Systematic Review of Sedentary Behaviour Andhealth Indicators in School-Aged Children and Youth

Tremblay et al.
International Journal of Behavioral Nutrition and Physical Activity 2011, 8:98

http://www.ijbnpa.org/content/8/1/98
REVIEW Open Access
Systematic review of sedentary behaviour and

health indicators in school-aged children and youth
Mark S Tremblay1*, Allana G LeBlanc1, Michelle E Kho2, Travis J Saunders1, Richard Larouche1, Rachel C Colley1,
Gary Goldfield1 and Sarah Connor Gorber3
Abstract
Accumulating evidence suggests that, independent of physical activity levels, sedentary behaviours are associated
with increased risk of cardio-metabolic disease, all-cause mortality, and a variety of physiological and psychological
problems. Therefore, the purpose of this systematic review is to determine the relationship between sedentary
behaviour and health indicators in school-aged children and youth aged 5-17 years. Online databases (MEDLINE,
EMBASE and PsycINFO), personal libraries and government documents were searched for relevant studies examining
time spent engaging in sedentary behaviours and six specific health indicators (body composition, fitness, metabolic
syndrome and cardiovascular disease, self-esteem, pro-social behaviour and academic achievement). 232 studies
including 983,840 participants met inclusion criteria and were included in the review. Television (TV) watching was
the most common measure of sedentary behaviour and body composition was the most common outcome
measure. Qualitative analysis of all studies revealed a dose-response relation between increased sedentary behaviour
and unfavourable health outcomes. Watching TV for more than 2 hours per day was associated with unfavourable
body composition, decreased fitness, lowered scores for self-esteem and pro-social behaviour and decreased
academic achievement. Meta-analysis was completed for randomized controlled studies that aimed to reduce
sedentary time and reported change in body mass index (BMI) as their primary outcome. In this regard, a meta-
analysis revealed an overall significant effect of -0.81 (95% CI of -1.44 to -0.17, p = 0.01) indicating an overall decrease
in mean BMI associated with the interventions. There is a large body of evidence from all study designs which
suggests that decreasing any type of sedentary time is associated with lower health risk in youth aged 5-17 years. In
particular, the evidence suggests that daily TV viewing in excess of 2 hours is associated with reduced physical and
psychosocial health, and that lowering sedentary time leads to reductions in BMI.
Keywords: Inactivity, sitting, TV, body composition, fitness, metabolic syndrome, cardiovascular disease, self-esteem,
pro-social behaviour, academic achievement
Introduction enjoyed over the past century and efforts to counteract

Engaging in regular physical activity is widely accepted the inactivity and obesity crisis [15].
as an effective preventative measure for a variety of This inactivity crisis is especially important in the pedia-
health risk factors across all age, gender, ethnic and tric population as recent data from the Canadian Health
socioeconomic subgroups [1-6]. However, across all age Measures Survey [8] suggest that only 7% of children and
groups, levels of physical activity remain low [7-12] and youth aged 6-19 years participate in at least 60 minutes of
obesity rates continue to rise [10,11,13,14]; collectively moderate- to vigorous-intensity physical activity per day,
threatening the persistent increase in life expectancy thus meeting the current physical activity guidelines from
Canada [16], the U.S. [6], the U.K [17], Australia [18] and
the World Health Organization (WHO) [5]. However,
even for those children and youth who meet current
* Correspondence: mtremblay@cheo.on.ca guidelines, there remains 23 hours per day for school,
1
Healthy Active Living and Obesity Research, Children’s Hospital of Eastern
Ontario Research Institute. 401 Smyth Road, Ottawa, Ontario, K1H 8L1, sleep, work, and discretionary time. Several sources report
Canada that children and youth spend the majority of their
Full list of author information is available at the end of the article
© 2011 Tremblay et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Tremblay et al. International Journal of Behavioral Nutrition and Physical Activity 2011, 8:98 Page 2 of 22
discretionary time engaging in sedentary pursuits (e.g. All study designs were eligible (e.g. cross sectional, retro-
watching television (TV) or playing video games) spective, prospective, case control, randomized controlled
[8,19-28]. Canadian children and youth are spending an trial (RCT), longitudinal). Longitudinal studies were
average of 8.6 hours per day, or 62% of their waking hours included if the data presented in the article was consistent
being sedentary [8]. Similar trends are being reported in with the age limits that were set (i.e. if the study looked at
the U.S. where children and youth spend an average of 6-8 participants at age 10 and then again at age 30, only base-
hours per day being sedentary [22-28]. Accumulating evi- line measurements from age 10 were used).
dence shows that, independent of physical activity levels, Studies were included only if there was a specific mea-
sedentary behaviours are associated with increased risk of sure of sedentary behaviour. Eligible exposures of seden-
cardio-metabolic disease, all-cause mortality, and a variety tary behaviours included those obtained via direct (e.g.,
of physiological and psychological problems [29-31]. measurements of sitting, or low activity measured by
Therefore, to maximize health benefits, approaches to accelerometer) and self-reported (e.g., questionnaires
resolve the inactivity crisis should attempt to both increase asking about TV watching, video gaming, non-school
deliberate physical activity and decrease sedentary beha- computer use, and screen time - composite measures of
viours, especially in the pediatric population. However, to TV, video games, computers) methods. Sedentary beha-
date, public health efforts have focused primarily on physi- viour was often measured as a composite measure of all
cal activity and have paid little attention to the mounting time engaging in sedentary behaviours including screen
evidence to support sedentary behaviour as a distinct time outside of school hours. Six health indicators were
behaviour related to poor health. chosen based on the literature, expert input, and a desire
A recent scoping review identified review articles, to have relevant measures from a range of holistic health
meta-analyses, and grey literature that examined the rela- indicators (i.e. not only physical health, but also emo-
tionship between sedentary behaviour and health [32]. tional, mental and intellectual health). The six eligible
The large majority of this information reported on the indicators in this review were:
relationship between screen time and body composition
and did not include other indicators of health [23-25]. 1. Body composition (overweight/obesity measured
Furthermore, none of these reviews followed the rigorous by body mass index (BMI), waist circumference, skin
process of a systematic review and are therefore not able folds, bio-impedance analysis (BIA), dual-energy x-
to be used to inform the development of clinical practice ray absorptiometry (DXA or DEXA));
guidelines. As a result, to our knowledge, there are no 2. Fitness (physical fitness, physical conditioning,
systematic, evidence-based sedentary behaviour guide- musculoskeletal fitness, cardiovascular fitness);
lines for any age group, anywhere in the world. Guide- 3. Metabolic syndrome (MS) and cardiovascular dis-
lines that do exist are largely based on expert opinion or ease (CVD) risk factors (unfavourable lipid levels,
narrative literature reviews [33,34]. blood pressure, markers for insulin resistance or
Therefore, the purpose of this systematic review was to type 2 diabetes);
gather, catalog, assess and evaluate the available evidence 4. Self-esteem (self-concept, self-esteem, self
examining sedentary behaviours in relation to selected efficacy);
health outcomes in children and youth 5-17 years of age 5. Behavioural conduct/pro-social behaviour (child
and present a summary of the best available evidence. behaviour disorders, child development disorder, pro-
Specifically, the review presents available evidence for social behaviour, behavioural conduct, aggression);
minimal and optimal thresholds for daily sedentary time 6. Academic achievement (school performance,
in children and youth, and when possible, how thresholds grade-point average).
differ across health outcome or demographic status (i.e.
age, gender). The information gathered in this review can No Language or date limits were imposed in the
serve to guide future research and inform the development search. The following definitions were used to help
of evidence-based clinical practice guideline recommenda- guide the systematic review [31]:
tions for safe and healthy amounts of daily sedentary beha-
viour in the pediatric population. - Sedentary: A distinct class of behaviours (e.g. sitting,
watching TV, playing video games) characterized by
Methods little physical movement and low energy expenditure
Study Inclusion Criteria (≤ 1.5 METs).
The review sought to identify all studies that examined the - Sedentarism: Engagement in sedentary behaviours
relationship between sedentary behaviour and a specific characterized by minimal movement, low energy
health outcome in children and youth (aged 5-17 years). expenditure, and rest.
- Physically active: Meeting established physical Twelve key content experts were contacted and asked
activity guidelines (e.g. see Tremblay et al. 2011 for to identify the most influential papers from their perso-
Canadian Physical Activity Guidelines [16]). nal libraries examining sedentary behaviour and health
- Physical inactivity: The absence of physical activity, in the pediatric age group. Government documents
usually reflected as the proportion of time not from the U.S [6], the U.K. [17], and Australia [18] were
engaged in physical activity of a pre-determined used for reference and to help guide the review process.
intensity and therefore not meeting established phy-
sical activity guidelines. Data extraction
Standardized data extraction tables were created; data
extraction was completed by one reviewer (AL) and
Study Exclusion Criteria checked by another (one of GG, RC, RL, or TS) for
As the volume of literature on sedentary behaviour was accuracy. Information was extracted regarding study
anticipated to be very high, to control the feasibility of characteristics (i.e. year, study design, country, number
this project, the following sample size limits were set a of participants, age), type of sedentary behaviour, mea-
priori: population based studies (observational, cross sec- sure of sedentary behaviour (i.e. direct, or indirect), and
tional, cohort, and retrospective studies) were required to health outcome. Reviewers were not blinded to the
have a minimum sample size of 300 participants; RCTs, authors or journals when extracting data.
and intervention studies were required to have at least
30 participants. Studies of ‘active gaming’ (e.g., Nintendo Risk of bias assessment
Wii™, Microsoft Kinect™, Sony’s Playstation Move™, The Downs and Black checklist was used to asses study
video arcades, etc.) were excluded. Finally, studies that quality [35]. This 27 point checklist assesses the quality
defined sedentary behaviour as ‘failing to meet physical of reporting (e.g. “Are the main findings of the study
activity guidelines’ were excluded from the review. clearly described”); external validity (e.g. “Were the sub-
jects asked to participate representative of the entire
Search strategy population from which they were recruited”); internal
The following electronic bibliographic databases were validity (e.g. “Were subjects randomized to intervention
searched using a comprehensive search strategy to iden- groups”); and power (e.g. “Was there sufficient power
tify relevant studies: Ovid MEDLINE(R) (1950 to Febru- such that the difference being due to chance is less than
ary Week 2 2010), Ovid EMBASE (1980 to 2010 Week 5%”). The maximum score a study can receive is 32, with
07), and Ovid psycINFO (1806 to February Week 3 higher scores indicating better quality. Inter-rater relia-
2010). The search strategy was created by a single bility was calculated using Cohen’s kappa.
researcher (JM) and run by a second researcher (AL). Quality of evidence was determined by the study
The search strategies can be found in Additional file 1. design and by Downs and Black score. Level of evidence
The search was limited to studies looking at ‘school-aged’ was used to explain the quality of available studies and
children and youth (mean age of 5-17 years). Articles the confidence of the findings [36]. RCTs were consid-
were extracted as text files from the OVID interface and ered to have the highest level of evidence while anecdo-
imported in to Reference Manager Software (Thompson tal reports were considered to have the lowest evidence.
Reuters, San Francisco, CA). Duplicate articles were first See Table 1 for more details. When possible, studies
removed using Reference Manager Software, and any were examined for differences among age and gender
remaining duplicates were removed manually. All articles subgroups.
were given a unique reference identification number in
the database. Analysis
Titles and abstracts of potentially relevant articles A meta-analysis was performed with the data that were
were screened by two reviewers (AL and one of GG, sufficiently homogeneous in terms of statistical, clinical,
MT, RC, RL or TS) and full text copies were obtained and methodological characteristics using Review Man-
for all articles meeting initial screening by at least one ager Software 5.0 (The Cochrane Collaboration, Copen-
reviewer. Two independent reviewers examined all full hagen Denmark). Pooled estimates for the meta-analysis
text articles (AL and one of GG, MT, RC, RL or TS) and their 95% confidence intervals were obtained using
and any discrepancies were resolved by discussion and the random effects estimator of DerSimonian-Laird [37].
consensus between the two reviewers. If the reviewers Studies were weighted by the inverse of their variance.
were unable to reach consensus, a third reviewer was Cochrane’s Q was used to test for heterogeneity among
asked to look at the article in question. Consensus was studies and the I2 (squared) index [10] was used to deter-
obtained for all included articles. mine the degree of heterogeneity [38]. Funnel plots were
Table 1 Criteria for assigning level of evidence to a recommendation

Level of evidence Criteria
Level 1 - Randomized control trials without important limitations
Level 2 - Randomized control trials with important limitations
- Observational studies (non-randomized clinical trials or cohort studies) with overwhelming evidence
Level 3 - Other observational studies (prospective cohort studies, case-control studies, case series)
Level 4 - Inadequate or no data in population of interest
- Anecdotal evidence or clinical experience
Adapted from: Lau DC et al. 2007 [36]
used to assess publication bias (data not shown). Qualita- reporting on male-only data. Translators were contracted
tive syntheses were conducted for remaining studies. to read non-English articles and complete any necessary
data extraction for studies that met inclusion criteria
Results (n = 8).
Description of studies Of the 232 studies, 170 studies reported data on body
After de-duplication, the preliminary search of electronic composition, 15 on fitness, 11 on MS and CVD, 14 on
databases, reference lists, and grey literature identified self-esteem, 18 on pro-social behaviour, and 35 on aca-
5,291 potentially relevant articles (Figure 1). Of these, demic achievement. The majority of studies (n = 223)
3,299 were identified in MEDLINE, 1,016 in EMBASE, used indirect measures to assess sedentary behaviour (i.e.
912 in psycINFO, and 64 through key informants, gov- parent-, teacher-, or self-report questionnaires). There
ernment documents, and bibliographies. After a preli- were 14 studies [24,27,28,39-49] that directly measured
minary review of titles and abstracts, 828 articles were sedentary behaviour with accelerometers and one that
included for detailed assessment of the full text article. directly measured television viewing through a monitor-
Of these, 232 met the criteria for study inclusion (8 ing device [50]. The direction of the association between
RCTs, 10 intervention studies, 37 longitudinal studies increased sedentary behaviour and health outcomes were
and 177 cross sectional studies). Individual study charac- similar between direct and indirect measures. Meta-ana-
teristics can be seen in Table 2. Reasons for excluding lysis was conducted for RCTs examining change in body
studies included: ineligible population (e.g. ineligible age mass index.
or sample size) (n = 161), ineligible exposure (e.g. diet,
physical activity) (n = 145), ineligible measure of seden- Risk of bias assessment
tary behaviour (i.e. not meeting physical activity guide- Risk of bias assessment was completed for all included
lines) (n = 19), ineligible outcome (n = 60), ineligible studies (Additional file 2). The mean Downs and Black
analysis (e.g. analysis focused on content of screen time score was 20.7 (range = 16-26). The studies were then
versus duration of screen time, analysis focused on active split into groups and labeled as ‘high quality’ (score 23-
video gaming) (n = 60), and ‘other’ (n = 216) (e.g. com- 26, n = 36), ‘moderate quality’ (score 19-22, n = 169), and
mentary article or methodological paper). Some studies ‘lower quality’ (score 16-18, n = 27). Quality of study did
were excluded for multiple reasons. Some articles (n = 9) not affect the outcome of the study; in other words, both
could not be retrieved due to missing or incorrect refer- lower quality and high quality studies showed a positive
ence information. relationship between increased time spent sedentary and
Table 2 provides a summary of all studies included in health risk. Inter-reviewer assessment using the Downs
the review. The majority of the studies included in this and Black tool was very high (kappa = 0.98).
systematic review were cross sectional (n = 177). In total,
data from 983,840 participants were included in this Data Synthesis
review. Studies ranged from 30 participants in interven- Body composition
tion studies and RCTs, to 62,876 participants in cross Of the 232 studies included in this review, 170 examined
sectional observational investigations. Articles were pub- body composition, with the majority of these focusing on
lished over a 51 year period from 1958 to 2009, and the relationship between overweight and obesity and
included participants ranging from 2-19 years of age. time spent watching TV (Table 3). Body composition was
Although the scope of the review focused on those 5-17 measured in a variety of ways including body mass index
years of age, studies that had a range below 5 years or (BMI), sum of skin folds, percent body fat and various
over 17 years were not excluded as long as the mean age composite measures (e.g. BMI + sum of skin folds). Of
was between 5-17 years. Included studies involved parti- the 8 RCTs, 7 showed that decreases in sedentary time
cipants from 39 countries; there were a greater number lead to reductions in body weight (see meta-analysis
of articles reporting on female-only data than those below for details). Intervention studies reported desirable
Figure 1 Flow of information through the different phases of the review.
changes in body weight, BMI, and weight status among steeper increases in BMI, body weight and fat mass over
children and youth who successfully decreased their time [64-82], nine longitudinal studies reported no signif-
sedentary time [51-60]. Three intervention studies icant relationship between time spent sedentary and
[61-63] reported that although sedentary behaviour weight status or fat mass [61-63,83-89]. Of the 119 cross
decreased, there was no change in weight status (mea- sectional studies, 94 reported that increased sedentary
sured through BMI and skinfold thickness); however, time was associated with one or more of increased fat
these studies had relatively short follow-up periods mass, increased BMI, increased weight status and
(~1 year) and no control group leading the authors increased risk for being overweight [28,90-182]. Risk for
hypothesized that a longer follow up period was needed obesity increased in a dose response manner with
to detect a significant change in body composition. increased time spent engaging in sedentary behaviours
While nine-teen longitudinal studies reported that chil- [92,106,110,128, 156,178]. Twenty-five cross sectional
dren who watched greater amounts of TV at baseline saw studies reported no significant relationship between
Table 2 Summary of characteristics of included studies

n analyzed
First Author Year Country Grade Age Mean age Total Boys Girls Units of Exposure Outcome
Range sedentary
behaviour
RANDOMIZED CONTROLLED
TRIALS
Epstein LH [265] 1995 US 8-12 10.1 61 hour week TV BC
Epstein LH [50] 2008 US 4-7 6 70 37 33 hour day TV BC
Goldfield GS [264] 2006 Canada 8-12 10.4 30 13 17 min day TV BC
Gortmaker SL [57] 1995 US 11.7 1295 668 627 hour day TV BC
Hughes AR [262] 1991 Scotland 5-11 8.8 134 59 74 hour day SB BC
Robinson TN [58] 1999 US 192 hour week TV, GAMES BC
Robinson TN [221] 2003 US 8-10 9.5 61 0 61 hour week TV BC, SE
Shelton D [263] 2007 Australia 3-10 7.5 43 20 23 hour day TV BC
INTERVENTION STUDIES
Epstein LH [56] 2000 US 8-12 10.5 76 24 52 hour month SB, ST BC, FIT
Epstein LH [59] 2004 US 8-12 9.8 60 23 39 times week TV BC
Epstein LH [60] 2005 US 8-16 58 28 30 hour day SB, TV BC
Gentile DA [61] 2009 US 9.6 1323 685 674 hour day ST BC
Goldfield GS [52] 2007 Canada 8-12 10.4 30 13 17 hour day SB BC, SE
Harrison M [62] 2003 Ireland 10.2 312 177 135 min day TV, ST BC
Ochoa MC [53] 2007 Spain 6-18 11.6 370 196 174 hour week TV BC
Salmon J [51] 2008 Australia 1011 10.8 311 152 159 hour day TV BC
Simon C [54] 2002 France 11.7 954 468 486 hour day TV, COMP BC, SE
Tanasescu M [55] 2000 Puerto Rico 7-10 9.2 53 22 31 hour day TV BC
LONGITUDINAL STUDIES hour
Aires L [83] 2010 Portugal 11-19 345 147 198 hour day SCREEN BC, FIT
Berkey CS [76] 2003 US 10-15 11887 5120 6767 hour day TV, GAMES BC
Bhargava A [77] 2008 US 7635 min day TV BC
Blair NJ [68] 2007 England 5.5 591 287 304 hour day SB, TV BC
Borradaile KE [86] 2008 US 11.2 1092 501 591 hour week TV BC
Burke V [71] 2006 Australia 7.6/10.8 1569 630 648 hour week SCREEN BC
Chen JL [78] 2007 Chinese 7-8 7.52 307 147 160 hour day TV, GAMES BC
Danner FW [66] 2008 US 7334 3674 3660 hour day TV BC
Dasgupta K [215] 2006 Canada 12.7/15.1/ 662 319 343 hour week SB, TV MS
17.0
Day RS [85] 2009 US 8-14 556 277 279 min day TV BC
Dietz WH [181] 1985 US 12-17 2153 hour day TV BC
Elgar FJ [79] 2005 Wales 11.7 654 293 361 hour week TV BC
Elgar FJ [79] 2005 Wales 15.3 392 181 211 hour week TV BC
Ennemoser M [237] 2007 German 6-8 332 min day TV SE, AA
Fulton JE [84] 2009 US 10-18 472 245 227 min day TV BC
Gable S [70] 2007 US 8000 hour day TV BC
Hancox RJ [88] 2004 New Zealand 5-15 1013 hour day TV BC, MS
Hancox RJ [72] 2006 New Zealand 5-15 603 372 339 hour day SCREEN BC
Henderson VR [67] 2007 US 11-19 2379 0 2379 hour day TV, SCREEN BC
Hesketh K [80] 1997 Australia 5-10 7.6 1278 630 648 hour day SCREEN BC
Hesketh K [80] 1997 Australia 8-13 10.7 1278 630 648 hour day SCREEN BC
Hesketh K [64] 2009 Australia 5-10 7.7 1943 972 971 hour day TV, GAMES BC
Hesketh K [64] 2009 Australia 8-13 1569 816 753 hour day TV, GAMES BC
Jackson LA [223] 2009 US 12 500 235 265 hour day COMP, SE
SCREEP
Jago R [82] 2005 US 5-6 6.5 138 65 73 min hr SB, TV BC
Janz KF [73] 2005 US 5.6/8.6 378 176 202 hour day SCREEN BC
Johnson JG [41] 2007 US hour day TV AA
Table 2 Summary of characteristics of included studies (Continued)

Kaur H [75] 2003 US 12-17 2223 1149 1074 hour day TV BC
Lajunen HR [128] 2007 Finland 15-19 5184 hour SB BC
Lonner W [238] 1985 US 9-19 14.2 367 hour day TV AA
Maffeis C [89] 1998 Italy 8.7 298 148 150 min day SCREEN BC
Mistry K [229] 2007 US hour day TV PRO
Mitchell JA [49] 2009 UK 11-12 11.8 5434 2590 2844 hour day SB BC, FIT
Must A [87] 2007 US 10-17 156 0 156 hour day SB, SCREEN BC
O’Brien M [69] 2007 US 2-12 653 hour week TV BC
Parsons TJ [74] 2005 England/Scotland/Wales 11/16 17733 hour day TV BC
Purslow LR [63] 2008 England 8-9 345 176 169 min day SB BC
Timperio A [65] 2008 Australia 10-12 344 152 192 times week SB, SCREEN BC
Treuth MS [29] 2007 US 11.9 984 0 984 min day SB BC
Treuth MS [27] 2009 US 13.9 984 0 984 min day SB BC
Wosje,K.S [205] 2009 US 6.75-7.25 214 hour day SCREEN FIT
CROSS SECTIONAL STUDIES
Al SH [192] 2009 International 12-18 17715 8503 9212 hour day TV BC
Albarwani S [207] 2009 Oman 15-16 529 245 284 hour week TV, COMP FIT
Alves JG [191] 2009 Brazil 7-10 733 407 326 hour day TV BC
Aman J [218] 2009 Sweden 11-18 14.5 2093 1016 991 hour week TV, COMP MS
Andersen LF [155] 2005 Norway 8-14 1432 702 730 hour day TV BC
Andersen RE [142] 1998 US 8-16 4063 1985 2071 hour day TV BC
Anderson SE [103] 2008 US 4-12 8 2964 1509 1455 hour day TV BC
Armstrong CA [213] 1998 US 9.28 588 304 284 hour day TV FIT
Asante PA [183] 2009 US 3-13 8.5 324 182 142 hour day SCREEN BC
Aucote HM [163] 2009 Australia 5-6 11.09 393 198 195 hour week TV, GAMES BC
Barlow SE [151] 2007 US 6-17 12.1 52845 hour day TV BC
Basaldua N [109] 2008 Mexico 6-12 8.9 551 278 273 hour day TV BC
Bellisle F [123] 2007 France 9-11 1000 500 500 hour day TV BC
Berkey CS [90] 2000 US Sep-14 10769 4620 6149 hour day TV BC
Beyerlein A [105] 2008 Germany 4.5-7.3 4967 2585 2382 hour day TV BC
Boone JE [164] 2007 US 15.9 9155 4879 4276 hour week SCREEN BC
Boone-Heinonen J [104] 2008 US 11-21 9251 hour SB BC
Boutelle KN [130] 2007 US 16-18 1726 890 836 hour day TV BC
Brodersen NH [235] 2005 England 11.8 4320 2578 1742 hour week SB SE, PRO
Bukara-Radujkovic G 2009 Bosnia 11-12 11.5 1204 578 626 hour day TV, COMP BC
[96]
Butte NF [119] 2007 US 6-17 10.8 897 441 456 hour day SCREEN BC
Caldas S [245] 1999 US 4-19 34542 hour day TV AA
Carvalhal MM [131] 2007 Portugal 10-11 3365 1755 1610 hour day TV, COMP BC
Chaput J [154] 2006 Canada 5-10 6.6 422 211 211 hour day SCREEN BC
Chen MY [78] 2007 Taiwan 13-18 15.03 660 351 309 hour day TV, COMP BC, SE,
PRO
Chowhan J [232] 2007 Canada 12-15 2666 hour day TV PRO
Christoforidis A [95] 2009 Greece 4-18 11.41 1549 735 814 hour day SCREEN BC, FIT
Collins AE [149] 2008 Indonesia 12-15 1758 815 916 hour day TV, COMP BC
Colwell J [200] 2003 Japan 12-13 305 159 146 hour day SCREEN BC, PRO
Cooper H [247] 1999 US 7-11 424 225 199 hour day TV AA
Crespo CJ [177] 2001 US 8-16 4069 1994 2075 hour day TV BC
Da CR [157] 2003 Brazil 7-10 446 107 107 hour day TV BC
Dasgupta K [215] 2007 Canada 13-17 1267 hour week SCREEN MS
Delva J [125] 2007 US 11265 5274 5991 hour week TV BC
Dietz WH [181] 1985 US 12-17 6671 hour day TV AA
Dietz WH [181] 1985 US 6-11 6965 hour day TV BC, AA
Dollman J [211] 2006 Australia 6 10-11 843 439 404 min Day TV FIT

Dumais SA [255] 2009 US 10-12 15850 hour TV AA
Dominick JR [225] 1984 US 10, 11 14-18 250 110 140 hour Day TV, GAME SE, PRO
Eisenmann JC [175] 2002 US 14-18 15143 hour day TV BC
Eisenmann JC [113] 2008 US’ 16.2 12464 6080 6384 hour day TV BC
Ekelund U [134] 2006 Europe 9-16 1921 911 1010 hour day TV BC, MS
Fetler M [249] 1984 US 6 10603 hour day SCREEN AA
Forshee RA [201] 2004 US 12-16 14 2216 1075 1141 hour day TV BC
Forshee RA [188] 2009 US 5-18 1459 734 725 hour week SCREEN BC
Gaddy GD [257] 1986 US 5074 hour day TV AA
Giammattei J [140] 2003 US 11-14 12.6 385 186 199 hour day TV BC
Gibson S [156] 2004 England 7-18 1294 655 639 min day TV BC
Gomez LF [150] 2007 Colombia 5-12 11137 5539 5598 hour day TV, GAMES BC
Gordon-Larsen P [176] 2002 US 11-19 15.9 12759 6290 6496 hour week TV, GAMES BC
Gortmaker SL [143] 1996 US 10-15 11.5 746 388 358 hour day TV BC
Gortmaker SL [57] 1999 US 6-11 1745 min week TV SE, AA
Gortmaker SL [57] 1999 US 12-17 1745 min week TV SE, AA
Graf C [167] 2004 Germany 6.8 344 177 167 hour day TV, COMP BC
Grusser SM [40] 2005 Germany 6 11.83 323 175 148 hour day TV AA
Hardy LL [133] 2006 Australia 11-15 2750 1446 1304 hour day SCREEN FIT
Hernandez B [178] 1999 Mexico 9-16 461 244 217 hour day TV BC
Hirschler V [144] 2009 Argentina 7-11 8.9 330 168 162 hour day TV BC
Holder MD [222] 2009 Canada 8-12 375 252 262 hour day SCREEN SE
Hume C [190] 2009 Netherlands 13 580 277 303 hour day SCREEN BC
Islam-Zwart K [195] 2008 US 480 198 282 hour day TV BC
Jackson LA [223] 2009 US 12.18 515 259 256 hour day GAMES, AA
COMP
Janssen I [166] 2004 Canada 11-16 5890 2812 3078 hour day TV, COMP BC
Janz K [174] 2002 US 4-6 5.3 462 216 246 hour day TV BC
Jaruratanasirikul S [241] 2009 Thailand 7-12 15.9 1492 562 929 hour GAMES AA
Johnson CC [41] 2007 US 12 1397 0 1397 hour day SB SE
Katzmarzyk PT [197] 1998 Canada 9-18 784 423 361 min day TV BC, FIT
Katzmarzyk PT [184] 1998 Canada 640 356 284 hour day TV BC, FIT
Kautiainen S [135] 2005 Finland 14-18 6515 2916 3599 hour day SCREEN BC
Keith TZ [256] 1986 US high school seniors 28051 hour day TV AA
Klein-Platat C [165] 2005 France 12 2714 1357 1357 hour week SB BC
Kosti RI [196] 2007 Greece 12-17 2008 1021 987 hour day TV BC
Kristjansson AL [243] 2009 Iceland 14-15 5810 2807 3004 hour day TV AA
Kuntsche E [230] 2006 International 11-15 31177 hour day TV PRO
Kuriyan R [117] 2007 India 6-16 598 324 274 hour day TV BC
Lagiou A [160] 2008 Greece 10-12 633 316 317 hour day TV, GAMES BC
Lajous M [92] 2009 Mexico 11-18 13.9 9132 3519 5613 hour day TV BC
Lajunen HR [128] 2007 Finland 17.6 4098 1981 2117 hour week COMP BC
Lasserre AM [116] 2007 Switzerland 10.1-14.9 12.3 5207 2621 2586 hour day TV BC
Laurson KR [107] 2008 US 7-12 709 318 391 hour week SCREEN BC
Lazarou C [217] 2009 Cyprus 11.7 622 306 316 hour day TV MS
Leatherdale ST [11] 2008 Canada 14-19 25416 12806 12610 hour day TV BC, PRO
Lioret S [127] 2007 France 3-14 1016 528 488 hour day SB, TV, COMP BC
Lobelo F [208] 2009 US 14-18 5210 0 5210 hour day SCREEN FIT
Lowry R [173] 2002 US 15349 7445 7828 hour day TV BC
Lutfiyya MN [118] 2007 US 5-17 7972 hour day TV BC
Maffeis C [114] 2008 Italy 8-10 9.3 1837 924 913 hour day TV BC
Mark AE [220] 2008 US 12-19 15.9 1803 1005 798 hour day TV BC, MS
McMurray RG [187] 2000 US 10-16 12.7 2389 1149 1240 hour day TV BC
Mihas C [193] 2009 Greece 12-17 14.4 2008 1021 987 hour day SCREEN BC

Mikolajczyk RT [194] 2008 Germany 11-17 13.5 4878 2433 2445 hour low/ SB BC
high
Moraes SA [135] 2006 Mexico 6-14 8.0/11.3 662 343 339 hour week
Morgenstern M [94] 2009 Germany/US 10-17 12.8 4810 2294 2516 hour day SCREEN BC
Morgenstern M [94] 2009 Germany/US 12-16 14 4473 2239 2234 hour day SCREEN BC
Mota J [199] 2006 Portugal 14.6 450 220 230 hour day TV, COMP BC
Muller MJ [179] 1999 Germany 5-7 1468 739 729 hour day TV BC
Nagel G [193] 2009 Germany 6-9 7.57 1079 498 hour day TV, GAMES BC
nastassea-Vlachou K 1996 Greece 6-13 4690 2279 2411 hour day TV AA
[240]
Nawal LM [148] 1998 US 5-18 62976 hour day TV, COMP BC
Nelson MC [233] 2006 US 7-12 11957 5979 5978 hour day SCREEN PRO
Neumark-Sztainer D 2004 US 11-18 14.9 4746 2382 2364 hour week TV SE, PRO
[224]
Nogueira JA [45] 2009 Brazil 8.3-16.8 13 326 204 122 hour day SB BC
Obarzanek E [180] 1994 US 9-10 10.1 2379 0 2379 hour week TV BC
Ohannessian CM [226] 2009 US 14-16 14.99 328 138 190 hour day SCREEN SE, PRO,
AA
Ortega FB [122] 2007 Spain 13-18.5 15.4 2859 1357 1502 hour day SB BC
Overby NC [219] 2009 Norway 6-19 723 375 348 min day TV
Ozmert E [42] 2002 Turkey 689 343 346 hour day TV PRO, AA
Padez C [99] 2009 Portugal 7-9 3390 1696 1694 hour day TV BC
Page RM [234] 2001 Philippine 15.1 3307 1267 1819 hour week TV PRO
Pate RR [210] 2006 US 12-19 15.4 3287 1686 1601 hour day TV FIT
Patrick K [169] 2004 US 11-15 12.7 878 407 471 min day TV BC
Pratt C [101] 2008 US 12 1458 223 1235 hour day SB BC
Purath J [185] 1995 US 3-5 365 189 176 hour day TV BC, MS
Ramos E [126] 2007 Portugal 13 2161 1045 1116 min week SB, TV, COMP BC
Rapp K [138] 2005 Germany 6.2 2140 1015 1125 hour day TV BC
Ridley-Johnson R [252] 1983 US 5-8 290 hour day TV AA
Roberts DF [250] 1984 US 539 hour week TV AA
Robinson TN [58] 1999 US 12.4 971 0 971 hour day TV BC
Ruangdaraganon N 2002 Thailand 6-12 9.4 4197 2126 2035 hour day TV BC
[141]
Russ SA [147] 2009 US 6-17 54863 28153 26710 hour day SCREEN BC, SE
Sakamoto A [236] 1994 Japan 4-6 307 165 142 times week GAMES PRO
Sakamoto A [236] 1994 Japan 4-6 537 287 250 hour week COMP, PRO
GAMES
Sakamoto A [236] 1994 Japan 4-5 118 118 0 hour week COMP, PRO
GAMES
Salmon J [136] 2006 Australia 5-12 1560 743 817 hour day TV BC
Sardinha LB [48] 2008 Portugal 9-10 9.8 308 161 147 hour day SB MS
Scott LF [254] 1958 US 6-7 407 hour TV AA
Sharif I [244] 2006 US 10-14 6522 3169 3353 hour day TV, GAMES PRO, AA
Sharif I [260] 2010 US 9-15 12 4508 2209 2299 hour day TV, GAMES AA
Shejwal B [246] 2006 India 16.05 654 368 286 hour day TV AA
Shields M [162] 2006 US/Can 2-17 8661 hour day SB, TV BC
Shin N [239] 2004 US 6-13 9 1203 605 598 min day TV AA
Singh GK [106] 2003 US 10-17 46707 24072 22635 hour day TV BC
Singh GK [106] 2003 US 10-17 46707 24072 22635 hour day TV BC
Skoric MM [258] 2009 Singapore 8-12 10 333 180 153 hour TV, GAMES AA
Smith BJ [161] 2007 Fiji 11-16 443 200 245 hour day TV BC
Spinks AB [124] 2007 Australia 5-12 518 282 236 min week SB, SCREEN BC
Steffen LM [98] 2009 US 8-11 526 256 270 hour day TV BC
Stettler N [168] 2004 Switzerland 8 872 410 462 hour day TV, GAMES BC

Sugiyama T [47] 2007 US 12-19 15.9 4508 2295 2213 hour day SB MS
Sun Y [91] 2009 Japan 12-13 . 5753 2842 2911 hour day TV BC
Taylor WC [158] 2002 US 6-15 11.1 509 231 278 kcal day SB BC
te Velde SJ [129] 2007 International 9-14 11.4 12538 6256 6282 hour day TV, COMP BC
Thompson AM [189] 2009 Canada 3, 7, 1777 795 982 min day TV BC
11
Toschke AM [112] 2008 Germany 5-6 4884 hour day TV BC
Toschke AM [121] 2007 Germany 5-6 5472 hour day TV BC
Trang NHHD [146] 2009 Australia 11-16 2660 1332 1328 hour day SCREEN BC
Tremblay MS [172] 2003 Canada 7-11 7261 hour day TV BC
Treuth MS [27] 2009 US 11-12 11.9 1579 0 1579 hour day SB BC
Tsai H [153] 2007 Taiwan 11-12 2218 1146 1072 hour day TV BC
Tsai H [145] 2009 Taiwan 11-12 1329 615 672 hour day SB, TV BC
Tucker LA [212] 1987 US 15.7 406 406 0 hour day TV FIT, SE,
PRO
Tucker LA [206] 1986 US 15.7 379 379 0 hour day TV FIT
Tucker LA [214] 1996 US 9-10 9.8 262 162 100 hour day TV FIT
Ussher MH [231] 1007 England 13-16 2623 hour day TV PRO, AA
Utter J [171] 2003 US 14.9 4480 2240 2240 hour day SCREEN BC
Utter J [152] 2007 New Zealand 5-14 1743 959 784 hour day TV, COMP BC
Vader AM [97] 2009 US 11, 7 11594 6162 5432 hour day TV BC
van Schie EG [261] 1997 Netherlands 10-14 11.5 346 171 175 hour day SCREEN PRO, AA
van Zutphen M [159] 2007 Australia 4-12 8 1926 939 987 min day TV BC
Vandewater EA [170] 2004 US 1-12 6 2831 1444 1387 hour day SB, SCREEN BC
Vaughan C [198] 2007 Australia 11-18 14 443 189 254 hour day SCREEN BC
Vicente-Rodriguez G 2008 Spain 13-18.5 1960 1012 948 hour day TV, GAMES BC
[110]
Violante R [137] 2005 Mexico 6-14 8624 258 4366 hour day TV BC
Wake M [186] 2003 Australia 5-13 9.1 2862 1445 1417 hour week SCREEN BC
Walberg HJ [251] 1984 US 2-6 13 2890 1445 1445 hour day TV AA
Walberg HJ [253] 1982 US 17 2001 1031 970 hour day TV AA
Waller CE [202] 2003 China 6-11 9 880 hour week TV BC
Wang Y [120] 2007 US 11.9 498 218 280 hour day SCREEN BC
Welch WW [248] 1986 Australia 3-4 9 9 1960 TV AA
Wells JC [108] 2008 Brazil 10-12 4452 2193 2258 hour day TV BC, MS
Whitt-Glover MC [24] 2009 US 6-19 749 351 398 min day SB BC
Wiggins J [227] 1987 US 4-12 483 252 231 min day TV SE, AA
Wolf AM [203] 1998 US 11-14 552 0 552 hour day TV BC
Wong SL [100] 2009 Canada 15.5 25060 12806 12254 hour day SB, SCREEN BC
Zabinski MF [132] 2007 US 11-15 878 425 453 hour day SB BC
SB, sedentary behaviour; TV, television viewing; COMP, computer time; GAME, video game playing; SCREEN, composite measure of 2 or more screen activities (i.e.
television viewing, computer time, or video game playing); BC, body composition; MS, measures of metabolic syndrome and/or cardiovascular disease (e.g.
insulin resistance, blood pressure); SE, self-esteem; PRO, pro-social behaviour; AA, academic achievement.
sedentary time and weight status [24,85,137,183-204]. Fitness

One study [131] reported an effect in boys but not girls Fifteen studies assessed the relationship between time
and one showed an effect in girls but not boys [139]. One spent engaging in sedentary behaviour and fitness (Table
study showed that among boys, being underweight was 4). Increased time spent being sedentary was associated
associated with more screen time [111]. The level of evi- with decreased scores for overall physical fitness, VO 2
dence reporting on the relationship between sedentary max, cardiorespiratory fitness, and musculoskeletal fit-
behaviour and body composition was of moderate quality ness. An intervention reported that targeting decreased
and was classified as Level 2 with a mean Downs and sedentary behaviour lead to increases in aerobic fitness
Black score of 20.6 (standard deviation: ± 1.9). [56]. This study (n = 13 boys and 26 girls, mean age =
Table 3 Summary table of results showing relation between sedentary behaviour and measures of body composition
Type of Number of Number of Narrative recommendation and main findings
Study Studies participants
RCT 8 1886 Reductions in sedentary behaviour are directly related to improved body composition.
Intervention 10 3547 TV watching and overweight/obesity were related in a dose-response manner (i.e. those who
watched more TV were more likely to be overweight/obese).
Longitudinal 33 85753 TV watching and overweight/obesity were related in a dose-response manner (i.e. those who
watched more TV were more likely to be overweight/obese).
Cross 119 691759 > 2 hrs of sedentary behaviour related to increased risk of being overweight or obese.
sectional
Total of all 170 782884 Meta-analysis was performed on randomized controlled studies that looked at change in BMI. They
studies found an effect of -0.89 kg/m2 (95% CI of -1.67 to -0.11, p = 0.03) decrease in mean BMI in the
intervention group.
> 2 hrs of sedentary behaviour per day is associated with an increased risk for overweight/obesity.
This risk increases in a dose-response manner.
Each additional hour of TV viewing increased risk for obesity. > 2 hrs/day significantly increased risk
for overweight/obesity.
Mean Downs and Black score = 20.9 (± 1.9), Level 2 evidence.
10.5 years) showed that an intervention to decrease tar- for MS and CVD (Table 5). All of the studies reported
geted sedentary behaviours (watching TV, playing com- that increased sedentary time was associated with
puter games, talking on the telephone, or playing board increased risk for MS or CVD. However, the results of
games) led to increases in both physical activity and non- these studies should be viewed with caution as the pro-
targeted sedentary behaviours. Longitudinal evidence was portion of children and youth who have measurable
conflicting. One longitudinal study showed that > 2 health risk factors for MS or CVD is quite low. Longitu-
hours per day of TV and computer use was associated dinal studies found that those watching more than 2
with decreased musculoskeletal fitness [205]; while the hours of television per day had higher serum cholesterol
second longitudinal study found no association between levels [88] and were more likely to have high blood
increased screen time and decreased fitness. Eight of 12 pressure [215] than their peers who watched less TV.
cross sectional studies showed that greater than 2 hours Cross sectional studies reported that high levels of
of screen time per day was associated with decreased screen time and self-reported sedentary behaviour were
VO2max, lower cardiorespiratory fitness, and lower aero- associated with increased risk for high systolic and dia-
bic fitness [95,206-212]. Two studies showed weak rela- stolic blood pressure [47,108,216,217], higher HbA1 c
tionships between television watching and fitness [218], fasting insulin [134,216], insulin resistance
[197,213]. Two studies showed no consistent association [48,219], and MS [220]. These risk factors increase in a
between television viewing and aerobic and musculoske- dose response manner with increased screen time
letal fitness [184,214]. The level of evidence related to fit- [216,220]. One cross sectional study reported a signifi-
ness was classified as Level 3 with a mean Downs and cant relationship between watching TV and increased
Black score of 20.9 (standard deviation: ± 2.1), indicating cholesterol in adolescents, but not in younger children
moderate quality of reporting. [185]. The level of evidence for MS and CVD risk fac-
Metabolic syndrome and risk for cardiovascular disease tors was classified as Level 3 with a mean Downs and
Eleven studies assessed the relationship between time Black score of 21.7 (standard deviation: ± 2.1), indicating
spent engaging in sedentary behaviour and risk factors moderate quality of reporting.
Table 4 Summary table of results showing relation between sedentary behaviour and fitness
RCT 0
Intervention 1 76 Reductions in sedentary behaviour lead to increased fitness.
Longitudinal 2 561 One study showed no association whereas one study showed higher musculoskeletal fitness in
those watching < 2 hrs of TV per day.
Cross 12 17227 > 2 hrs of screen time per day is associated with better VO2max scores, better musculoskeletal
sectional and cardiorespiratory fitness scores.
Total of all 15 17864 Those watching less than 2 hours of TV a day showed higher results for fitness testing and more
studies favourable bone health.
Table 5 Summary table of results showing relation between sedentary behaviour and markers for metabolic syndrome
and cardiovascular disease
RCT 0
Longitudinal 2 1675 > 2 hr of TV per day is associated with higher serum cholesterol levels. > 1.2 hrs of TV per day is
associated with increased systolic blood pressure.
Cross 9 17339 > 2 of screen time per day is associated with higher blood pressure and increased risk for
sectional metabolic syndrome.
Intervention 0
Total of all 11 19014 Increased screen time is associated with increased risk for markers of metabolic syndrome and
studies cardiovascular disease. Risk increases in a dose-response manner.
Self esteem behaviour (Table 7). The one longitudinal study examin-
Fourteen studies assessed the relationship between time ing the relationship between sedentary behaviour and
spent engaging in sedentary behaviour and self-esteem pro-social behaviour found that sustained TV exposure
(Table 6). One RCT aimed to increase physical activity and (i.e. ≥ 2 hours per day) was a significant risk factor for
decrease TV viewing [221], leading to a trend in improve- behavioural problems [229]. Cross sectional studies
ments in self-esteem (P = 0.26) and concerns with body reported similar findings. Those who watched less TV
shape (p = 0.03). Intervention studies that targeted changes were more emotionally stable, sensitive, imaginative,
in sedentary behaviour produced inverse changes in physi- outgoing, self-controlled, intelligent, moralistic, college
cal self-worth and self-esteem [52,54]. Cross sectional stu- bound, and less likely to be aggressive or to engage in
dies showed that increased screen time was associated with risky behaviour [42,115,230-235]. Two studies found a
higher depressive symptoms, low self-esteem, and significant relationship between increased computer use
decreased perceptions of self-worth [44,115,147,212, and behaviour problems in boys [111,236] but not girls.
221-223]. There was evidence for a dose-response relation- One study showed that increased TV viewing was asso-
ship as each additional hour of screen time seemed to ciated with aggression in girls but not boys [225]. The
increase the risk for lower self-esteem [147]. Two studies level of evidence for studies reporting on pro-social
[224,225] reported that increased TV viewing was asso- behaviour was classified as Level 3 with a mean Downs
ciated with decreased self-esteem in boys but not girls, and and Black score of 19.9 (standard deviation: ± 1.3) indi-
increased aggression in girls but not boys. Two studies cating moderate quality of reporting.
showed no significant relationship [226,227]. One study Academic achievement
[228] showed a significant relationship between increased Thirty five studies assessed the relation between time
TV viewing and decreased self-esteem in adolescents but spent engaging in sedentary behaviour and academic
not in young children. The level of evidence for studies achievement (Table 8). Academic achievement was mea-
examining self-esteem was classified as Level 3 with a sured in a variety of ways but included measures of I.Q.,
mean Downs and Black score of 21.0 (standard deviation: school grades, grade point average (GPA), performance
± 2.4) indicating moderate quality of reporting. on standardized tests, and self-report questionnaires (e.g.
Pro-social behaviour students rated their own level of academic achievement).
Eighteen studies assessed the relationship between time The longitudinal studies included in this review found
spent engaging in sedentary behaviour and pro-social that children who watched higher amounts of TV had
Table 6 Summary table of results showing relation between sedentary behaviour and self-esteem
RCT 1 61 Girls who decreased sedentary behaviour had lower body dissatisfaction and showed a trend
towards improved self-esteem.
Intervention 2 984 Decreases in sedentary behaviour lead to improved self worth and self-esteem.
Longitudinal 0
Cross 11 71068 Those with higher reported sedentary behaviour had poorer scores on self worth. This association
sectional seems to increase in a dose-response manner
Total of all 14 72113 Each additional hour of TV viewing was associated with decreases in self-worth and self-concept.
studies Mean Downs and Black score = 21.0 (± 2.4), Level 3 evidence.
Table 7 Summary table of results showing relation between sedentary behaviour and pro-social behaviour
RCT 0
Longitudinal 1 2707 Watching > 2 hrs of TV per day is a risk factor for social behaviour problems
Intervention 0
Cross 17 91934 Individuals watching > 3 hrs of TV per day are more likely to exhibit poor social behaviours and be
sectional more aggressive. Limited evidence to suggest this relationship is stronger in boys.
Total of all 18 94391 > 2 hrs of TV per day is associated with poor pro-social behaviour.
studies Those watching less than 3 hrs of TV per day scored more positively in aspects of pro-social
behaviour
greater difficulties with attention as teenagers [41], Change in mean BMI before and after the intervention
showed lower progression for reading level [237], and (at the longest point of follow-up for each study) was
performed worse on cognitive tests [238] than those used as the point estimate for the meta-analysis of the
watching less than one hour of television per day. The RCT data. Of the 8 RCTs, only 6 had data that could be
majority of cross sectional studies (75%) reported that used to calculate the change in BMI after the interven-
children and youth who watched higher levels of TV tion [50,58,221,262-264] (the other two reported on pre-
tended to spend less time doing homework, studying, valence of overweight and obesity) [57,265]. Of the
and reading for leisure which may lead to a decrease in remaining six studies, one [50] examined standardized
academic achievement [42,181,239-255]. This association estimates of BMI only and one [262] presented only med-
increased in a dose response manner [181,244,248]. Ten ian change in BMI and not a mean change. Study authors
of the cross sectional studies found no significant rela- were contacted for missing information, but no addi-
tionship [57,226,227,238,256-261]. One study [228] tional data was made available and thus these studies
found that this relationship was significant in adolescents were excluded from the meta-analysis. Meta-analysis of
but not younger children. The evidence for academic the 4 RCTs that remained revealed an overall significant
achievement was classified as Level 3 with a mean Downs effect of -0.89 kg/m2 (95% CI of -1.67 to -0.11, p = 0.03)
and Black score of 19.2 (standard deviation: ± 2.1) indi- indicating an overall decrease in mean BMI associated
cating moderate quality of reporting. with the interventions (Figure 2). The Chi square test for
Quantitative data synthesis heterogeneity was not significant but the I2 was 46% indi-
Data for each of the outcomes were assessed to deter- cating that there was low to moderate heterogeneity in
mine if they were sufficiently homogeneous to make the data. The funnel plot showed no indication of publi-
meta-analysis appropriate. The only outcome for which cation bias (data not shown).
data were consistently collected and reported and for Meta-analyses were not undertaken for other outcomes
which the characteristics of the studies were similar or study designs because there was substantial heteroge-
enough to undertake a meta-analysis was body composi- neity in the units of measures and type of reporting of
tion. However, this was only for the RCTs; the longitudi- sedentary behaviour, as well as the specific measures of
nal, cross sectional and intervention studies that each outcome. For example, when reporting on the rela-
examined body composition had too many inconsisten- tion between time spent watching TV and overweight
cies to allow for a quantitative synthesis of results. and obesity, one study may report the relation between
Table 8 Summary table of results showing relation between sedentary behaviour and academic achievement
RCT 0
Longitudinal 3 3530 Watching > 1 hr of TV per day is associated with attention difficulties.
Intervention 0
Cross 32 157637 > 2 hrs of screen time per day resulted in lower academic achievement.
sectional
Intervention 0
Total of all 35 161167 > 2 hrs of screen time per day is negatively associated with academic achievement.
studies Dose-response relation between time spent playing video games, watching TV and using the
computer (for non-academic purposes). > 3 hrs/day associated with poor school performance and
lower I.Q. scores.
Figure 2 Meta-analysis of randomized controlled studies examining decreases in sedentary behaviour and effect on body mass index.
the frequency of TV watching and skin fold thickness, only based on a small number of RCTs and that only half
whereas another may examine the relation of daily of the RCTs included in the review were included in the
volume of TV watching and BMI. Even for studies that meta-analysis. Nonetheless, this meta-analysis of RCTs,
examined the same outcome, for instance BMI, some which are considered to be the highest quality of research
would report the proportion overweight or obese, while evidence, coupled with the qualitative syntheses of data
others would report mean BMI. In addition, some studies from the other study designs, provides consistent evi-
reported on data for males or females only, while others dence of the inverse relationship between sedentary
reported only overall estimates and many were missing behaviour and health outcomes, and that reducing seden-
key information about participant characteristics or study tary behaviour can improve body composition. Further-
design. As a result, we were unable to determine com- more, this finding was consistent with the results of
mon point estimates and associated measures of errors observational studies and previous reviews [19-21,23,25].
for many of the studies. Due to the scope of the review, it Studies included in this review used primarily indirect
was not feasible to contact every author for individual measures (i.e. parent, teacher, and self-report question-
data to re-run the analyses. Developing reporting stan- naires) to assess time spent engaging in sedentary beha-
dards for primary studies examining the relationship viour. Those studies that did use direct (i.e. accelerometer)
between sedentary behaviour and health would help to measures found that children and youth are spending a
ensure that appropriate data are available for future large proportion of their day (up to 9 hours) being seden-
meta-analyses. tary [24,27,29,39-47,49,178]. Therefore, for some children
and youth, a viable approach to improving health may be
Discussion to work towards a reduction of at least some of their
Based on this systematic review of 232 studies, sedentary sedentary behaviours either through smaller, micro-inter-
behaviour (assessed primarily through increased TV ventions (e.g. interrupting prolonged sedentary time), or
viewing) for more than 2 hours per day was associated lager macro-interventions (e.g. population-based interven-
with unfavourable body composition, decreased fitness, tions and public health initiatives). Decreasing sedentary
lowered scores for self-esteem and pro-social behaviour time is important for all children and youth, but it may be
and decreased academic achievement in school-aged chil- may be especially important to promote gradual decreases
dren and youth (5-17 years). This was true for all study in the most sedentary group as a stepping stone to meeting
designs, across all countries, using both direct and indir- sedentary behaviour guidelines [266].
ect measurements, and regardless of participant sample
size. All studies examining risk factors for MS and CVD Strengths and limitations
disease reported that increased sedentary time was asso- Strengths of this review included a comprehensive search
ciated with increased health risk; however, the included strategy, a-priori inclusion and exclusion criteria and ana-
studies examined a wide range of risk factors, and thus lyses, and inclusion of non-English language articles. We
there was insufficient evidence to draw conclusions on included direct and indirect measures of sedentary beha-
the relationship for metabolic risk as a whole. viour and focused on 6 diverse health indicators in chil-
High heterogeneity of the included studies limited dren and youth. Although efforts were made to include
meta-analysis to RCTs examining the relationship grey literature (e.g. by contacting key informants and
between television viewing and BMI. This revealed a reviewing government documents), we did not include
trend to support the hypothesis that decreased time conference proceedings and other types of grey literature
spent sedentary is associated with decreases in BMI. This because it was impractical and unfeasible to sift through
result should be interpreted cautiously, given that it is all unpublished work, and also because of limitations in
the quality of reporting in conference abstracts [267,268]. information demonstrates similar trends as those seen in
We do not anticipate that additional, unpublished work RCTs and intervention studies, we believe that the evi-
would change the results. dence presented in this review provides important
Our study has limitations, including the types of out- insights into the relationship between sedentary beha-
come measurements and analyses reported in the pri- viour and health outcomes in school-aged children and
mary studies and primary study quality. The scope of this youth.
review was large and included a great deal of health indi-
cators and measurement tools. A more detailed meta- Future work
analysis would have allowed us to estimate the overall The purpose of this review was to provide an evidence
effect sizes for each outcome. However, due to the het- base to inform clinical practice sedentary behaviour
erogeneity of the data, it was impossible to complete guidelines for children and youth [266]. Future work is
such analysis. Furthermore, some studies had missing needed to translate this information into clinical practice
information on participant characteristics making it guidelines and disseminate this information to health
impossible to determine if basic demographics act as a care providers and the general public. While this review
confounder for the relationship between sedentary beha- was limited to children and youth, similar work is
viour and health. Many studies also grouped their vari- needed to inform sedentary guidelines for young chil-
ables into tertiles, or groups that also took into account dren aged 0-5 years, adults, and older adults.
physical activity level. Although it was still possible to As the accessibility and popularity of multiple forms
ascertain information regarding the association between of screen-based technology increases among the pedia-
level of sedentary behaviour and health indicators, it tric population, future work needs to continue to focus
made it very difficult to compare the information across on media engagement. Specifically, with increasing
studies. Similarly, very few studies measured time spent popularity for hand-held, portable devices, ‘sedentary
being sedentary directly (i.e. with direct observation or multitasking’ is becoming increasingly common. Chil-
accelerometry). Previous work [269,270] has shown sig- dren and youth are able to watch television, talk on the
nificant differences between direct and indirect measures phone, and use the computer at the same time. This is a
of physical activity; similar work needs to be completed relatively new phenomenon and we are currently una-
with respect to sedentary behaviour to gain a better ware what, if any, are the health effects associated with
understanding of possible biases in previous studies. this high level of ‘multi-screen’ time. This is also true
Indirect measurements of sedentary behaviour often lead for the effect of advancements in technology and their
to grouping for analyses. This may lead to bias in the associated health effects. For example, ‘active video gam-
results of the systematic review as many studies arbitra- ing’ (e.g., Nintendo Wii™, Microsoft Kinect™, Sony’s
rily grouped their participants as ‘’high users” if they Playstation Move™) is advertised as an effective mode
watched more than 2 hours of television per day. This of physical activity. Although it is true that some games
could perhaps be falsely leading us to conclude that 2 can require sufficient energy expenditure for health ben-
hours is the critical cut-point or threshold. Further work efits [271], the socio-cognitive and physiological aspects
using direct (i.e. accelerometer) measures of sedentary of remaining indoors for long periods are unknown.
behaviour and screen time as continuous variables will Furthermore, children and youth can learn quite quickly
help to clarify if a cut-point of 2 hours is in fact biased. how to use minimal gestures (e.g., using wrist move-
The final important limitation of this review was the ment only) to play the game thereby substantially redu-
type of primary studies that were available for analysis. cing energy expenditure.
Studies with small sample sizes were excluded; however Finally, as described above, the vast majority of the cur-
we do not believe that this had a significant impact upon rent evidence has been based on self-report questionnaires
the strength or direction of associations observed in this focused on TV viewing and body composition. It is now
review. The majority of studies (78.4%) included in this clear that these two variables are related. Future work
review were cross sectional, observational studies, using needs to move beyond this relationship and focus on
indirect (i.e. parent-, teacher, or self-report) measure- other modes of sedentarism (e.g., prolonged sitting, passive
ments of sedentary behaviour. Cross sectional data make transport) and other associated health indicators. To do
it impossible to infer causation and results should there- this, objective measures of the time, type and context of
fore be interpreted with caution. However, it should be sedentary pursuits will be needed in combination with
noted that due to ethical considerations, it may be impos- robust and standardized measures of health indicators.
sible to conduct a RCT on the effects of long periods of
sedentary behaviours in children and youth. Due to the Conclusions
large and diverse sample sizes available in population- Physical inactivity and sedentary behaviour are pervasive
based cross sectional research, and given that this and persistent public health challenges to overcome. This
review demonstrates that there is a need to advocate for Canada. 2Department of Physical Medicine and Rehabilitation, Johns Hopkins
University. 600 North Wolfe Street, Baltimore, Maryland, 21202, USA. 3Office
increases in physical activity AND decreases in sedentary of the Task Force on Preventive Health Care, Public Health Agency of
behaviour. It is believed that a multi-level, multi-sectoral Canada. 785 Carling Avenue, Ottawa, Ontario, K1A 0K9, Canada.
approach is required for this to be successful [11]. Ulti-
Authors’ contributions
mately, resolving the problem of inactivity requires a sus- MT was responsible for the initiation, conceptualization and design of the
tained change in individual daily activity and sedentary systematic review; oversaw the data collection and extraction, analysis, and
patterns. From a public health perspective, a reduction in interpretation of data and was responsible for revising the manuscript
critically for important intellectual content. AL was responsible for
sedentary behaviour may be easier than increasing physi- conducting the search, data collection and extraction, the risk of bias
cal activity per se because there are fewer restrictions (i.e. assessment, analysis and interpretation of data, and drafting the manuscript.
no need to change clothing or use special equipment), MEK was responsible for the design and methodology of the review and
revising the manuscript critically for important intellectual content. SCG was
and can be easily attained with minimal burden to a per- responsible for the design and methodology of the manuscript, conducting
son’s time or financial resources. the meta-analysis, and revising the manuscript critically for important
This systematic review summarizes the current evi- intellectual content. RC, GG, TS and RL were responsible for data collection
and extraction, risk of bias assessment, and were responsible for revising the
dence examining the relationship between sedentary manuscript critically for important intellectual content. JM was responsible
behaviours and a series of health indicators. It was for the generation of systematic review search terms. MS was responsible for
determined that increased sedentary time was associated methodology of the review. All authors have read and approved the final
manuscript. MT is the guarantor of the paper.
with negative health outcomes in both boys and girls;
this was true across all study designs with the majority Competing interests
of studies (85.8%) reporting similar relationships. The All authors received partial financial support from the Public Health Agency
of Canada; no other competing interests exist.
majority of current work has focused on television view-
ing and body composition and suggests that children Received: 8 April 2011 Accepted: 21 September 2011
and youth should watch less than 2 hours of TV per Published: 21 September 2011
day during their discretionary time. Furthermore, chil-
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Tremblay et al.

International Journal of Behavioral Nutrition and Physical Activity 2011, 8:98

REVIEW Open Access

Systematic review of sedentary behaviour and

Introduction enjoyed over the past century and efforts to counteract

Table 1 Criteria for assigning level of evidence to a recommendation

Figure 1 Flow of information through the different phases of the review.

Table 2 Summary of characteristics of included studies

Table 2 Summary of characteristics of included studies (Continued)

Table 2 Summary of characteristics of included studies (Continued)

Table 2 Summary of characteristics of included studies (Continued)

Table 2 Summary of characteristics of included studies (Continued)

sedentary time and weight status [24,85,137,183-204]. Fitness

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