week and breaks > = 3 min/day [115]]
^q 2: Null and unfavourable [1: Null for changes in homework from time 1 to time 2, but unfavourable for time 1 homework [57]; 1: Unfavourable for senior high, but null for junior high [141]]
^r 1: Null and unfavourable [1: null for recess, but unfavourable for PE [115]]
^s 19/25 studies used subjective exposure measure with no psychometric testing
^t 7: null and unfavourable [1: Unfavourable for cram school attendance and weekend sleep duration, and weekday homework duration and weekday sleep, but null for all other weekday and weekend sleep and homework combinations and cram school attendance [147]; 1: Unfavourable for screen time, null for exercise habits [62]; 1: Unfavourable for some sleep quality aspects in older children, but null for all aspects in younger children [148]; 1: Dose response: More null associations for: weekdays (13/22 null associations) and 1–2 h of homework comparisons (8/10 null associations); more unfavourable associations for ≥3 and 2–3 h (both 7/10 unfavourable associations), and weekends (21/30 unfavourable associations) [149]; 1: Unfavourable screen time for girls and girls stressed about homework, and MVPA for boys and boys stressed about homework; Null for sleep, girls MVPA, boys not stressed about homework MVPA, boys screen time, and girls not stressed about homework screen time [74]; 1: Unfavourable for sleep, computer, overall sedentary screen time, and various other screen time; Null for passive and active videogames [91]; Dose response: generally unfavourable for aspects of sleep duration and quality at > 3 h of homework, null for 1–2 and 2–3 h of homework [150]]; 2: Null and favourable [1: Favourable for video games, talking on the phone, TV on weekdays; Null for TV on weekends, texting, video chatting [93]; 1: Favourable for homework on school nights, null for homework before school [151]]; 2: Favourable and unfavourable [1: Dose response: favourable for 1–3 h, unfavourable for > 3 h [152]; 1: Unfavourable for sleep and overall homework; Favourable for video games, talking on the phone, TV on weekdays, screen time on weekdays, sleep and weekday homework [94]; 1: Favourable, null, and unfavourable [1: Unfavourable for PC for boys, TV and weekday homework for boys, TV and weekday homework for girls, PC and weekday homework for girls, PC on weekend and homework on weekends for girls; favourable for TV and weekend homework for girls; null for all physical activity and homework combinations [108]]
^u 2: Null and unfavourable [1: Unfavourable only for LPA and MVPA during school split for boys and girls, but null for all other time, weight class, gender, and outcome comparisons (36 null comparisons) [75]; 1: Null when comparing days with and without PE, unfavourable for school-related sedentary behaviours for all other comparisons [137]]
^v 1: Null and unfavourable [Dose response: For fully adjusted analyses unfavourable for all comparisons between not sedentary and most sedentary, null for comparisons with less and more sedentary to most sedentary [45]])

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