A collaborative approach to adopting/ adapting guidelines. The Australian 24-hour movement guidelines for children (5-12 years) and young people ...
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Okely et al. Int J Behav Nutr Phys Act (2022) 19:2
https://doi.org/10.1186/s12966-021-01236-2
RESEARCH Open Access
A collaborative approach to adopting/
adapting guidelines. The Australian 24-hour
movement guidelines for children (5-12 years)
and young people (13-17 years): An integration
of physical activity, sedentary behaviour,
and sleep
Anthony D. Okely1,2* , Davina Ghersi3,4, Sarah P. Loughran1,2, Dylan P. Cliff1,2, Trevor Shilton5, Rachel A. Jones1,2,
Rebecca M. Stanley1,2, Julie Sherring1, Natalie Toms6, Simon Eckermann7, Timothy S. Olds8, Zhiguang Zhang1,
Anne‑Maree Parrish1, Lisa Kervin1, Sandra Downie6, Jo Salmon9, Clair Bannerman10, Tamie Needham11,
Elaine Marshall12, Jordy Kaufman13, Layne Brown1, Janecke Wille14, Greg Wood15, David R. Lubans16,
Stuart J. H. Biddle17, Shane Pill18, Anthea Hargreaves19, Natalie Jonas20, Natasha Schranz8,21, Perry Campbell22,
Karen Ingram23, Hayley Dean23, Adam Verrender1, Yvonne Ellis1, Kar Hau Chong1, Dorothea Dumuid8,
Peter T. Katzmarzyk24, Catherine E. Draper25, Hayley Lewthwaite7 and Mark S. Tremblay26
Abstract: Background: In 2018, the Australian Government updated the Australian Physical Activity and Sedentary
Behaviour Guidelines for Children and Young People. A requirement of this update was the incorporation of a 24-hour
approach to movement, recognising the importance of adequate sleep. The purpose of this paper was to describe
how the updated Australian 24-Hour Movement Guidelines for Children and Young People (5 to 17 years): an integration of
physical activity, sedentary behaviour and sleep were developed and the outcomes from this process.
Methods: The GRADE-ADOLOPMENT approach was used to develop the guidelines. A Leadership Group was
formed, who identified existing credible guidelines. The Canadian 24-Hour Movement Guidelines for Children and Youth
best met the criteria established by the Leadership Group. These guidelines were evaluated based on the evidence in
the GRADE tables, summaries of findings tables and recommendations from the Canadian Guidelines. We conducted
updates to each of the Canadian systematic reviews. A Guideline Development Group reviewed, separately and in
combination, the evidence for each behaviour. A choice was then made to adopt or adapt the Canadian recommen‑
dations for each behaviour or create de novo recommendations. We then conducted an online survey (n=237) along
with three focus groups (n=11 in total) and 13 key informant interviews. Stakeholders used these to provide feedback
on the draft guidelines.
*Correspondence: tokely@uow.edu.au
1
Faculty of Arts, Social Sciences and Humanities, School of Health
and Society, University of Wollongong, Wollongong, NSW 2522, Australia
Full list of author information is available at the end of the article
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the
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to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory
regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this
licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativeco
mmons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 2 of 21 Results: Based on the evidence from the Canadian systematic reviews and the updated systematic reviews in Australia, the Guideline Development Group agreed to adopt the Canadian recommendations and, apart from some minor changes to the wording of good practice statements, maintain the wording of the guidelines, preamble, and title of the Canadian Guidelines. The Australian Guidelines provide evidence-informed recommendations for a healthy day (24-hours), integrating physical activity, sedentary behaviour (including limits to screen time), and sleep for chil‑ dren (5-12 years) and young people (13-17 years). Conclusions: To our knowledge, this is only the second time the GRADE-ADOLOPMENT approach has been used to develop movement behaviour guidelines. The judgments of the Australian Guideline Development Group did not dif‑ fer sufficiently to change the directions and strength of the recommendations and as such, the Canadian Guidelines were adopted with only very minor alterations. This allowed the Australian Guidelines to be developed in a shorter time frame and at a lower cost. We recommend the GRADE-ADOLOPMENT approach, especially if a credible set of guidelines that was developed using the GRADE approach is available with all supporting materials. Other countries may consider this approach when developing and/or revising national movement guidelines. Keywords: Methodology, GRADE-ADOLOPMENT, Public health recommendations, Guideline development Background The GRADE-ADOLOPMENT approach allows guide- The first National Physical Activity Recommenda- line developers to follow the GRADE process for devel- tions for Children and Adolescents were released by oping guidelines more eficiently by adapting or adopting the Australian Government in 2004 [1]. These were an existing evidence-based guidelines [10]. This approach updated in 2012 and, for the first time, included sepa- prevents the need to undertake (or repeat) resource and rate sedentary behaviour guidelines for the same age time-intensive tasks such as conducting full systematic group [2, 3]. In recent years, guidelines have evolved reviews. It also allows local guideline developers to take to accommodate – from a movement perspective – the local contextual factors into consideration. entire day [4]. This perspective is called 24-hour inte- Based on the Canadian Guideline Development Panel’s grated movement guidelines [5], and acknowledge that use of the GRADE approach to develop the Canadian individual movement behaviours – physical activity, 24-Hour Movement Guidelines for Children and Youth, sedentary behaviour and sleep – need to be considered the GRADE-ADOLOPMENT approach was used in in combination with one other when examining their the development of the Australian 24-Hour Movement associations with health in children and young people. Guidelines for Children and Young People. The purpose In 2016, Canada released the first integrated 24-hour of this paper was to describe how GRADE-ADOLOP- movement guidelines for school-age children and MENT approach was used to develop the Australian youth [5]. The evidence underpinning these guidelines 24-Hour Movement Guidelines for Children and Young showed a monotonic relationship between the num- People. This process started in May 2018 and was com- ber of movement behaviour guidelines met by an indi- pleted in December 2018, with the Guidelines released in vidual and associated health indicators [6–8]. That is, April 2019. meeting all three guidelines was better than meeting any two, and meeting any combination of two guide- lines was better than meeting just one, which in turn Methods was better than meeting none. In early 2018, the Aus- Guideline ADOLOPMENT structure tralian Government provided funding to update the The GRADE-ADOLOPMENT process followed the Australian Physical Activity and Sedentary Behaviour framework described in detail by Schünemann and col- Guidelines for Children and Young People, with the leagues [10]. Several steps that were identified in the request that these be 24-hour movement guidelines. Appraisal of Guidelines for Research & Evaluation II The benefit for Australia was leveraging the signifi- (AGREE-II) instrument [11] were added by the Leader- cant work completed in Canada on the development ship Group. A summary of the timeline and sequence of of their 24-hour guidelines resulting in the process steps used is shown in Fig. 1. requiring considerably less time and fewer resources. The benefits of adapting guidelines produced by others Step 1: Establishment of a Leadership Group. This was something Australia had successfully done with group comprised the project Principal Investigators their 24-hour movement behaviour guidelines for the (ADO, SPL, DPC, AMP, TSO, LK, SE, RAJ, RMS, early years [9]. MST), a guideline methodologist (DG), and repre-
Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 3 of 21
Fig. 1 Timeline and sequence of events involved in the development of the Australian 24-hr movement guidelines for children and young people:
an integration of physical activity, sedentary behaviour, and sleep
sentatives from the Australian Government (owner JS, NS, EM, SD, NT) at appropriate time points in
and funder of the Guidelines; SD, NT), National the process. As the Australian guidelines sought to
Heart Foundation of Australia (key stakeholder; adopt or adapt the Canadian Guidelines using the
TS), and professional support from Early Start at GRADE-ADOLOPMENT process (assuming these
the University of Wollongong (JS/YGE). This group would be appropriate as per Step 3 – see below for
was formed in April 2018 and met fortnightly up to details), it was agreed that the Principal Investiga-
the end of August 2018 to provide strategic advice tor from the Canadian Guidelines (MST) would be
and direction, guidance, and budget account- part of the leadership group.
ability to the project. Ad-hoc subcommittees were Step 2: Formation of a Guideline Development Group.
formed for the areas of stakeholder consultation A Guideline Development Group (GDG) was
(RAJ, RMS, JS), communication and dissemina- formed which included additional expert research-
tion (TS, SD, NT, JS, ADO) and surveillance (ADO, ers, representatives from key stakeholder groupsOkely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 4 of 21
(including parents and Indigenous Australian com- tion. The Australian Guideline Development Group
munities), and methodology experts (Table S1). considered the evidence-to-decision criteria that
The role of the GDG is described in detail in Step influenced the direction and strength of each of
5. Efforts were made to achieve geographical repre- the draft recommendations made by the Canadian
sentation across Australia within the confines of the Guideline Development Panel. These were based on
budget. the GRADE tables, summary of findings tables, and
Step 3: Identification of credible existing guidelines recommendations made available by the Canadian
and definition of criteria for selection of the guidelines. Guideline Leadership Committee.
We were aware of two sets of 24-hour integrated
movement guidelines for children and young people. Assessed against the stated GRADE approach to evi-
These were from Canada [12] and New Zealand [13]. dence synthesis (i.e., 60% of randomised controlled tri-
The New Zealand Guidelines adopted those from als [RCTs] were statistically significant and positive),
Canada. The Canadian 24-hour Movement Guide- the evidence base was graded “Low” or “Very Low”
lines were considered along with other existing inte- in most cases. The Guideline Development Group
grated or physical activity and sedentary behaviour then made a decision to support or not support the
guidelines that met the following criteria: 1) pub- 2016 Canadian Guidelines based on the evidence and
lished in the past five years (or in the process of being other criteria used to make recommendations includ-
published); 2) addressed clear research questions ing values and preferences; feasibility, acceptability
(contained all Population, Intervention, Compara- and equity issues; resources; balance of benefits and
tor and Outcome [PICO] elements); 3) followed the harms; and quality of the evidence [11]. Parts of the
GRADE process; 4) allowed for updating (provided EtD framework that were able to be followed during
access to full systematic reviews, which were reg- the Guideline Development Group meeting included
istered with the Prospective Register of Systematic presenting the evidence and keeping track of the dis-
Reviews (PROSPERO) and provided full access to cussion and judgments. Following the Guideline
the search strategy); 5) included existing and acces- Development Group meeting, a transparent record
sible GRADE tables and summaries of findings; and of the discussions was communicated to those who
6) completed a risk-of bias assessment [10]. Table 1 attended for verification.
contains a summary of the national physical activity Step 5 Determine availability, completeness, and cur-
and sedentary behaviour guidelines in children and rency of information about EtD criteria. The next
young people that the leadership group was able to component in the general stages of GRADE-ADO-
identify and the evaluation of each against these cri- LOPMENT (see Appendix 2 [10]) was to determine
teria. Only the 2016 Canadian 24-Hour Movement the availability, completeness, and currency of the
Guidelines for Children and Youth met all criteria information about the EtD criteria. For this, the cri-
and were therefore chosen as the guidelines to be teria for updating reviews found in Appendix 4 of
adopted or adapted following the GRADE-ADO- the GRADE-ADOLOPMENT paper [10] was used
LOPMENT process. (see Table 2). Based on this information, the Leader-
ship Group made a decision to update the Canadian
The AGREE-II tool was used to determine the cred- systematic reviews focusing only on the critical out-
ibility of the Canadian Guidelines (as per Stage 1 of the comes (see [14] for a list of these for each systematic
suggested GRADE-ADOLOPMENT Protocol – see review) for randomized controlled trials and cohort
Appendix 1 [10]. Following the credibility assessment, study designs because the sources of these reviews
the ADOLOPMENT framework moves on to the evalu- were older than three months (i.e., they had an end
ation and final selection of the guidelines that will be date before February 2018) [10]. The exception was
adopted or adapted. It was agreed by the Leadership the systematic review for the combinations of move-
Group that it would be appropriate to adopt the Cana- ment behaviours. Because there were fewer studies
dian Guidelines as they were determined to be of appro- in this area it was decided to also include cross-sec-
priate quality, their scope/applicability was appropriate tional studies in this systematic review. The Leader-
for Australia, the topic was a priority for Australia and ship Group decided not to update the reviews for
the research questions and PICOs (Population, Interven- non-critical outcomes (see [14] for a list of these) or
tion, Comparators, and Outcomes) for the systematic for cross-sectional studies because the consensus was
reviews that served as the evidence base were relevant. that even if an update was to uncover new studies,
Step 4: Evaluate and complete GRADE Evidence-to- they would be graded very-low to low quality and as
Decision (EtD) frameworks for each recommenda- such, would not result in a change to the final guide-Table 1 Existing international Physical Activity Guidelines for Children and Young People
Criteria USA China Chile Netherlands New Canada France Germany Norway Mexico Spain Australia Austria Denmark Paraguay Turkey Qatar Argentina
2018a 2017 2017 2017 Zealand 2016 2016 2016 2016 2015 2015 2014 2013 2014 2014 2014 2014 2013
2017
Followed N N ? N Y Y N N ? Y Y Y N N Y N N Y
GRADE process
Okely et al. Int J Behav Nutr Phys Act
Addresses clear Y N ? N Y Y Y ? ? Y Y Y N ? Y N N Y
questions (can
identify PICO
elements)
Has benefits Y N ? Y Y Y Y Y Y Y Y Y Y ? Y Y Y Y
(2022) 19:2
and harms
assessments
Assessed using N N ? N Y Y N N ? N N Y N N N N N N
AGREE
Allows for ? N ? Y N Y Y N ? Y Y N ? Y N N Y
updating
Has existing Y N ? Y Y Y Y Y ? N Y Y Y ? Y N N Y
and acces‑
sible evidence
tables
/summaries
Has risk of bias Y N ? Y Y Y N ? ? Y Y Y N ? Y N N Y
assessment
Were inte‑ ? N ? N Y Y N N ? N N N N ? N N N N
grated (24hr)
Costs associ‑ N ? ? ? N Y N N ? ? ? N N ? ? ? ? ?
ated with
implementing
guideline
Acccompany‑ N N ? ? N Y Y N ? ? ? N Y ? ? ? ? ?
ing – how they
are going to
implement –
disseminate
the guidelines
Reference: Appendix 1. GRADE-ADOLOPMENT (Schünemann et al., J Clin Epidemiol. 2017)
a
under development during guideline development process but made available to Australian Guideline Development Group
Key: Y=yes; N=no; ?=unsure
Page 5 of 21Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 6 of 21
lines, and there were already many such studies that Youth; discuss proposed stakeholder consultations;
were used to inform the guidelines. identify research gaps; and plan the launch, dissemina-
tion, promotion, integration, and evaluation activities
The Australian Leadership Group made the PICOs that for the Australian 24-hour Movement Guidelines for
guided the four systematic reviews for the 2016 Cana- Children and Young People.
dian Guidelines available for comment by the Australian The process at the Guideline Development Group
Guideline Development Group prior to the Consensus meeting involved reviewing the evidence for each
meeting. This latter group was asked to comment on the movement behaviour (physical activity, sedentary
appropriateness of each of the PICOs for the Australian behaviour, and sleep) individually, starting with the
context. Some of the initial comments sought clarifica- 2016 Canadian systematic reviews and integrating the
tion on the selection of the specific search terms for some Australian updates into these reviews. The evidence for
of the outcomes. These comments were resolved by indi- each behaviour, including the conclusions of the Cana-
cating that the search terms would be or were captured dian review and how this process informed their guide-
in the Australian or Canadian searches, respectively, lines, was then discussed. The Guideline Development
although this information was not clear in the PICOs. Group then followed the GRADE-ADOLOPMENT
Other queries related to the inclusion of information in process to decide to adopt or adapt the 2016 Canadian
the summary tables or in the PROSPERO registration or recommendations for each behaviour or create de novo
to the definitions of specific terms. Where changes were recommendations. In addition, the Panel examined the
suggested, these were discussed by the Leadership Group results of the integrated behaviours systematic review
and agreement reached. None of the proposed changes and compositional data analyses from Canada [21],
were substantial enough to warrant changing any of the infused expert opinion into the evidence (such as fea-
existing PICOs except for the sedentary behaviour PICO. sibility, acceptability, equity issues, values and prefer-
The Australian Leadership group decided to include ences, resources, and balance of benefits and harms),
“psychological distress” (which included stress, anxiety and combined evidence of absolute effects across mul-
symptoms, depressive symptoms, and mental health) as tiple outcomes [22–25]. This led to an informed assess-
an additional critical outcome and to move the outcome ment of whether the panel either agreed or disagreed
of “self-esteem” from an important to critical outcome. with the judgements made by the Canadian Guideline
In addition, two additional considerations were made Development Panel. If the Australian Guideline Devel-
to all the systematic reviews. These were to: 1) consider opment Group agreed with the judgements, the recom-
and discuss cost-effectiveness and resource use as per the mendations were adopted, and the Panel moved on to
GRADE-ADOLOPMENT approach and in the context discuss the wording of the guidelines. If the Panel disa-
of the proposed Guideline recommendation; and 2) use greed with the judgements, the recommendations were
the evidence to seek to address the applicability of the adapted, and the Panel moved on to describe the rea-
recommendations to Indigenous Australians and their sons for deviation in the EtD framework. It was noted
communities. during the Guideline Development Group meeting that
The updates to the four systematic reviews initially per- a recommendation could be adopted and still added to
formed for the Canadian Guidelines were conducted with or translated for adoption in the wording and adjusted
searches completed up to the end of July 2018. For each if necessary, based on this detailed discussion.
systematic review, the quality of evidence was assessed by The next three sections of the Guideline Develop-
outcome/indicator, study design, and age group, using the ment Process [26] are not components of the GRADE-
GRADE approach [15, 16]. Each systematic review used ADOLOPMENT process but were important when
the same PICO as the corresponding systematic review assessing the appropriateness of the adopted guidelines
completed for the 2016 Canadian Guidelines [17–20]. with key stakeholders and the development of plans for
The results of these systematic review updates were the Australian Government (owner of the Guidelines)
presented at the Guideline Development Group meet- to consider for promotion and activation of the Guide-
ing from 22-23 August 2018. The specific objectives of lines and potential monitoring and surveillance. This
this meeting were to review, discuss, debate and inter- process was also followed in updating the Australian
pret findings from the Canadian systematic reviews 24-hr Movement Guidelines for the Early Years [9].
and Australian updated searches, including composi-
tional analyses that were performed using data from Stakeholder consultations
Canada and Australia. Other objectives were to review The online survey developed as part of the 2016 Cana-
and adopt/adapt the Preamble and the actual Cana- dian Guidelines [14] was modified for the Australian con-
dian 24-Hour Movement Guidelines for Children and text to seek feedback from stakeholders regarding theirOkely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 7 of 21
Table 2 Criteria for updating reviews and teacher; Australian Indigenous young person; Active
Criterion Minor update (all criteria must apply)
Healthy Kids Australia Project Officer; and an Australian
Indigenous parent. A total of 11 individuals participated
Prior Review (for question) A credible systematic review exists in three focus groups and thirteen interviews (1 par-
Full text reviewed for the ≤20 articles ticipant per interview). Recruitment occurred through
Research Question of interest
existing partnerships and connections. Focus groups
New Studies ≤5 studies
and interviews lasted between 30 and 90 mins and were
Evidence profile available? Available
conducted from October 2018 to February 2019 in New
Outcomes all addressed All important outcomes addressed
South Wales, Australian Capital Territory, Tasmania,
Reference: Appendix 4: GRADE-ADOLOPMENT [10]. South Australia, Victoria and Western Australia by a
member of the guideline development group from their
state/territory. The focus groups and interviews were
level of agreement with the draft Australian Guidelines audio-recorded and transcribed verbatim and inductive
which eminated from the Guideline Development Group thematic data analyses by two researchers were employed
meeting. The Human Research Ethics Committee of the and consensus reached on any discrepancies through dis-
University of Wollongong approved the administration cussion [27]. Ethics approval was obtained from Human
of the survey and use of a passive consent process (HE Research Ethics Committee of the University of Wollon-
2018/370). The survey sought feedback regarding the gong (HE 2018/370). A subcommittee of the Guideline
clarity of the title, preamble, and guidelines as well as lev- Development Group reviewed the survey, focus group
els of agreement with the text. Basic demographic infor- and key informant interview results, and suggested revi-
mation was requested, and respondents were afforded sions to the Guidelines based on the stakeholder feed-
the opportunity to provide comments on all components back, ensuring changes remained true to the available
of the guidelines. Guideline Development Group mem- evidence base. Revisions agreed upon by the Leader-
bers were asked to disseminate the survey through their ship Group were then circulated to the entire Guideline
networks and used a snowball sampling methodology Development Group for comment and final revisions.
to optimise reach and input from relevant stakehold- Consensus was achieved on the final Guidelines.
ers. The survey was open from September 17 to October
29, 2018. After the survey closed, numerical responses Results
from participants were tabulated and analysed. Written Updates to systematic reviews
comments were consolidated into themes and summa- The results of the updates to the Canadian system-
ries were prepared. The stakeholder survey also allowed atic reviews by the Australian Leadership Group are
respondents to express their interest in publicly disclos- described below.
ing their support for the guidelines pending their review
of the final draft. To facilitate this, interested respondents Physical activity
were asked to provide an email address where the final For physical activity, 5,085 new studies were identified
guidelines could be sent. from a search of databases, with 132 studies remaining
In addition, focus groups (conducted in person) and key after screening title and abstracts. Of these, 42 studies
informant interviews (in person and remotely) were con- met the criteria to be included in the update.
ducted. These targeted key stakeholders who were diffi- Eleven studies examined the relationship between
cult to reach through the online survey, such as parents of physical activity and body composition.
varying socioeconomic status and cultural backgrounds Two studies used an RCT design, four studies used a
– in particular Australian Indigenous and low-socioeco- non-randomized trial (NRT) design, and the remaining
nomic groups. Specific questions about the acceptability five studies used a longitudinal design. Among the two
and perceived importance, clarity of the Guidelines and RCT’s, one study reported a mix of favourable and null
preamble, facilitators and barriers to implementation findings [28], whereas the other study showed no inter-
and dissemination, and dissemination and implementa- vention effect on body composition [29]. From the four
tion recommendations for the Guidelines were asked. NRT studies, one reported null effects of a physical activ-
The focus groups were supplemented with key inform- ity intervention on adiposity outcomes [30]. The remain-
ant interviews held with a culturally and linguistically ing three studies reported significant favourable effects
diverse parent; sports coach; teacher and policy maker on adiposity outcomes [31–33]. Among the five longitu-
from the disability sector; principal of a school located dinal studies, favourable associations between physical
in a low socioeconomic area; school counsellor; policy activity and body composition were reported [34–37].
maker from the education sector; after-school director One longitudinal study reported a mix of favourable andOkely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 8 of 21 null associations for total physical activity and body com- academic achievement [62–64] cognition [65, 66], or position [38]. mathematics engagement [64, 67]. Four studies showed Nine studies examined the relationship between physi- mixed relationships between physical activity and aca- cal activity and cardiometabolic biomarkers. One study demic achievement [64], cognition [66] and mathematics used an NRT design; this study found significant favour- engagement [67]. One study found unfavourable associa- able intervention effects on systolic blood pressure, total tions between light-intensity physical activity (LPA) and cholesterol and fasting glucose [30]. Among the eight cognition [68]. longitudinal studies, six showed a favourable relationship Two studies examined the relationship between physi- between total physical activity, moderate- to vigorous- cal activity and harm/injuries. Both studies used a lon- intensity physical activity (MVPA), moderate-intensity gitudinal design [69, 70]. The results were mixed, with physical activity (MPA) and cardiometabolic biomark- one study showing that total, LPA, and VPA were nega- ers [35, 37, 39–42]. Two studies showed no relationship tively related to spinal pain [70], whereas the other study between total physical activity and cardiometabolic bio- showed no relationship with spinal pain [69]. markers [43, 44]. Overall, most of the updated studies showed that total Six studies examined the relationship between physical physical activity was favourably associated with different activity and fitness. One study used an RCT design. This health indicators (adiposity, cardiometabolic biomarkers, study reported a favourable effect on aerobic fitness at fitness, cognitive development and behavioural conduct/ post-test [45]. Five studies used a NRT design. Of these, pro-social behaviour). The assessed quality of overall evi- three studies showed a favourable effect on components dence using GRADE criteria for these outcomes did not of health-related fitness among those in the interven- change by including these additional studies from the tion group compared with the control group [33, 46–48]. updated review. One study reported mixed effects from a physical activ- ity intervention on aerobic fitness across subsamples at Sedentary behaviour post-test (favourable effect for Grade 6 children but not The sedentary behaviour updated systematic review Grades 1 to 5) [49]. One study reported a favourable captured 15,953 new studies with 286 studies remaining effect on endurance, co-ordination and shoulder mobility after titles and abstracts were screened. Of these, 34 stud- [32]. One longitudinal study showed a favourable, dose- ies met the criteria to be included in the update. response gradient between vigorous-intensity physical Fifteen studies examined the associations between activity (VPA) and aerobic fitness [50]. sedentary behaviour and body composition. One study Three studies examined the relationship between phys- used a group NRT design, and 14 studies used a lon- ical activity and behavioural conduct/pro-social behav- gitudinal design. The group NRT (n=41) showed no iour. One RCT showed no effect from an intervention effect on total sitting time (during school time or over to increase MVPA on time in play and social skills [51]. the whole day), although sitting in long bouts (>10 min) One NRT showed there were positive effects of MVPA decreased and the number of sit-to-stand transitions on effort and time on task [52]. One longitudinal study increased as a result of the intervention [71]. However, reported that physical activity was associated with fewer the effects on body mass index and waist circumference peer problems, but also that MVPA was unfavourably z-scores were not statistically significant. The 14 longitu- associated with hyperactivity problems (boys and girls) dinal studies included 22,565 participants aged between and conduct problems (boys only) [53]. 7 and 15 years. Eight of these studies found that higher Eleven studies examined the relationship between durations or frequencies of accelerometer-derived sed- physical activity and cognition/academic achievement. entary time [72, 73] screen time [74–77], TV viewing Four were RCTs; three of these found positive effects [78] and weekend internet use [79] were significantly on on-task behaviour [54–56]. Two studies found no associated with less favourable body composition. One intervention effect on content recall [57] or standard- study reported that increased weekend TV was associ- ized test performance [56]. One study found no change ated with moving between healthy weight and over- on mathematical test performance following a physi- weight categories between waves 1-3 (ages 4-5 years cal activity intervention [56]. Four studies used a NRT to 6-7 years). However, associations for computer use design. Two of these showed a positive effect on on- (weekday or weekend) or weekday TV were not associ- task behaviour [58, 59] and one showed no effect [60]. ated with changes in weight category at any wave (2, 3 or Two studies showed no effect on sustained attention or 4), nor were changes in weekend TV between waves 1-2 executive functions (processing speed, selective atten- or 1-4 [80]. Four studies reported no associations with tion) [60, 61]. Among the six longitudinal studies, four indices of body composition [38, 42, 81, 82]. One study showed no relationships between physical activity and found that higher levels of device-measured sedentary
Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 9 of 21
behaviour were associated with better body composition Seven studies examined the association between sleep
in 454, 10-yr old children [35]. duration and emotional regulation in children and youth.
Six longitudinal studies examined the associations Five studies used an RCT design. Four studies showed
between sedentary behaviour and metabolic syndrome/ an effect on emotional regulation [98–101]. One study
cardiovascular disease risk factors. Three of these stud- showed no effect of time in bed on mood [102]. Out of
ies reported a dose-response gradient; higher screen time two longitudinal studies [103, 104], one study reported
and higher sedentary time were associated with higher that longer sleep was related to better emotional regu-
cardiometabolic risk [40, 41, 75]. The remaining studies lation at follow-up [104], the other study reported that
showed a negative or null association between screen daily variability in sleep duration predicted greater symp-
time, sedentary time and blood pressure/cardiometabolic tomatology [103].
risk factors [35, 42, 43]. Six studies examined the association between sleep
Four studies examined the relationship between sed- duration and cognition in children and youth. Five stud-
entary behaviour and behavioural conduct/pro-social ies used an RCT; four of these reported that longer sleep
behaviour. All were longitudinal in design and found was associated with better cognition [105–108]. One
that higher levels of non-specified screen time [83, 84], study showed no sleep duration effects on cognition
TV viewing [85] and video game use [86] were associ- [109]. One longitudinal study showed significant favour-
ated with unfavourable behavioural conduct/pro-social able associations between average nightly sleep duration,
behaviour. executive function and sedentary behaviour [110].
Six longitudinal studies examined the relationship Three studies examined the association between sleep
between sedentary behaviour and academic achieve- duration and academic achievement in children and
ment. Four of these found that higher levels of total youth. Two studies used a longitudinal design; one study
screen time [86–88], and higher levels of non-school reported that short sleep duration did not predict cumu-
sedentary time excluding TV [89], were associated with lative grade point averages at follow-up [111]. The other
lower academic achievement. Conversely, higher levels study reported nonlinear positive associations of sleep
of device-measured sitting time, reading and homework duration with grade point average and English test scores
outside of school were associated with higher academic [103]. One RCT showed that extended sleep of 18.2 min
achievement [66, 68], and more time spent in homework per night was significantly associated with improved
outside of school [68]. mathematics and English grades [112].
One longitudinal study examined the relationship Three studies examined the association between sleep
between sedentary behaviour and self-esteem [90]. This duration and quality of life/well-being in children and
study reported that in boys, higher levels of screen time youth. These longitudinal studies reported mixed results
were associated with lower self-esteem. Conversely, in [113–115]. Gustaffson et al. reported that longer sleep
girls, higher levels of TV viewing were associated with duration was associated with better overall health in 12-
higher self-esteem. to 15-year-olds, but there was no association in 10-year-
Six longitudinal studies reported on the relationship olds [113]. Magee et al. reported that long sleep duration
between sedentary behaviour and psychological distress was associated with a decline in physical and school
[91–96]. Four of these studies showed that higher levels functioning [114]. Price et al. reported that compared
of screen time were associated with higher levels of psy- with children who had psychosocial health-related qual-
chological distress [91, 92, 94, 95]. ity of life problems, children who did not slept slightly
The assessed GRADE quality of overall evidence did less at 6-7 years, but not 8-9 years [115].
not change for longitudinal studies examining adiposity One longitudinal study examined the association
(“Very Low”) or for RCTs examining psychosocial health between sleep duration and cardiometabolic biomark-
(“Moderate”). ers in children and youth. This study reported that
females who had longer sleep duration had higher lev-
Sleep els of systolic blood pressure and diastolic blood pres-
For the updated sleep systematic review, 2,764 new stud- sure. Among males, an inverse association was found,
ies were identified from the search of databases, with where those who had longer sleep duration had lower
1956 studies remaining after screening title and abstracts. levels of systolic blood pressure and diastolic blood
A total of 21 additional studies met the inclusion criteria pressure [116].
for the update. The assessed quality of overall evidence using GRADE
One longitudinal study reported a significant unfavour- criteria for these outcomes (“moderate” for RCTs and
able association between short sleep duration and adi- “very low” for longitudinal studies) did not change as a
posity gain [97]. result of including these additional studies.Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 10 of 21 Integrated higher sleep, or lower sedentary behaviour, each relative The final systematic review update included studies that to remaining behaviours [133]. investigated combinations of physical activity, sedentary Five cross-sectional studies examined the association behaviour, and sleep and their association with health between combinations of movement behaviours and car- indicators. The updated searches yielded 168 studies, diometabolic health in children and youth [6, 135–138]. with 20 additional studies meeting the inclusion criteria Better cardiometabolic health was reported in one study for the update. for children meeting all three guidelines (physical activ- Three longitudinal studies examined the association ity, screen time and sleep) [139] compared with chil- between combinations of movement behaviours and dren meeting none, one or two guidelines; and children body composition in school-aged children and youth meeting both physical activity and sedentary screen time [117–119]. According to one study, reallocation of time guidelines, compared to those not meeting these two from sleep, sedentary behaviour or LPA to MVPA was guidelines. One study found that, among children with associated with lower adiposity [118]. Another study high levels of SB, those with high VPA had better choles- reported that reallocation of time from sedentary behav- terol markers than those with low VPA [138]. Better car- iour to MVPA was associated with lower adiposity [120]. diometabolic health was reported for the reallocation of However, no associations were reported for reallocations time to VPA from LPA [137], and to MVPA from seden- from sedentary behaviour to LPA [119]. tary behaviour or LPA [136]. No associations were seen Of the cross-sectional studies, two found lower adipos- for other reallocations. One study reported better car- ity among children meeting all three guidelines (physi- diometabolic health among children with higher MVPA, cal activity, screen time and sleep) compared to those relative to the remaining movement behaviours [135]. meeting none or any one or two of these guidelines [6, Six studies examined the associations between combi- 8]. One study found lower adiposity among those meet- nations of movement behaviours and fitness. One lon- ing physical activity guidelines and those meeting sleep gitudinal study found that the reallocation of time to and screen time guidelines, compared to those who VPA from sedentary behaviour or LPA was associated were not [121]. Another study reported lower adiposity with better fitness [140]. Of the five cross-sectional stud- among clusters of children with high physical activity ies, one study reported better fitness among children compared to clusters with combinations of low physi- who met all three guidelines [139]; and among children cal activity/high sleep, high screen time/low sleep or who met both physical activity and sedentary screen high non-screen sedentary behaviour /poor diet [122]. time guidelines, compared to those who did not meet Three studies found children characterised by the com- these two guidelines. One study found children charac- bination of high physical activity/low sedentary behav- terized by high physical activity had better fitness than iour had lower adiposity than those characterised by low groups characterized by low physical activity/ high sleep, physical activity/high sedentary behaviour [123–125]. high screen time/low sleep, or high non-screen seden- Two 24-hour isotemporal substitution studies reported tary behaviour /low sleep [141]. In another study, bet- that the reallocation of time to MVPA from either sleep, ter fitness was associated with the reallocation of time sedentary behaviour or LPA was associated with lower to VPA from sedentary behaviour [140]. The remaining adiposity [126, 127]. In one of these studies, the real- study reported better fitness among children with higher location of time to LPA from sedentary behaviour was MVPA and with lower sedentary behaviour, relative to associated with lower adiposity, as was the reallocation other movement behaviours [135]. of time to sleep from sedentary behaviour or LPA in Two cross-sectional studies examined the associa- some age groups/sexes in both the studies [126]. In the tion between combinations of movement behaviours five isotemporal substitution studies [128–132] of wak- and health-related quality of life [142, 143]. One study ing activities only (not including sleep), lower adipos- reported better health-related quality of life children with ity was reported when time was reallocated away from higher MVPA, relative to other movement behaviours sedentary behaviour and given to either: MPA, VPA or [142]. In the other study, better health-related quality of MVPA [128, 129]. Reallocations from sedentary behav- life was reported among children meeting all three guide- iour to LPA were favourable in two studies [128, 130], lines (physical activity, screen time and sleep) compared but unfavourable in another study [129]. Reallocations with children meeting none, one or two of these guide- from LPA [128, 131] or MPA [128] to VPA were asso- lines; and for children meeting both the sleep and screen ciated with lower adiposity. Of two compositional data guidelines, compared to those not meeting these two studies [133, 134], both reported lower adiposity with guidelines. higher MVPA or lower LPA, each relative to remaining Two cross-sectional studies examined the association behaviours, while one also reported lower adiposity with between combinations of movement behaviours and
Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 11 of 21
behavioural outcomes [135, 139]. Better behavioural out- Australia with 49.5% from New South Wales, 8.1% from
comes were reported in one study for children meeting Victoria, 4.3% from Queensland, 7.0% from Western
all three guidelines (physical activity, screen time and Australia, 7.5% from South Australia, 6.5% from the Aus-
sleep) compared with children meeting none, one or two tralian Capital Territory, 0.5% from the Northern Terri-
of these guidelines; and for children meeting both the tory, and 5.4% from Tasmania. Approximately one out of
physical activity and screen time guidelines, compared nine respondents were from outside Australia (11.3%).
to those not meeting these two guidelines [139]. In the Respondents identified as being from the following sec-
second study, better behavioural outcomes were reported tors: education (49.7%), research/academia (19.8%), pub-
for children with higher sleep, relative to other move- lic health (8.0%), healthcare/services (6.4%), government
ment behaviours [135]. (5.4%), Commonwealth/State Departments of Health
The assessed quality of overall evidence using GRADE (4.8%), sport (2.1%), other (2.1%), physical activity/fitness
criteria for these outcomes did not change as a result of (1.1%), and recreation (0.5%).
including these additional studies. The proportion of respondents who strongly agreed or
somewhat agreed that the title, preamble, and guidelines
Consensus were clearly stated was very high, ranging from 83% to
The Australian Guideline Development Group reached 97%. The proportion who strongly agreed or somewhat
consensus in the interpretation of the evidence for each agreed with the message in these sections ranged from
movement behaviour and for the integration of the three 38% to 72%. A summary of the responses from the stake-
behaviours. On the basis of the evidence from the sys- holder survey is in Table 3. For the open-ended questions,
tematic reviews from Canada, the Canadian GRADE most suggestions were related to the wording, identifica-
tables and recommendations, and the updated systematic tion of key groups for implementing the 24-Hour Move-
reviews in Australia, the Guideline Development Group ment Guidelines, and determining the support these
adopted the Canadian recommendations. groups would require. Forty percent of respondents were
Following the consensus that Australia would adopt interested in supporting the Guidelines once released.
the Canadian recommendations, the Guideline Develop- Thirteen key informant interviews and three focus
ment Group then discussed if the wording of the Cana- groups were conducted. The results supported the find-
dian Guidelines, title and preamble was appropriate for ings from the online survey. All key stakeholders unani-
the Australian context. As a result of this discussion, sev- mously agreed with the ‘integrated’ nature of the new
eral minor changes were made to the wording of the title, 24-Hour Movement Guidelines. Stakeholders suggested
preamble, and guidelines. Group members were able to that integrating the Guidelines made the information
suggest a change, provide a rationale for the change. This more accessible. Several stakeholders commented that
was then discussed by the group. The Guideline Develop- it made sense to have them integrated as the behaviours
ment Group determined if the proposed change would be were so closely interrelated.
consistent with the quality and strength of the evidence All stakeholders suggested that the new 24-Hour
recommended and ensured it would not unintention- Movement Guidelines were clearly presented and were
ally alter the interpretation of the guideline. Consensus understandable, in general, for professional and policy
was required for a change to be accepted. Table S2 sum- makers “but not for the children themselves” [Education
marised the changes in wording between the Canadian Sector, ACT]. Some stakeholders suggested that they
and Australian Guidelines. Members of the Guideline thought the prescription (i.e. the number of hours) of
Development Group endorsed the draft title, pream- each behaviour was helpful.
ble, and guidelines, that were used for the stakeholder Several stakeholders, including children and young
consultations. people, suggested that the wording of the physi-
cal activity component of the Guidelines was con-
Stakeholder consultations and final guidelines fusing and needed to be modified. The wording of
The draft guidelines developed and approved by the the Guideline relating to sedentary behaviour also
Guideline Development Group at the August 2018 meet- raised some questions. Stakeholders were not clear
ing were used to seek broader consultation through what was meant by “long periods of time” and how
an online stakeholder survey, focus groups and key this would be operationalised by children and young
informant interviews. At the close of the online survey, people. Some stakeholders suggested that additional
responses from 237 participants were tabulated and ana- information further highlighting the importance of
lysed. The number of responses varied by question with sleep routines, quality of sleep as well as the relation-
between 186 to 237 responses for closed-ended ques- ship between the movement behaviours and broader
tions. Respondents were from every state and territory in health outcomes such as self-esteem, health andOkely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 12 of 21 wellbeing would have been a valuable addition to the suggested that if schools committed to promoting the guidelines. Guidelines and incorporating them into all areas of Irrespective of the sector, all stakeholders suggested learning then the evidence-base supporting the rela- that they would be able to use the new 24-Hour Move- tionship between these behaviours and educational ment Guidelines in their professional practice or in outcomes would need to be clear. If the promotional their home environment. Several suggestions to maxim- materials were optimal, a number of avenues could be ise their uptake were provided by the stakeholders. For used in the school environment to promote the Guide- example, the inclusion of “examples of different types of lines (e.g. newsletters, social media, health and physical physical activities” [Education sector, NSW and VIC] education departments in schools, homeroom leaders/ or “examples of how to limit screen time” [Children and teachers, and school counsellors). Young People from a number of Australian states and Given the diverse target group for the Guidelines, the territories] were suggested. An explanation of some of importance of tailored dissemination approaches was the more complex words such as moderate- to vigor- emphasised by all stakeholders. Irrespective of the tar- ous-intensity physical activity was also suggested. For get age, stakeholders suggested that consistent messag- optimal use within the Education Sector, key stakehold- ing between families, schools and other places/people of ers suggested that the Guidelines should be embedded influence was critical. within the Australian Curriculum and the link between Several barriers were highlighted by stakeholders the 24-Hour movement behaviours and educational that would need to be considered in the development outcomes and learning needed to be clear. Key stake- of promotional material. The obvious social change holders were highly conscious and aware of the already around smart phones and screen time has changed the overcrowded curriculum and the high workload of staff nature of screen-based activities and was a consistent and students. They suggested that teachers and princi- barrier mentioned by many stakeholders. Other barri- pals were unlikely to incorporate or promote the Guide- ers included the time-poor reality of parents, the over lines in their core business unless there was direct link scheduled child and young person, and cost and access to educational outcomes. Some stakeholders suggested to facilities. that the integrated nature (i.e. having all three behaviours Another barrier mentioned was the media highlight- together) of the Guidelines could potentially result in end ing the potential risks or injuries associated with physical users feeling overwhelmed and in turn disregarding the activity. Uncertainty around ongoing funding at State and Guidelines. Stakeholders suggested perhaps the market- Federal levels to support existing or new programs, such ing and promotional material should take on a ‘tiered as Ride to School initiatives and NSW Premier’s Be Active approach’, inclusive of a very simple version for children Challenge was also highlighted as a barrier for further and young people to a more complex version for parents promotion of the new Guidelines. and professionals. Stakeholders suggested that promoting all three move- The stakeholders suggested several dissemination ment behaviours would be an ongoing challenge. Physi- options for the new 24-Hour Movement Guidelines. cal activity and sedentary behaviours have been a key Most stakeholders suggested a multi-level approach focus for several years, however incorporating healthy that could be inclusive of flyers and brochures in com- sleep behaviours into public health messaging is new. munity centres, gyms and health professional environ- Thus, a concerted effort would be needed to ensure that ment, promotion through external facilitated sport all behaviours are equally promoted in the dissemination in schools, ministerial communications at both the of the new Guidelines. The final guidelines, including the Federal and State levels, social media campaigns, tra- title and preamble, are provided in Figs. 2 and 3. ditional media campaigns (inclusive of personal tes- timonies), websites, peak bodies for educators and Dissemination, implementation, and evaluation plans principals, additional professional development for A sub-group of the Guideline Development Group devel- educators and inclusion in pre-service training. oped a summary of suggested dissemination and imple- The main dissemination avenue suggested was mentation activities. This included key communication through parents and schools. Parents would have more strategies in the lead up to and after the official launch influence in promoting these behaviours for children of the Guidelines, with government and non-government (5-12 years), while schools could have a greater impact support for the integration of the guidelines into schools, for young people (i.e. those aged 13-17 years). As sug- primary and allied health services, sport and recreation, gested previously, the direct link between the move- and as part of whole-of-government approaches. Consul- ment behaviours and children’s educational outcomes tation with key users of the Guidelines during the Guide- and learning would need to be the focus. Stakeholders line Development Group meeting indicated that targeting
Okely et al. Int J Behav Nutr Phys Act (2022) 19:2 Page 13 of 21
Table 3 Summary results of closed-ended stakeholder survey questions.
Question Total (n) Strongly Somewhat Combined Neither agree nor Somewhat Strongly
agree, % (n) agree, % (n) agreement % (n) disagree, % (n) disagree, % (n) disagree, % (n)
Is the title clearly 237 124 (52.3) 74 (31.2) 198 (83.5) 7 (3.0) 28 (11.8) 4 (1.7)
stated?
Do you agree with the 235 90 (38.3) 93 (39.6) 183 (77.9) 22 (9.4) 26 (11.1) 4 (1.7)
title?
Is the preamble clearly 210 123 (58.6) 78 (37.1) 201 (95.7) 3 (1.4) 4 (1.9) 2 (1.0)
stated?
Do you agree with the 209 133 (63.6) 63 (30.1) 196 (93.8) 6 (2.9) 6 (2.9) 1 (0.5)
preamble?
Would you use the 210 90 (42.9) 88 (41.9) 178 (84.8) 15 (7.1) 13 (6.2) 4 (1.9)
preamble?
The 24-hour Guidelines 199 125 (62.8) 58 (29.2) 183 (87.1) 5 (2.5) 8 (4.0) 3 (1.5)
are clearly stated
Do you agree with the 200 144 (72.0) 50 (25.0) 194 (97.0) 3 (1.5) 3 (1.5) 0 (0.0)
Guidelines?
Total (n) Much more More useful, % (n) Neutral, % (n) Less useful, % (n) Much less
useful, % (n) useful, % (n)
In comparison to sepa‑ 197 65 (33.0) 97 (49.3) 162 (82.2) 31 (15.7) 4 (2.0)
rate physical activity,
sedentary behaviour,
and sleep guidelines,
do you find these inte‑
grated Guidelines…
Total (n) Always Frequently Combined High Use Occasionally Seldom/never
Would you use the 196 79 (39.3) 96 (47.8) 175 (87.1) 21 (10.5) 5 (2.5)
24-Hour Guidelines?
parents and schools using a multi-level approach would physical activity among children and young people. The
be most beneficial in enhancing awareness and adoption sub-committee recommended physical activity, seden-
of the guidelines. A “world-café” workshop [144, 145] tary behaviour, and sleep questions that could be incor-
was conducted as part of the Guideline Development porated into the AusPlay Survey (Sport Australia), an
Group meeting to brainstorm communication, dissemi- interview-administered telephone questionnaire for 5- to
nation, and implementation activities in relation to media 14-year-old children and a self-report for 15- to 17-year-
and complementary packages, training, and scaling-up of olds. These questions are shown in Table S4.
proven programs.
Discussion
This paper describes the process to develop the Aus-
Research gaps and surveillance recommendations tralian 24-Hour Movement Guidelines for Children and
Research gaps were identified through the updates of the Young People (5 to 17 years): An Integration of Physical
systematic reviews and during discussions at the Guide- Activity, Sedentary Behaviour, and Sleep and the out-
line Development Group meeting. This included thinking come. The evolution from separate guidelines for each
about surveillance and monitoring of the new guide- of these behaviours to integrated guidelines for this
lines. The full set of research gaps were distributed to the age group is relatively new. Feedback on the integrated
Guideline Development Group after the meeting for fur- approach for this age group was well received by key
ther feedback and agreement (summarised in Table S3). stakeholders. The Australian Guideline Development
A surveillance sub-committee was established at the Group was positive in their response to the task of devel-
Guideline Development Group meeting and tasked with oping integrated guidelines. This was aided by having the
recommending questions/methods that could be used for Canadian 24-Hour Movement Guidelines for Children
surveillance and monitoring of the Guidelines. This sub- and Youth to refer to and the presence of panel members
committee met three times via teleconference. This com- who were experienced with the 24-Hour approach to
mittee included representatives from Sport Australia and guideline development. The Australian guideline devel-
the Australian Bureau of Statistics, the two organisations opment followed the GRADE-ADOLOPMENT pro-
who routinely collect nationally representative data on cess. A strength of the guideline development processYou can also read
