Open access

Systematic review of sedentary behaviour and health indicators in the early years (aged 0–4 years)

Publication: Applied Physiology, Nutrition, and Metabolism
5 July 2012

Abstract

Accumulating evidence suggests that young children spend excessive time being sedentary. The purpose of this systematic review was to determine the relationship between sedentary behaviours and health indicators during the early years (ages 0–4 years). Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, this review aimed to present the best available evidence on the threshold of sedentary behaviour associated with healthy measures of adiposity, bone health, motor skill development, psychosocial health, cognitive development, and cardiometabolic health indicators in infants, toddlers, and preschoolers. Online databases, personal libraries, and government documents were searched for relevant studies. Studies that included an intervention (or experimental) group or prospective analysis were included. Twenty-one unique studies, representing 23 papers and 22 417 participants, met inclusion criteria; 7 studies included information on infants, 13 on toddlers, and 10 on preschoolers. Of these, 11, 6, and 8 studies reported data on adiposity, psychosocial health, and cognitive development, respectively. No included study reported on motor skill development, bone, or cardiometabolic health indicators. In conclusion, this review found low- to moderate-quality evidence to suggest that increased television viewing is associated with unfavourable measures of adiposity and decreased scores on measures of psychosocial health and cognitive development. No evidence existed to indicate that television viewing is beneficial for improving psychosocial health or cognitive development. In several instances a dose–response relationship was evident between increased time spent watching television and decreased psychosocial health or cognitive development. This work may be used as evidence to inform public health guidelines. (PROSPERO registration: CRD4011001280.)

Résumé

De plus en plus d’études mettent à jour le fait que les jeunes enfants consacrent trop de temps en mode sédentaire. Cette analyse documentaire se propose d’établir la relation entre les comportements sédentaires et des indicateurs de santé au cours de la petite enfance (0–4 ans). Cette analyse faite en utilisant la méthodologie GRADE (« Grading of Recommendations Assessment, Development, and Evaluation ») se propose de présenter les meilleures données probantes concernant le seuil de comportement sédentaire associé à des mesures de l’adiposité-santé, de la santé des os, du développement des habiletés motrices, de la santé psychosociale, du développement cognitif et des facteurs de risque de maladie cardiométabolique chez les nourrissons, les tout-petits et les enfants d’âge préscolaire. La recherche a été effectuée dans les bases de données en ligne, les bibliothèques personnelles et les documents gouvernementaux afin d’en ressortir les études pertinentes. Les études présentant une intervention auprès d’un groupe (expérimental) ou une analyse prospective sont incluses dans l’analyse documentaire. Vingt-et-une études distinctes couvrant 23 articles et comptant 22 417 participants répondent aux critères d’inclusion; sept études s’adressent à des nourrissons, treize à des tout-petits et dix, à des enfants d’âge préscolaire. Parmi ces études, onze présentent des observations sur l’adiposité, six, des observations sur la santé psychosociale et huit, des observations sur le développement cognitif. Aucune parmi les études incluses ne traite de développement des habiletés motrices, de santé des os et des indicateurs de santé cardiométabolique. En conclusion et selon cette analyse documentaire, la qualité des données probantes est de faible à modérée pour suggérer que consacrer plus de temps à regarder la télévision est associée à des mesures désavantageuses de l’adiposité et à de plus faibles valeurs des mesures de santé psychosociale et de développement cognitif. Il n’y a pas de données probantes suggérant que le fait de regarder la télévision est bénéfique pour l’augmentation de la santé psychosociale et du développement cognitif. Dans plusieurs cas, on observe une relation dose-réponse entre l’augmentation du temps consacré à regarder la télévision et la diminution de la santé psychosociale ou du développement cognitif. Cette analyse peut servir de base à l’élaboration des directives en matière de santé publique. (PROSPERO numéro d’enregistrement : CRD4011001280.)

Introduction

Sedentary behaviour is an important area of study in health research. It is defined as any waking behaviour associated with an energy expenditure ≤1.5 METs and a sitting or reclining posture, and is considered separate and distinct from a lack of moderate- to vigorous-intensity physical activity (i.e., not meeting specified physical activity guidelines) (Sedentary Behaviour Research Network 2012; Tremblay et al. 2010). Canadian research on school-age children (aged 5–18 years) indicates that on average they spend 8.6 h per day, or 62% of their waking hours, engaging in sedentary behaviour (Colley et al. 2011). These sedentary activities, especially those that are screen-based, are associated with increased risk for obesity, and decreased fitness, self-esteem, pro-social behaviour, and academic achievement (Tremblay et al. 2011c).
Accumulating evidence indicates sedentary lifestyles are also occurring in the early years (defined in this paper as aged 0–4 years; i.e., birth to 4.99 years). For example, several sources report that children in the early years spend 73%–84% of their waking hours being sedentary (Reilly et al. 2004; Vale et al. 2010). Furthermore, most children in the early years engage in more than 1 h per day of screen time (Carson et al. 2010) and are being exposed to screen-based activities before the age of 2 years (Zimmerman et al. 2007). Consequently, there is an increased interest in the health implications of excessive sedentary behaviour during this critical period of growth and development. Evidence suggests that compared with school-aged children, screen time may be associated with additional negative health outcomes in the early years (Christakis et al. 2009; Lillard and Peterson 2011). Furthermore, sedentary behaviour habits formed during the early years may track over time (Janz et al. 2005). As a result, there may be several immediate and long-term health benefits by encouraging appropriate sedentary behaviour habits in this age group (United Nations General Assembly 2001; World Health Organization 2010).
Information related to sedentary behaviour for young children was recently released as part of new physical activity guidelines in Australia (Australian Government Department of Health and Ageing 2010) and the United Kingdom (Start Active Stay Active 2011). Though the United Kingdom identified no specific cut-point for sedentary behaviour time, guidelines from Australia state that screen time is not appropriate for those <2 years of age, and should be limited to <1 h per day for those aged 2–5 years (Australian Government Department of Health and Ageing 2010). Further, guidelines from Australia and the United Kingdom recommend limiting time spent being restrained for long periods of time. Similarly, the American Academy of Pediatrics discourages media use in children <2 years of age and that it should be limited to <2 h of quality educational screen time per day for children older than 2 years (American Academy of Pediatrics, Council on Communications and Media 2011a, 2011b). Finally, recommendations from the Canadian Pediatric Society state that television viewing should be limited to 1 to 2 h per day for children of all ages (Ford-Jones and Nieman 2003). However, to date, recommendations on appropriate levels of sedentary behaviour have not been informed by a systematic review that focuses specifically on sedentary behaviour.
Therefore, the purpose of this paper is to present evidence examining the relationship between sedentary behaviour and health indicators in the early years (aged 0–4 years). Specifically, this systematic review aims to synthesize the best available evidence on the optimal dose (i.e., frequency, interruptions, time, and type) of sedentary behaviour, as measured by direct and indirect methods, associated with improved health indicators in infants (1 month – 1.0 year), toddlers (1.1–3.0 years), and preschoolers (3.1–4.99 years). The evidence presented in this review can serve to inform the development of evidence-based sedentary behaviour guidelines for this age group.

Methods

This review is registered with the international prospective register of systematic reviews PROSPERO network (registration no. CRD4011001280). More information on PROSPERO is available at http://www.crd.york.ac.uk/prospero/.

Quality assessment

The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to guide our evaluation of the evidence from this systematic review, including a priori ranking of health indicators and risks of harm for decreasing sedentary behaviours and quality assessment of the evidence. In brief, GRADE is an internationally endorsed framework that provides a systematic and transparent methodology for clarifying research questions, determining outcomes of interest, summarizing relevant evidence, and presenting recommendations based on the quality of available evidence. For this review, included studies were divided by age group and then by health indicator. Quality of evidence for each health indicator was assessed based on study design, risk of bias, consistency of results, directness of the intervention, precision of results, and possible dose–response gradient during data extraction. Randomized control trials begin at the highest quality evidence but may be decreased due to study limitations, inconsistency of results, indirectness of evidence, imprecision, or reporting bias. Observational studies begin at the lowest quality evidence but may be increased if the magnitude of treatment effect is large, if there is a reported dose–response relationship, or if all plausible biases would decreased the magnitude of effect. Details on data extraction are presented in the following sections. Details on GRADE methodology can be found elsewhere (Balshem et al. 2011; Guyatt et al. 2011a, 2011b, 2011c, 2011d, 2011e, 2011f, 2011g, 2011h).

Study inclusion criteria

The review sought to identify studies that examined the relationship between sedentary behaviour time and a specified health indicator in the early years (infants: 1 month – 1.0 years; toddlers: 1.1–3.0 years; preschoolers: 3.1–4.99 years). Studies were included only if there was a specific measure of sedentary behaviour time obtained via direct (e.g., measurements of sitting, sedentary behaviour through accelerometery, or direct observation) or self-reported (e.g., television viewing, video gaming, and “screen time” — defined as composite measures of television, computers, video games) methods. Sedentary behaviour time may also have been measured as a composite of total time engaged in sedentary behaviours. Health indicators were chosen a priori by an expert panel that convened in March 2011 as part of the Canadian sedentary guidelines for the early years development process (Tremblay et al. 2012). Health indicators were chosen based on expert consensus and to harmonize with research from Australia and the United Kingdom. Priority of relevant health indicators was determined by consensus a priori (see Table 1). The 6 eligible health indicators were
1.
Adiposity (e.g., body mass index (BMI), waist circumference, skinfolds, bio-impedance analysis (BIA), dual-energy X-ray absorptiometry (DXA or DEXA);
2.
Bone and skeletal health (e.g., bone mineral density (BMD), bone mass (i.e., bone mineral content (BMC));
3.
Motor skill development (e.g., motor proficiency, gross motor skills, locomotor and object control);
4.
Psychosocial health (e.g., self-concept, self-esteem, emotions, happiness, social–peer interaction, acceptance, aggression, temperament);
5.
Cognitive development (e.g., language development, attention);
6.
Cardiometabolic health indicators (e.g., plasma lipids, lipoprotein concentrations (e.g., high-density lipoprotein cholesterol, triglycerides), hypertension, fasting glucose, insulin resistance, inflammatory markers (e.g., C-reactive protein).
Table 1.
Table 1. A priori consensus rankings assigned by the Guideline Development and Research Committee for each health indicator by age group.

Note: Health indicators were ranked based on whether they were critical for decision-making, important but not critical, or of low importance for decision-making. The focus when searching and summarizing the evidence was on indicators that were important or critical. Rankings were based on the GRADE framework (Guyatt et al. 2011a). NA, not applicable.

Studies were included if they were published and peer reviewed, and employed one of the following designs: randomized controlled trial, quasi-experimental, intervention, prospective cohort, or any study that has either a comparison group or a follow-up period (Dishman et al. 2004; Haynes et al. 1990). Longitudinal studies were included if the data presented in the article were consistent with established age limits (i.e., the study was required to have at least 1 measurement from the 0- to 4-year-old period). Details on included study designs and relevant definitions can be found in Appendix A. Inclusion criteria included limits on study design so that only the highest quality evidence was included, to minimize risk of bias, and to ensure our search identified a manageable number of possible studies. No language or date limits were imposed in the search; however, because of issues of feasibility, potential papers published in languages other than English or French (n = 7) were excluded.

Study exclusion criteria

Studies examining “active gaming” (e.g., Nintendo Wii, Microsoft Kinect, Sony’s Playstation Move, video arcades, etc.) and those that defined sedentary behaviour as “failing to meet physical activity guidelines” were excluded.

Search strategy

A comprehensive strategy was used to identify relevant studies in the following electronic bibliographic databases: Ovid MEDLINE(R) (1948 to 11 May 2011), Ovid EMBASE (1947 to 11 May 2011), and Ovid psycINFO (1806 to week 2 of May 2011), EBSCO SPORTDiscus (1985 to 11 May 2011), and Cochrane Central Database (up to May 2011). The search strategy (see Appendix B) was created by A.G.L., with the help of an expert in library and information services, and run by A.G.L. Database searches were limited to studies involving “infant”, “toddler”, or “preschool” children (exact age limitations varied by database). References were extracted as text files from the OVID, EBSCO, and Cochrane interfaces and imported in to Reference Manager Software (version 11; Thompson Reuters, San Francisco, Calif., USA). Duplicate articles were first removed using Reference Manager Software; remaining duplicates were removed manually. All articles were assigned a unique reference identification number in the database.
Titles and abstracts of potentially relevant articles were screened by 2 independent reviewers (V.C. and A.G.L.) and full text copies were obtained for articles meeting initial screening criteria. The same reviewers independently examined all full text articles for inclusion in the review; any discrepancies were discussed by the reviewers. If they were unable to reach consensus, a third reviewer was asked to examine the article, and in some cases, the questionable articles were presented to the entire guideline development panel and consensus on inclusion was achieved.
In addition to our search, 6 key content experts were contacted and asked to identify the most influential papers from their personal libraries examining sedentary behaviour and health in the early years. Two of these experts were involved in the development of preschool guidelines in Australia and the United Kingdom. Content experts were also consulted to help identify key health indicators and guide decisions on search terms. To further help identify studies and to guide the review process, government documents from Canada (Canadian Pediatrics Society), Australia (Australian Government Department of Health and Ageing 2010), and the United Kingdon (Start Active Stay Active 2011) were used for reference.

Data extraction

Standardized data extraction tables were created through consultation with methodological experts and input from the guideline development panel; data extraction was completed by 1 reviewer and checked by another for accuracy (one of V.C., S.C.G., M.E.K., or A.G.L.). Information was extracted regarding study characteristics (year, study design, country, number of participants, age), type of sedentary behaviour, measure of sedentary behaviour, and health indicator. Within each age group, at least 2 reviewers (V.C., S.C.G., M.E.K., A.G.L.) independently assessed the quality of evidence for all studies (Guyatt et al. 2011a, 2011b, 2011c, 2011d, 2011e, 2011f, 2011g). If there was a discrepancy, the reviewers discussed their assessment until consensus was achieved. Based on these assessments, the impact of the risk of bias assessments on our overall confidence in the effect size across studies was examined, within and across each outcome (e.g., adiposity) and age group (e.g., infants). Reviewers were not blinded to the authors or journals when extracting data.

Analysis

By age group (i.e., infants, toddlers, or preschoolers), we identified all studies contributing to each health indicator. By health indicator, meta-analysis was planned for data that were sufficiently homogeneous in terms of statistical, clinical, and methodological characteristics using Review Manager Software 5.0 (The Cochrane Collaboration, Copenhagen, Denmark). Otherwise, qualitative synthesis was conducted for remaining studies. A priori comparisons for subgroup analysis were planned as follows: by direct or indirect measurement; by dose of sedentary behaviour (i.e., frequency, interruptions, time, or type); finally, by study quality (if sufficient homogeneity existed, through risk of bias assessment).

Harms of decreased sedentary behaviour

To ensure that both benefits and harms of interventions to decrease sedentary time were considered, potential harms associated with decreased sedentary time were discussed. Similar to discussions regarding importance of health indicators mentioned above, potential harms associated with decreased sedentary time were ranked by priority (unimportant, important, or critical) a priori by 4 reviewers (S.C.G., M.E.K., A.G.L., M.S.T.). A search was conducted on risks ranked as “important” or “critical”. Musculoskeletal injury was the only risk ranked as critical and an Ovid MEDLINE search was performed to assess the evidence. To maximize the search, all study designs were included (see search strategy in Appendix B).

Results

The preliminary search of electronic databases identified 6240 potentially relevant articles (Fig. 1). Of these, 2041 were identified in MEDLINE, 2411 in EMBASE, 601 in psycINFO, 640 through SportDiscus, 547 through Cochrane Central Database, and 113 through key informants, government documents, and bibliographies. After de-duplication, 5265 relevant articles remained. A preliminary review of titles and abstracts resulted in 288 articles being included for detailed assessment of the full text. Of these, 21 unique studies represented in 23 papers met the criteria for study inclusion. Individual study characteristics can be seen in Table 2. Reasons for excluding studies included ineligible age (n = 107), ineligible exposure (e.g., diet, not meeting physical activity guidelines) (n = 64), ineligible outcome (n = 29), ineligible analysis or study design (e.g., review, cross-sectional analysis) (n = 173); many studies were excluded for multiple reasons. No studies were excluded because of active gaming.
Fig. 1.
Fig. 1. Prisma flow diagram of included studies. a, Databases included the following: Medline (n = 2041), Embase (n = 2411), PsycINFO (n = 601), SportDiscus (n = 640), Cochrane central database (n = 547); b, some full text articles were excluded for multiple reasons; c, 21 unique studies represented in 23 papers.
Table 2.
Table 2. Descriptive characteristics of included studies.

Note: BMI, body mass index; TV, television.

a
Analysis was in part retrospective and examined age at which children first started watching television (7.2 months for those with a language delay, 11.9 months for those without a language delay); therefore, information was included with other studies focused on infants.
b
Christakis and Zimmerman (2007) and Zimmerman and Christakis (2007) both used data from the Panel Study of Income Dynamics; Foster and Watkins (2010) and Zimmerman and Bell (2010) both used data from the National Longitudinal Study of Children and Youth.
Table 2 provides a summary of all studies included in the review. In total, data from 22 417 participants were included. Study sample size ranged from 19 (Gupta et al. 1994) to 5493 (Reilly et al. 2005) participants. Articles were published over a 17-year period from 1994 (DuRant et al. 1994; Gupta et al. 1994) to 2010 (Cheng et al. 2010; Foster and Watkins 2010; Pagani et al. 2010; Zimmerman and Bell 2010). Included studies involved participants from 8 countries. Almost all (21 of 23) included papers presented data from prospective cohort studies with follow-up periods between 1 month and 8 years.
Quality of evidence by age group and across outcomes can be found in Tables 3–5. Nine unique studies examined the relationship between sedentary behaviour and health in infants, 12 in toddlers, and 10 in preschoolers. The outcomes of interest represented in the included studies were adiposity (n = 11), cognitive development (n = 8), and psychosocial health (n = 6). No included studies examined the relationship between sedentary behaviour and bone skeletal health, motor development, or cardiometabolic health in the early years (aged 0–4 years). Some studies included results for more than 1 age category and were presented accordingly. All studies used parent, caregiver, or teacher reports to quantify the time children spent watching television. Because of the heterogeneity of measurements (for both sedentary exposure and health indicator), meta-analysis was not possible for any outcomes. Subgroup analysis was not possible for measurement type, dose, or study quality.
Table 3.
Table 3. Is sedentary behaviour associated with poor health outcomes in infants (<12 months)?

Note: Bibliography: Adiposity, Zimmerman and Bell (2010); cognitive, Schmidt et al. (2009), Alston and James-Roberts (2005), Zimmerman and Christakis (2007), Foster and Watkins (2010), Tomopoulos et al. (2010), Chonchaiya and Pruksananonda (2008), Christakis et al. (2009), Zimmerman et al. (2005). TV, television; BMI, body mass index; OR, odds ratio.

a
Includes 1 prospective cohort study (Zimmerman and Bell 2010).
b
Each additional hour of commercial television (with advertisements) associated with an increase of 0.11 BMI z scores, no effect seen for noncommercial television, therefore authors conclude it is the content of the television (advertising) and not the sedentary behaviour that is the cause of the increase in BMI (Zimmerman and Bell 2010).
c
Data from Alston and James-Roberts (2005) not presented because the analysis did not investigate the relationship between television exposure and cognitive development.
d
Includes 1 case control study (Chonchaiya and Pruksananonda 2008) and 6 prospective cohort studies (Christakis et al. 2009; Foster and Watkins 2010; Schmidt et al. 2009; Tomopoulos et al. 2010; Zimmerman et al. 2005; Zimmerman and Christakis 2007).
e
Dose–response relationship was seen for increased exposure and poorer cognitive performance in 3 studies (Chonchaiya and Pruksananonda 2008; Tomopoulos et al. 2010; Zimmerman and Christakis 2007).
f
Case control study (Chonchaiya and Pruksananonda 2008): n = 56 (case), n = 110 (control).
g
Each additional hour of violent or nonviolent programming associated with increased attention problems (Zimmerman and Christakis 2007).
h
Adjusted odds of onset of television viewing before 12 months and exposure to 2+ hours a day for increased risk of language delay (Chonchaiya and Pruksananonda 2008).
i
Each additional hour of exposure associated with a decrease in child’s vocalization count (Christakis et al. 2009).
j
Each hour of television viewing associated with increases on reading recognition and comprehension and memory scores respectively; no significant effect on math scores (Zimmerman et al. 2005).
k
Adjusted log transformed coefficients for effects of media exposure at 6 months with cognitive and language development at 14 months, respectively (Tomopoulos et al. 2010).
l
No effect of television viewing at 1 year of age and attention at 7 years of age when covariates are controlled (Foster and Watkins 2010); no effect of television exposure at 6–24 months on language and visual motor skills at 3 years (Schmidt et al. 2009).
Table 4.
Table 4. Is sedentary behaviour associated with poor health outcomes in toddlers (aged 1.1–3.0 years)?

Note: Bibliography: Adiposity, Lumeng et al. 2006, Reilly et al. 2005, Blair et al. 2007, Pagani et al. 2010; psychosocial, Cheng et al. 2010, Christakis and Zimmerman 2007, Tomopoulos et al. 2007, Mistry et al. 2007, Pagani et al. 2010; cognitive, Pagani et al. 2010, Mistry et al. 2007, Foster and Watkins 2010, Christakis et al. 2009, Zimmerman et al. 2005, Zimmerman and Christakis 2007, Schmidt et al. 2009, Christakis and Zimmerman 2007. BMI, body mass index; OR, odds ratio; TV, television.

a
b
Dose–response between increased television viewing and BMI (Reilly et al. 2005); hours of television watched per day and % body fat (Blair et al. 2007); hours of television and BMI (Pagani et al. 2010); Lumeng 2006 looked at television as dichotomous variable and did not have a dose–response relationship.
c
Sample size totals based on adjusted analyses.
d
Each additional hour of commercial television (with advertisements) associated with an increase of 0.11 BMI scores, no effect seen for noncommercial television; therefore, authors conclude it is the content of the television (advertising) and not the sedentary behaviour that is the cause of the increase in BMI (Zimmerman and Bell 2010).
e
Odds ratio for watching 4.1–8 h and 8+ hours per week respectively.
f
Odds ratio for each additional hour of sedentary time (outcome is BMI) (Reilly et al. 2005).
g
Odds ratio for 1–3 h of television viewing and 3+ hours (compared with <1 h of television per day) (outcome is change in body fat) (Blair et al. 2007).
h
Standardized beta for each additional hour of television (outcome is BMI (Pagani et al. 2010).
i
No association between ≥2 h per day of television viewing and adiposity (Lumeng et al. 2006).
k
Two of the included studies showed evidence for a dose–response relationship between increased television viewing and poor measures of psychosocial health (Christakis and Zimmerman 2007, Pagani et al. 2010, Zimmerman et al. 2005).
l
Mean scores on pro-social scale for 1 h of television to >4 h; dose–response relationship (Cheng et al. 2010).
m
Odds ratios for aggressive behaviour and externalizing problems on Child Behavior Checklist for a 1-h increase in television viewing; no effect seen for oppositional defiant problems; effects are stronger when programming was noneducational (Tomopoulos et al. 2007).
n
For each additional hour of television viewing victimization score increases by 10% (Pagani et al. 2010).
o
Significant effects for early exposure only for emotional reactivity, significant effects of early and sustained exposure on aggressive and externalizing behaviours, respectively, no effects seen on anxious–depressed scale (Mistry et al. 2007).
p
Increased odds of antisocial behaviour at 7–9 years for each additional hour of violent programming that boys watched at 2–4 years; no effect seen for nonviolent and educational programming (Christakis and Zimmerman 2007).
r
Effects of sustained exposure (30–33 months and 5.5 years) on attention scores (Mistry et al. 2007)
s
Each additional hour of exposure associated with a decrease in child’s vocalization count (Christakis et al. 2009).
t
Each hour of television viewing associated with a 7% decrease in classroom engagement and 6% decrease in math achievement (Pagani et al. 2010)
u
Each additional hour of violent or nonviolent programming associated with increased attention problems (Zimmerman and Christakis 2007)
v
No effect on attention, Foster and Watkins (2010); no effect of television exposure at 6–24 months on language and visual motor skills at 3 years (Schmidt et al. 2009).
Table 5.
Table 5. Is sedentary behaviour associated with poor health outcomes in preschool children (aged 3.0–4.9 years)?

Note: Bibliography: Adiposity, Dennison et al. 2004, DuRant et al. 1994, Zimmerman and Bell and 2010, Jago et al. 2005, Proctor et al. 2003, Brown et al. 2010; psychosocial, Pagani 2010, Christakis and Zimmerman 2007, Zimmerman et al. 2005; cognitive, Zimmerman and Christakis 2007. RCT, randomized clinical trial; TV, television; BMI, body mass index.

a
Mean difference in television viewing ≥2 h per day in intervention group, BMI also decreased in intervention group, but difference was nonsignificant (Dennison et al. 2004).
b
Includes 5 prospective cohort studies (DuRant et al. 1994; Jago et al. 2005; Proctor et al. 2003; Zimmerman and Bell 2010); Brown et al. (2010) was a prospective study but only presented cross-sectional analysis for the variables in question and was therefore excluded from further analysis.
c
Dose–response gradient was reported in 1 study (Proctor et al. 2003) but was insufficient to warrant upgrading quality.
d
Each additional hour of commercial television (with advertisements) associated with an increase of 0.11 BMI z scores, no effect seen for noncommercial television; therefore, authors conclude it is the content of the television (advertising) and not the sedentary behaviour that is the cause of the increase in BMI (Zimmerman and Bell 2010).
e
Mean BMI for 3+ hours of television compared with <1.8 h television and video viewing over the 7 years of the study; mean sum of skinfolds (mm) for 3+ hours compared with <1.8 h over the 7 years of the study; model controlled for age, sex, baseline anthropometry, and physical activity levels (Proctor et al. 2003).
f
Increased BMI across 3 years associated with increased television viewing (hours per day) (Jago et al. 2005).
g
Television viewing was not correlated with skinfolds, BMI, or waist-hip ratio, although data were collected over 1 year and the data were collapsed so while the study design was longitudinal, the analysis was only quasi longitudinal (DuRant et al. 1994).
h
Includes 3 prospective cohort studies (Christakis et al. 2009; Pagani et al. 2010; Zimmerman et al. 2005).
i
Increased odds of antisocial behaviour at 7–9 years for each additional hour of violent programming boys watched at 2–4 years; no effect seen for nonviolent and educational programming (Christakis and Zimmerman 2007).
j
Increased odds of bullying at 6–11 years for each additional hour of television watched at age 4 (Zimmerman et al. 2005)
k
For each hour of increased television viewing between 29 and 53 months there is a 6% increase in victimization (Pagani et al. 2010).
l
Includes 1 prospective cohort study (Zimmerman and Christakis 2007).
m
No effect of television viewing at age 4–5 on attention problems at age 9–10 years (Zimmerman and Christakis 2007).

Data synthesis

Overall, in infants, there was moderate-quality evidence to suggest television viewing elicited no benefits and may be harmful to cognitive development; and low-quality evidence to suggest increased television viewing was associated with unfavourable adiposity. In toddlers, there was moderate evidence suggesting television viewing has a negative impact on adiposity, moderate evidence to suggest it negatively affected psychosocial health, and low-quality evidence to suggest it has a negative impact on cognitive development. In preschoolers, there was low- to high-quality evidence on television’s negative impact on adiposity, moderate-quality evidence between increased television and decreased scores on measures of psychosocial health, and low-quality evidence on the inverse relationship between television viewing and cognitive development.

Adiposity

Eleven studies examined the relationship between sedentary behaviour and measures of adiposity; none in infants, 4 in toddlers, and 6 in preschoolers; 1 study included data from those aged 0–6 years. All included studies had parent-reported television viewing as the main exposure. Adiposity was measured through BMI (Dennison et al. 2004; DuRant et al. 1994; Pagani et al. 2010; Reilly et al. 2005), BMI z scores (Zimmerman and Bell 2010), change in body fat (Blair et al. 2007), and mean sum of skinfolds (DuRant et al. 1994; Proctor et al. 2003). One prospective cohort (Zimmerman and Bell 2010) reported on the relationship between television viewing and BMI z scores across young children (defined as ages 0–6 years). They reported that increased television viewing was associated with increased adiposity; however, when commercialized television viewing was controlled for, this relationship disappeared. No studies examined this relationship specifically in infants.
In toddlers, 4 prospective studies were included. Three of these studies reported a dose–response relationship between hours of television viewing and increased BMI (Pagani et al. 2010; Reilly et al. 2005) and percent body fat (Blair at al. 2007). The remaining study dichotomized groups by those who watched more (or less) than 2 h of television per day, making it impossible to discern any dose–response relationship. We upgraded the quality of evidence from low to moderate because of the dose–response relationship, which means that as the number of hours of television exposure increased so did the level of adiposity (Table 4); we identified no serious risk of bias, inconsistency, indirectness, or imprecision.
In preschoolers, 1 randomized trial (Dennison et al. 2004) and 5 prospective studies were included (Brown et al. 2010; DuRant et al. 1994; Jago et al. 2005; Proctor et al. 2003; Zimmerman and Bell 2010). The purpose of the randomized trial was to decrease television viewing through a preschool educational program. Although the program was successful in decreasing the time preschoolers watched television, this was not associated with any significant changes in BMI. Of the 5 prospective studies, 1 reported a dose–response relationship with those in the highest tertile of television and video viewing (≥3 h·day–1) having greater increases in body fat (measured through BMI, sum of skinfolds and triceps skinfolds) in early adolescents (mean age = 11.1 years) than those in the lowest tertile of television and video viewing (≥1.75 h·day–1). This finding remained after controlling for level of physical activity and was worse for those who had the highest overall levels of sedentary behaviour (Proctor et al. 2003). Two of the 5 studies reported that those who watched more television during the preschool period had higher skinfold measurements (Proctor et al. 2003) and BMI (Jago et al. 2005) later in life (at age 11 years and 6 years, respectively). The studies had low- to high-quality evidence and no serious risk of bias, inconsistency, indirectness, or imprecision (Table 5).

Psychosocial health

Six studies examined the relationship between sedentary behaviour and measures of psychosocial health (e.g., hyperactivity, self-control, engagement); none of the included studies reported on infants, 5 reported on toddlers and 3 reported on preschoolers.
In toddlers, 5 prospective studies reported that higher levels of television viewing were associated with lower scores on pro-social checklists (e.g., hyperactivity, pro-social behaviour) (Cheng et al. 2010), higher risk for aggressive behaviour and externalizing problems (Mistry et al. 2007; Tomopoulos et al. 2007) and increased risk for victimization (i.e., was called names, hit or pushed, or made fun of by other children) (Pagani et al. 2010). In preschoolers, 3 prospective cohort studies (Christakis and Zimmerman 2007; Pagani et al. 2010; Zimmerman et al. 2005) reported a dose–response relationship between increased television viewing and poor measures of psychosocial health. Each additional hour of television viewing was associated with increased odds for antisocial behaviour (Christakis and Zimmerman 2007), victimization (Pagani et al. 2010), and maternal reported bullying (Zimmerman et al. 2005). In both toddlers and preschoolers, a stronger association between screen time and poor measures of psychosocial health was observed when the content of the screen time was either violent or noneducational in nature (Christakis and Zimmerman 2007; Tomopoulos et al. 2007). Overall, the studies had moderate-quality evidence and no serious risk of bias, inconsistency, indirectness, or imprecision; evidence of a dose–response relationship existed for toddlers and preschoolers (Tables 4 and 5).

Cognitive development

Eight studies examined the relationship between sedentary behaviour and cognitive development; 7 of these were in infants, 5 were in toddlers, and 1 was in preschoolers. Three of these studies examined cognitive development across the early years and the data were therefore included for more than a single age group (Foster and Watkins 2010; Zimmerman et al. 2005; Zimmerman and Christakis 2007). The studies had low- to moderate-quality evidence and no serious risk of bias, inconsistency, indirectness, or imprecision (Tables 3–5); evidence of a dose–response relationship existed for infants. Indicators and measurements of cognitive development varied across age group and study.
One case-control study (Chonchaiya and Pruksananonda 2008) and 6 prospective cohort studies (Christakis et al. 2009; Foster and Watkins 2010; Schmidt et al. 2009; Tomopoulos et al. 2010; Zimmerman et al. 2005; Zimmerman and Christakis 2007) examined this relationship in infants. Of these, 2 studies (Foster and Watkins 2010; Schmidt et al. 2009) reported no relationship between early television viewing and measures of attention, language, or visual motor skills. Three studies (Chonchaiya and Pruksananonda 2008; Tomopoulos et al. 2010; Zimmerman and Christakis 2007) reported a dose–response relationship between increased exposure to television and decreased cognitive performance; attention; vocalization count and language delays; and reading recognition, comprehension, and memory scores. We upgraded the quality of evidence from low to moderate because of the dose–response relationship between increased television exposure and decreased cognitive outcomes (Table 3).
Five prospective cohort studies (Christakis and Zimmerman 2007; Foster and Watkins 2010; Mistry et al. 2007; Pagani et al. 2010; Zimmerman et al. 2005) examined the relationship between television viewing and cognitive development in toddlers. Of these, 2 studies (Foster and Watkins 2010; Schmidt et al. 2009) reported no significant relationship. The remaining 3 studies (Christakis et al. 2009; Mistry et al. 2007; Pagani et al. 2010) reported a dose–response relationship with each additional hour of television exposure related to decreased vocalization, classroom engagement, and math scores. One low-quality prospective cohort study (Zimmerman and Christakis 2007) reported on the relationship between television viewing and cognitive development in preschoolers. The studies examining cognitive outcomes for toddlers and preschoolers were low quality (Tables 3 and 4).

Risk of decreased sedentary behaviour

A total of 57 articles were found through a search of Ovid MEDLINE and by scanning reference lists. None of these studies met the inclusion criteria. Most reported on the danger of furniture falling on young children and were not related to one of our health indicators of interest.

Discussion

This review aimed to use the best quality evidence to report on the relationship between sedentary behaviour time and health indicators during the early years. Current evidence supports the idea that increased television viewing is associated with unfavourable measures of adiposity, psychosocial health, and cognitive development. Further, no evidence exists to suggest television viewing is beneficial for improved psychosocial or cognitive development. In several instances, a dose–response relationship existed between increased time spent watching television and decreased psychosocial or cognitive development. This is consistent with evidence in older children (aged 5–17 years) that reported an association between increased screen time and unfavourable body composition, decreased fitness, lowered scores for self-esteem, and pro-social behaviour and decreased academic achievement (Tremblay et al. 2011c).
The results of this review do not provide specific information on the dose (i.e., frequencies, interruptions, times, or types) of sedentary behaviour necessary for good health, nor do they provide definitive information as to how this relationship differs between boys and girls. All studies reported on the relationship between television viewing and a health indicator (i.e., no other types of sedentary behaviour were explored). We would like to highlight that television viewing is only a crude measure of sedentary behaviour and it is likely that caregivers underestimate this time, meaning that our results may in fact be underestimating its overall impact of television viewing on poor health. Therefore, future work should focus on using direct measures (i.e., accelerometers, inclinometers) within large cohorts of children so that groups can be stratified by volume of sedentary behaviour, sex, and age group. Direct measurements would also allow researchers to better understand the sedentary patterns children engage in throughout the day. This information would help to identify specific times when parents, caregivers, and educators should promote reductions in sedentary behaviours.
Effort was made to determine possible risks associated with decreasing children’s sedentary time. However, no studies that specifically examined the association between decreased sedentary time and increased health risk could be identified. The lack of evidence may be indicative of the lack of potential harms associated with decreasing sedentary time. It is possible that parents may feel their children are “missing out” if they abstain from watching television, as there is a misconception amongst the general public that television provides unique learning (Active Healthy Kids Canada 2009, 2010; Zimmerman et al. 2007) and socializing (Holt et al. 2008) opportunities. Though there is evidence to show that violent television is more harmful than educational programming (Christakis and Zimmerman 2007; Zimmerman and Christakis 2007), evidence supporting the idea that children learn better through electronic stimulation is lacking. In fact, the opposite appears to be true (i.e., children learn better by engaging with parents and caregivers than with a television) (Barr and Wyss 2008; Barr et al. 2007; Nielsen et al. 2008; Zack et al. 2009). The authors do wish to acknowledge the safety benefits of restraining children (i.e., in a stroller, car seat) and encourage parents and caregivers to put safety first, but to try and limit this time. For example, on a long car ride, breaking up sedentary time with activity breaks may be beneficial for young children.
The authors would like to acknowledge some specific strengths and limitations to this review. This review followed the rigorous methodological standards that have been established for systematic reviews. Furthermore, this review used the GRADE framework to guide the review process and assess the evidence. In accordance with GRADE, as many decisions as possible were made a priori, which helps to limit potential bias throughout the review. Furthermore, all steps of the review (i.e., inclusion criteria, exclusion criteria, data extraction, GRADE tables) were done in duplicate to minimize error. However, using such a rigorous methodology also creates limitations. For example, it is possible this review would have benefited from including studies that used a lower quality design (i.e., cross-sectional). Further, all included studies used parental report measures of television viewing as a proxy measure of sedentary time. Future work should focus on using both direct and reported (parent, caregiver) measures to assess total daily sedentary behaviour, and its subcomponents beyond television viewing, in this age group. Ideally this would include multiple follow-up measurements so the longitudinal effects of high levels of sedentarism at a young age can be better understood. It is also important that future work aims to harmonize methods for data collection and analysis so that meta-analysis can be performed.

Conclusion

To our knowledge, this is the first published systematic review aimed specifically at clarifying the relationship between sedentary behaviour time and health indicators in the early years (aged 0–4 years). This review has found evidence that increased television viewing is associated with unfavourable measures of adiposity and decreased scores on measures of psychosocial health and motor skill development. In many cases, risks associated with television viewing increased in a dose–response manner. No benefits of increased television viewing were found. This work may be used as evidence to inform public health guidelines.

Conflict of interest

No competing interests were disclosed by authors. M.E.K. is funded by a Fellowship Award and Bisby Prize from the Canadian Institute of Health Research (CIHR). I.J. holds Tier 2 Canada Research Chair positions at Queen’s University. J.A.S. is supported by a Social Sciences and Humanities Research Council – Joseph-Armand Bombardier CGS Master’s Scholarship. B.W.T. holds a CIHR New Investigator Award. V.C. is supported by a CIHR – Frederick Banting and Charles Best Doctoral Award.

Authors’ contributions

A.G.L. and M.S.T. were responsible for the initiation, conceptualization, and design of the systematic review; oversaw the data collection and extraction, GRADE analysis, and interpretation of data; and were responsible for revising the manuscript critically for important intellectual content. A.G.L. was the primary author of the manuscript. M.E.K. and S.C.G. were responsible for the design and methodology of the review, GRADE assessment, and revising the manuscript critically for important intellectual content. A.G.L. and V.C. were responsible for data collection and extraction, risk of bias assessment, and were responsible for revising the manuscript critically for important intellectual content. C.D., I.J., J.C.S., J.A.S., and B.W.T. oversaw the data collection and extraction, analysis, and interpretation of data, and were responsible for revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript. M.S.T. is the guarantor of the paper.

Acknowledgements

The authors are grateful to Dr. Margaret Sampson at the Children’s Hospital of Eastern Ontario for her contributions to developing the search strategy for this project. Further, the authors would like to recognize the invaluable input and guidance from Dr. Anthony Okely at the University of Wollongong and Dr. John Reilly from the University of Strathclyde.

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Appendix A

Glossary of terms and relevant study designs (Sedentary Behaviour Research Network 2012; Tremblay et al. 2010; http://www.csep.ca/CMFiles/Guidelines/PAGuidelinesGlossary_E.pdf).

Glossary of terms:

Sedentarism: Extended engagement in behaviours characterized by minimal movement, low energy expenditure, and rest.
Sedentary: A distinct class of behaviours characterized by low energy expenditure (school work, reading, TV, computer, video games) that is characterized by little physical movement and low energy expenditure (≤1.5 METs).
Physically active: Meeting established guidelines for physical activity (see Canadian guidelines at www.csep.ca/guidelines).
Physical inactivity: The absence of physical activity, usually reflected as the proportion of time not engaged in physical activity of a predetermined intensity
Active video gaming: Video games that are designed to promote movement and interaction from the participant(s). Some examples include Nintendo Wii, Microsoft Kinect, Sony’s Playstation Move, and video arcades that require movement.
Recreational screen time: Television watching, video game playing, using the computer, or use of other screens during discretionary time (i.e., nonschool- or work-based use) that are practiced while sedentary.
Frequency: The number of times an exercise or activity is performed. Frequency is generally expressed in sessions, episodes, or bouts per day or week.
Interruptions: Interruptions refer to the number of times sedentary behaviour is interrupted by physical activity thus decreasing the amount of prolonged sedentary behaviour.
Time: The length of time in which a sedentary behaviour is performed. Duration is generally expressed in minutes.
Type: The type of activity that the individual is engaging in. As sedentary physiology is a fairly new field and technology is constantly providing new types of sedentary behaviours, this may be in constant flux.

Experimental studies

Randomization, random allocation, random sample: A sample derived by selecting sampling units (such as patients) such that each unit has an independent (and generally equal) chance of being selected. Selection is determined by chance, often with the aid of a table of randomly ordered numbers.
Randomized trial (randomized control(led) trial, randomized clinical trial, RCT): Experiment in which individuals are randomly allocated to receive or not receive an experimental preventative, therapeutic, or diagnostic procedure and then followed to determine the effect of the intervention.
Nonrandomized control trial (or quasi experimental): Experiment in which assignment of patients to the intervention groups is at the convenience of the investigator or according to a preset plan that does not conform to the definition of random.
Before–after trial: Investigation of therapeutic alternatives in which individuals of 1 period and under 1 treatment are compared with individuals at a subsequent time, treated in a different fashion. If the disorder is not fatal and the “before” treatment is not curative, the same individuals may be studied in the before and after periods, strengthening the design through increased group comparability for the 2 periods.
Crossover trial: A method of comparing 2 or more treatments or interventions in which subjects or patients, on completion of the course of 1 treatment, are switched to another. Typically, allocation to the first treatment is by random performance in 1 period is used to judge their performance in others, usually reducing variability.
Community based clinical trial: Designed to be administered directly through primary health care physicians, community health care centres, and outpatient facilities.

Observational studies

Cohort: A group of persons with a common characteristic or set of characteristics. Typically, the group is followed for a specified period to determine the incidence of a disorder or complications of an established disorder (that is, prognosis), as in cohort study.
Cohort analytic study: Prospective investigation of the factors that might cause a disorder in which a cohort of individuals who do not have evidence of an outcome of interest but who are exposed to the putative cause are compared with a concurrent cohort who are also free of the outcome but not exposed to the putative cause. Both cohorts are then followed to compare the incidence of the outcome of interest.
Prospective cohort study: A group of individuals is selected at random from a defined population. After the cohort is selected, baseline information on potential risk factors is collected, and individuals are followed over time to track the incidence of disease between those people subsequently exposed or not exposed to the risk factor of interest.
Case-control study: Study generally used to test possible causes of a disease or disorder, in which individuals who have a designated disorder are compared with individuals who do not have the disorder with respect to previous current exposure to a putative causal factor. For example, persons with cancer (cases) are compared with persons without cancer (controls) and history of hepatitis is determined for the 2 groups. Often referred to as a retrospective study because the logic of the design leads from effect to cause. In essence, this type of study is an attempt to look backward in time to identify the characteristics that may have contributed to the development of the disease.
Panel study: Study used prospectively to measure participants at multiple time points in an effort to determine the cause–effect relationship between and exposure and an outcome.

Appendix B: Search strategies

Table B1.
Table B1. MEDLINE.
Table B2.
Table B2. EMBASE. 
Table B3.
Table B3.  Searches.
Table B4.
Table B4. SPORTDiscus. 
Table B5.
Table B5. Preschool SB_May10: HALO.
Table B6.
Table B6. Risk and harms of decreased sedentary behaviour. Database(s): Ovid MEDLINE(R) 1948 to week 3 of November, 2011. Search strategy.

Information & Authors

Information

Published In

cover image Applied Physiology, Nutrition, and Metabolism
Applied Physiology, Nutrition, and Metabolism
Volume 37Number 4August 2012
Pages: 753 - 772

History

Received: 5 February 2012
Accepted: 9 April 2012
Version of record online: 5 July 2012

Key Words

  1. infants
  2. toddlers
  3. preschoolers
  4. inactivity
  5. sitting
  6. television
  7. adiposity
  8. psychosocial health
  9. cognitive development
  10. motor skill development
  11. bone and skeletal health
  12. cardiometabolic health indicators

Mots-clés

  1. nourrissons
  2. tout-petits
  3. enfants d’âge préscolaire
  4. inactivité
  5. assis
  6. télévision
  7. adiposité
  8. santé psychosociale
  9. développement cognitif
  10. développement des habiletés motrices
  11. santé des os et du squelette
  12. indicateurs de santé cardiométabolique

Authors

Affiliations

Allana G. LeBlanc
Healthy Active Living and Obesity Research Group, Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada.
John C. Spence
Faculty of Physical Education and Recreation, University of Alberta, W1-16h Van Vliet Centre, Edmonton, AB T6G 2H9, Canada.
Valerie Carson
School of Kinesiology and Health Studies, Queen’s University, 28 Division St., Kingston, ON K7L 3N6, Canada.
Sarah Connor Gorber
Office of the Task Force on Preventive Health Care, Public Health Agency of Canada, 785 Carling Avenue, Ottawa, ON K1A 0K9, Canada.
Carrie Dillman
Department of Pediatrics, McMaster University, 1280 Main St. West, Hamilton, ON L8S 4L8, Canada.
Ian Janssen
School of Kinesiology and Health Studies, Queen’s University, 28 Division St., Kingston, ON K7L 3N6, Canada.
Michelle E. Kho
Department of Physical Medicine and Rehabilitation, Johns Hopkins University, 600 North Wolfe Street, Baltimore, MD 21202, USA.
Jodie A. Stearns
Faculty of Physical Education and Recreation, University of Alberta, W1-16h Van Vliet Centre, Edmonton, AB T6G 2H9, Canada.
Brian W. Timmons
Department of Pediatrics, McMaster University, 1280 Main St. West, Hamilton, ON L8S 4L8, Canada.
Mark S. Tremblay
Healthy Active Living and Obesity Research Group, Children’s Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada.

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57. A Multicomponent Intervention to Reduce Screen Time Among Children Aged 2-5 Years in Chandigarh, North India: Protocol for a Randomized Controlled Trial
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113. Does Gadget Usage Hamper the Psychological Aspects of Pre-Schoolers?
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123. Association between objectively evaluated physical activity and sedentary behavior and screen time in primary school children
124. Systematic review of the relationships between sedentary behaviour and health indicators in the early years (0–4 years)
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127. Compliance with the Australian 24-hour movement guidelines for the early years: associations with weight status
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132. Guía de práctica clínica (GPC) para la prevención, diagnóstico y tratamiento del sobrepeso y la obesidad en adultos
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135. Longitudinal study of the associations between change in sedentary behavior and change in adiposity during childhood and adolescence: Gateshead Millennium Study
136. Screen Time and Health Indicators Among Children and Youth: Current Evidence, Limitations and Future Directions
137. Methodological quality is underrated in systematic reviews and meta-analyses in health psychology
138. What mums think matters: A mediating model of maternal perceptions of the impact of screen time on preschoolers' actual screen time
139. The relationship between screen time, nighttime sleep duration, and behavioural problems in preschool children in China
140. Does Childhood Temperamental Activity Predict Physical Activity and Sedentary Behavior over a 30-Year Period? Evidence from the Young Finns Study
141. Increasing Canadian paediatricians’ awareness and use of the new Canadian Physical Activity and Sedentary Behaviour Guidelines for ages 0 to 17 years
142. Physical activity, sedentary behavior and their correlates in children with Autism Spectrum Disorder: A systematic review
143. Prospective associations between energy balance-related behaviors at 2 years of age and subsequent adiposity: the EDEN mother–child cohort
144. Maternal and early life nutrition and physical activity: setting the research and intervention agenda for addressing the double burden of malnutrition in South African children
145. Developing Intervention Strategies to Optimise Body Composition in Early Childhood in South Africa
146.
147.
148. “GET-UP” study rationale and protocol: a cluster randomised controlled trial to evaluate the effects of reduced sitting on toddlers’ cognitive development
149. The effect of a cluster randomised control trial on objectively measured sedentary time and parental reports of time spent in sedentary activities in Belgian preschoolers: the ToyBox-study
150. Early Intervention to Encourage Physical Activity in Infants and Toddlers
151. Outdoor time, physical activity and sedentary time among young children: The 2012–2013 Canadian Health Measures Survey
152. A scoping review examining physical activity measurement and levels in the first 2 years of life
153. Comparing physical activity and sedentary time among overweight and nonoverweight preschoolers enrolled in early learning programs: a cross-sectional study
154. Ambiente escolar, comportamento sedentário e atividade física em pré‐escolares
155. School environment, sedentary behavior and physical activity in preschool children
156. Mediation of the Physical Activity and Healthy Nutrition Behaviors of Preschool Children by Maternal Cognition in China
157. Effects of Child Care Intervention on Physical Activity and Body Composition
158. Physical activity and screen use policy and practices in childcare: results from a survey of early childhood education services in New Zealand
159. Standing Classrooms: Research and Lessons Learned from Around the World
160. Adherence to Canadian physical activity and sedentary behaviour guidelines among children 2 to 13 years of age
161. Time use clusters in children and their associations with sociodemographic factors
162. A psychosocial analysis of parents' decisions for limiting their young child's screen time: An examination of attitudes, social norms and roles, and control perceptions
163. Fit 5 Kids TV Reduction Program for Latino Preschoolers
164. Objectively measured sedentary behaviour and health and development in children and adolescents: systematic review and meta‐analysis
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166. Can the Epidemiologist Learn more from Sedentary Behaviour than from the Measurement of Physical Activity?
167. Informing Active Play and Screen Time Behaviour Change Interventions for Low Socioeconomic Position Mothers of Young Children: What Do Mothers Want?
168. Prevalence and influences of preschoolers’ sedentary behaviors in early learning centers: a cross-sectional study
169. Tracking of maternal self-efficacy for limiting young children’s television viewing and associations with children’s television viewing time: a longitudinal analysis over 15-months
170. Reducing electronic media use in 2–3 year-old children: feasibility and efficacy of the Family@play pilot randomised controlled trial
171. An objective assessment of toddlers’ physical activity and sedentary levels: a cross-sectional study
172. Supporting Physical Activity in the Childcare Environment (SPACE): rationale and study protocol for a cluster randomized controlled trial
173. UK Preschool-aged children’s physical activity levels in childcare and at home: a cross-sectional exploration
174. Adherence to combined lifestyle factors and their contribution to obesity in the IDEFICS study
175. Dépistage et prise en charge des anomalies respiratoires de l’enfant obèse : syndrome d’apnée obstructive du sommeil et syndrome d’obésité hypoventilation
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177. Systematic review of sedentary behavior and cognitive development in early childhood
178. Prevalence of sedentary behavior in children under 2years: A systematic review
179. Mothers’ perceptions of the UK physical activity and sedentary behaviour guidelines for the early years (Start Active, Stay Active): a qualitative study
180. Knowledge and awareness of Canadian Physical Activity and Sedentary Behaviour Guidelines: a synthesis of existing evidence
181. BMI and Healthcare Cost Impact of Eliminating Tax Subsidy for Advertising Unhealthy Food to Youth
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183. Correlates of Total Sedentary Time and Screen Time in 9–11 Year-Old Children around the World: The International Study of Childhood Obesity, Lifestyle and the Environment
184. Prevalence and stability of active play, restricted movement and television viewing in infants
185. Sedentary Behavior Research Priorities—NHLBI/NIA Sedentary Behavior Workshop Summary
186. Active Play Opportunities at Child Care
187. Physical activity and sedentary behaviour of toddlers and preschoolers in child care centres in Alberta, Canada
188. Early physical activity and sedentary behaviours
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192. Short-Term Influence of Revised Provincial Accreditation Standards on Physical Activity, Sedentary Behavior, and Weight Status in Alberta, Canada Child Care Centers
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194. Secular Changes of Adiposity and Motor Development in Czech Preschool Children: Lifestyle Changes in Fifty-Five Year Retrospective Study
195. Physical environments, policies and practices for physical activity and screen‐based sedentary behaviour among preschoolers within child care centres in M elbourne, A ustralia and K ingston, C anada
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198. Sedentary behavior and health outcomes among older adults: a systematic review
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205. Sedentary Behavior and Health Outcomes: An Overview of Systematic Reviews
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