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Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
ABSTRACT
In recognition of the increasing time spent in sedentary activities in modern life, an emerging area of study linking
sedentary time to health has highlighted its role in the development of chronic diseases. Therefore, the objective of this
systematic review was to investigate the indicators and characteristics of sedentary behavior associated with cardiovascular
risk factors in children and adolescents. The databases SciVerse Scopus, MEDLINE®/PubMed and LILACS were selected as a
source of reference, using the associated terms “sedentary lifestyle” or “sedentary behavior” or “sedentary” AND “cardiovascular
diseases” AND “child or adolescent” to identify studies published from January 2006 to March 2019. The methodological
quality of the studies was evaluated and a score was assigned. Fifty articles were included in this review at the end. Ex-
tensive sedentary time, especially greater screen and TV exposure time, were associated with cardiovascular risk factors.
In addition, the accumulation of prolonged sedentary bouts with few breaks in sedentary time tended to compromise
the cardiometabolic profile. These findings highlight the importance of differentiating and considering these various
indicators and characteristics of sedentary behavior. Further studies are needed to elucidate the multiple and overlapping
facets of sedentary behavior and their relationship with health, and to encourage the development of evidence-based
recommendations for this population. Level of Evidence I; Systematic Review of Level I Studies.
Keywords: Sedentary behavior; Cardiovascular diseases; Child; Adolescent; Systematic review.
RESUMO
Em reconhecimento ao crescente tempo gasto em atividades sedentárias na vida moderna, uma emergente área de estudo
tem relacionado o tempo sedentário à saúde e destacado seu papel no surgimento de doenças crônicas. Assim, o objetivo
desta revisão sistemática foi investigar os indicadores e as características do comportamento sedentário associados aos fatores
de risco cardiovascular em crianças e adolescentes. As bases de dados SciVerse Scopus, MEDLINE®/PubMed e LILACS foram
consultadas utilizando a combinação dos termos “sedentary lifestyle” OR “sedentary behaviour” OR sedentary AND “cardiovas
-
cular diseases” AND child or adolescent, para identificar estudos publicados de janeiro de 2006 a março de 2019. A análise da
qualidade metodológica dos estudos foi realizada, e um escore foi atribuído. Ao final, 50 artigos foram incluídos nesta revisão.
O elevado tempo sedentário e, principalmente, a maior exposição ao tempo de tela e televisão, foram associados a fatores
de risco cardiovascular. Além disso, o acúmulo de prolongadas sessões e poucas interrupções no tempo sedentário parecem
comprometer o perfil cardiometabólico. Destaca-se a importância em diferenciar e considerar estes diversos indicadores e
características do comportamento sedentário. Estudos devem ser conduzidos para compreensão das múltiplas e superpostas
facetas do comportamento sedentário e relações com a saúde, favorecendo o desenvolvimento de recomendações baseadas
em evidências para essa população. Nível de evidência I; Revisão sistemática de estudos de nível I.
Descritores: Comportamento sedentário; Doenças cardiovasculares; Criança; Adolescente; Revisão sistemática.
RESUMEN
En reconocimiento al creciente tiempo invertido en actividades sedentarias en la vida moderna, una emergente área de
estudio ha relacionado el tiempo sedentario a la salud, destacando su papel en el surgimiento de enfermedades crónicas. Así, el
objetivo de esta revisión sistemática fue investigar los indicadores y las características del comportamiento sedentario asociados
a los factores de riesgo cardiovascular en niños y adolescentes. Las bases de datos SciVerse Scopus, MEDLINE®/PUBMED y LILACS
fueron consultadas utilizando la combinación de términos “sedentary lifestyle” OR “sedentary behavior” OR sedentary AND
“cardiovascular diseases” AND child or adolescent para identificar estudios publicados entre enero de 2006 y marzo de 2019. Se
realizó el análisis de la calidad metodológica de los estudios y fue atribuido un puntaje. Al final, 50 artículos fueron incluidos en esta
revisión. El elevado tiempo sedentario y, principalmente, la mayor exposición al tiempo de exposición de pantalla y la televisión,
fueron asociados a factores de riesgo cardiovascular. Además, la acumulación de prolongadas sesiones y pocas interrupciones
en el tiempo sedentario parecen comprometer el perfil cardiometabólico. Se destaca la importancia de diferenciar y considerar
estos diversos indicadores y características del comportamiento sedentario. Deben ser conducidos estudios para la comprensión
de las múltiples y sobrepuestas facetas del sedentarismo y relaciones con la salud, favoreciendo el desarrollo de recomendaciones
basadas en evidencias para esa población. Nivel de Evidencia I; Revisión sistemática de estudios de Nivel I.
Descriptores: Conducta sedentaria; Enfermedades cardiovasculares; Niño; Adolescente; Revisión sistemática.
SEDENTARY BEHAVIOR AND CARDIOVASCULAR RISK IN
CHILDREN: A SYSTEMATIC REVIEW
COMPORTAMENTO SEDENTÁRIO E RISCO CARDIOVASCULAR EM CRIANÇAS: UMA REVISÃO SISTEMÁTICA
COMPORTAMIENTO SEDENTARIO Y RIESGO CARDIOVASCULAR EN NIÑOS: UNA REVISIÓN SISTEMÁTICA
Karina Lúcia Ribeiro Canabrava1,2
(Physical Education Professional)
Paulo Roberto dos Santos Amorim3
(Physical Education Professional)
Valter Paulo Neves Miranda3,4
(Physical Education Professional)
Silvia Eloiza Priore4
(Nutritionist)
Sylvia do Carmo Castro
Franceschini4 (Nutritionist)
1. Universidade Federal de Minas
Gerais, Health Sciences Graduate
Program, Belo Horizonte, MG, Brazil.
2. Centro Federal de Educação
Tecnológica de Minas Gerais,
Contagem, MG, Brazil.
3. Universidade Federal de Viçosa,
Department of Physical Education,
Viçosa, MG, Brazil.
4. Universidade Federal de Viçosa,
Department of Nutrition and
Health, Viçosa, MG, Brazil.
Correspondence:
Karina Lúcia Ribeiro Canabrava.
Centro Federal de Educação
Tecnológica de Minas Gerais,
Contagem, MG, Brazil. 32146054.
karinacanabrava@yahoo.com.br
Article received on 09/14/2016 accepted on 04/22/2019
DOI: http://dx.doi.org/10.1590/1517-869220192505168868
SyStematic Review aRticle
Artigo de revisão sistemáticA
Artículo de revisión sistemáticA
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Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
INTRODUCTION
Sedentary behavior, which is distinct from physical inactivity, is
defined as activities performed in a sitting or reclining position that
involve energy expenditure similar to the resting level (≤ 1.5 metabolic
equivalent units), such as watching TV, using the computer, and motori-
zed transportation usage.
1,2
Despite the apparent simplicity of the term,
sedentary behavior is complex and not limited to a single component.1
Considering that increasing time is being spent on sedentary acti-
vities of modern life, an emerging area of studies relates sedentary time
to health status and highlights its potential role in the development of
chronic diseases.2 It has been suggested that prolonged sitting is asso-
ciated with deleterious effects on cardiovascular and metabolic health,
regardless of whether individuals meet the recommendations for daily
physical activity. Therefore, it is considered a risk factor for adiposity and
cardiovascular diseases, distinct from physical inactivity.3
Epidemiological studies among adults have demonstrated that
sedentary time is associated with increased risk of cardiovascular mor-
bidity and mortality, independent of moderate-to-vigorous physical
activity.4 Specific behaviors have been assessed and it was found that
individuals with high screen time, defined as the sum of time spent
watching TV and using the computer or other screen devices,5 are
at a greater risk of future cardiovascular events.
4
In addition to total
sedentary time, patterns of sedentary time accumulation have been
evaluated; studies show that a reduction in prolonged sedentary bouts
and increasing breaks in sedentary time are beneficially associated
with health in the adult population.6
Among children and adolescents, screen time has also been asso-
ciated with markers of cardiovascular disease.7,8 A review7 revealed that
excessive TV time was associated with physical and psychosocial health
and provided the evidence for the guidelines for limiting screen time.5
Regarding other aspects of sedentary behavior, the evidence is still
limited because TV time has been the most commonly used indicator
of sedentary behavior for the pediatric population.7
Thus, the growing interest of the pediatric research community in
sedentary behavior has generated much discussion on the determi-
nants of sedentary behavior and its impact on the health of children
and adolescents.
7,8
Different domains, indicators, and patterns of this
health-compromising behavior have been addressed.8 Converging the
evidence obtained thus far and indicating the observed gaps may facili-
tate the planning of future studies and development of evidence-based
guidelines for this population. Therefore, the objective of the present
systematic review was to determine the main indicators and patterns
of sedentary behavior associated with risk factors for cardiovascular
disease in children and adolescents.
MATERIALS AND METHODS
The review was conducted according to the criteria proposed for
systematic reviews and meta-analyses (Preferred Reporting Items for
Systematic Reviews and Meta-Analyses - PRISMA).
9
The search was
performed in the following electronic databases: SciVerse Scopus,
MEDLINE/PUBMED (Medical Literature Analysis and Retrieval System
Online), and Literatura Latino-Americana e do Caribe em Ciências
da Saúde (LILACS). The following combinations of health terms and
descriptors were used: (“sedentary lifestyle” or “sedentary behavior” or
sedentary) AND (“cardiovascular diseases”) AND (child or adolescent).
In addition to the descriptors, the terms “sedentary behavior” and
“sedentary” were included for widening the search and incorporating
studies that might be within the scope of this review, because the
term “estilo de vida sedentário” was included as a health descriptor
(Medical Subject Headings, MeSH) only in 2010. Considering that
2006 was the year that marked the calling for research focusing on
sedentary behavior,2 this review investigated studies published from
January 1, 2006 to January 31, 2016. There was a subsequent update
in the study and a new search was performed considering the period
between February 1, 2016 and March 31, 2019. In the PUBMED search
engine, the search filter of “age group” was applied and the search was
restricted to studies involving participants aged between zero and 18
years. Additional records were obtained from the review of the refer-
ence lists of the articles analyzed for eligibility.
The following inclusion criteria were used: 1) studies that addressed
the topic through analysis of the association between sedentary behavior
and cardiovascular risk (CR) factors; 2) studies with samples comprising
children and/or adolescents; 3) original articles; and, 4) articles published
in English, Portuguese, or Spanish. All study designs were eligible.
To examine sedentary behavior, the review included studies that
assessed exposure using subjective and/or objective methods. Sev-
eral indicators and patterns of sedentary behavior were analyzed: total
sedentary time (total daily volume of sedentary activities), bouts of
sedentary time (continuous periods of sedentary time), breaks (inter-
ruptions in prolonged sedentary time), screen time (sum of time spent
watching TV, playing video games (VG), using the computer, and/or
other screen devices), time spent in watching TV or videos, playing VG,
and using the computer.
To assess the relationship of sedentary behavior with CR factors, the
review included studies assessing body adiposity, blood pressure (BP)
levels, lipid profile, and insulin and glucose levels. Several studies used
a CR score by combining risk factors, because this can provide a better
measure of cardiovascular health than risk factors taken individually. Thus,
studies evaluating CR by combining two or more risk factors within the
scope of this review were also included.
The following exclusion criteria were used: duplicate articles, review
articles, editorials, and letters to the editor. In addition, studies addressing
sedentary behavior as a synonym of physical inactivity and/or analyzing
sedentary behavior in conjunction with physical inactivity were excluded.
After the initial search in the databases, the software for managing
references, EndNote
®
, was used to import the selected records and
exclude duplicate records. Subsequently, the titles and abstracts of the
records retrieved were analyzed to select potentially relevant articles.
When the title and abstract were insufficient, a full-text search was
performed. After screening the records, copies of the full texts were
obtained for eligibility analysis. The assessment of the methodological
quality of the studies was performed using the Downs and Black scale
10
adapted to include cross-sectional studies. The studies were assessed
using 17 questions relating to external and internal validity, and scored
according to the provided information, with the maximum score being
17 points. Article search, analysis, and inclusion were performed by one
reviewer. A second reviewer was consulted when there were questions
about including or excluding the article.
During data extraction, the results of studies exploring the associations
between sedentary behavior and CR factors, in which the analyses con-
sidered physical activity as a potential confounding factor, were reported.
When adjustment for physical activity was not performed, the results were
presented, and the information was highlighted in the summary table.
RESULTS
The initial search (2006 – 2016) in the databases yielded 641 records,
of which 387 were obtained from the Scopus database, 216 from ME-
DLINE/PUBMED, and 38 from LILACS. The updated search (2016 – 2019)
yielded 172 records, of which 124 were obtained from Scopus, 38 from
MEDLINE/PUBMED, and 10 from LILACS. Twelve records were added after
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Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
a review of the reference lists of the articles analyzed for eligibility. Thus,
a total of 825 records were identified. After excluding duplicates (n =
213), 612 records were obtained for title and abstract screening. Of those
screened, 546 records were excluded (irrelevant topics, adult population,
and non-original articles). Therefore, 66 full-text articles were analyzed
for eligibility. Then, 16 articles were excluded because they evaluated
sedentary behavior combined with physical activity (n = 4), considered
sedentary behavior as a synonym of physical inactivity (n = 1), analyzed
the association of sedentary behavior and other risk factors that were
not within the scope of this review (n = 6), sampled an adult population
(n = 3), or reviewed articles exclusively (n = 2). Finally, 50 articles were
included in the qualitative summary.11-60 (Figure 1)
All included studies had minimum and maximum methodological
quality scores of 12 and 16, respectively. Few studies utilized random
(4%) or longitudinal (10%) design; the majority used a cross-sectional
approach (86%). A higher percentage of studies were conducted in the
United States (22%) and Canada (14%). Most articles were published in
2013, 2014, and 2015. (Chart 1)
In terms of age groups, the studies analyzed children (16%), ado-
lescents (42%), and children + adolescents (42%). Sedentary behavior
was most often evaluated using only questionnaires (62%), with only
18% of studies using accelerometry, and 16% using both approaches.
Additionally, 4% of the studies used an exposure time assessment. The
most frequently used indicators of sedentary behavior were screen time
(46%), TV time (44%), and total sedentary time (44%). (Chart 1)
Sedentary Behavior and Body Adiposity
As is shown in Table 1, most studies report a lack of association
between total sedentary time and body mass index (BMI),
18,21,32,35,52,56
waist circumference (WC),
18,22,25,31,32,35,36,43,52,56,57
and body fat (BF).
18,43,52,54,56
However, some studies reported a positive association between total
sedentary time and adiposity, with children and adolescents in the
highest tertile of sedentary time being at a greater risk of being over-
weight or obese.36,45 Total sedentary time was also associated with
increased WC.45,53,58 Moreover, a 2-year follow-up of children aged 6 to
8 years showed that total sedentary time was directly associated with
increasing BF percentage.58
The evaluation of the patterns of sedentary time accumulation,
80-minute bouts of sedentary time were positively associated with BMI
32
and WC.32 In addition, short bouts were associated with reduced WC.35
Breaks in prolonged sedentary time were also assessed and studies
showed that an increased number of breaks was related to reduced
BMI35 and WC32,35 in children and adolescents.
Regarding the type of sedentary activity, prolonged screen time
was frequently associated with increased BMI,
13,28,38,45,47,52
WC,
28,31,38,45
waist-to-height ratio (WHR),
38
and skin-fold thickness.
46
Moreover, TV
time assessed individually was positively associated with BMI,14,28,33,35,47
WC,22,26,28,35,39,43,47 WHR,26,48 and BF.11,14,20,43 In general, children and ado-
lescents who spent more time watching TV were at a higher risk for
being overweight and having high values of BF indicators. Some authors
reported that the combined computer and VG usage was positively
associated with adiposity.
19,28,35
However, this association was not de-
monstrated in most studies when computer or VG usage were assessed
individually.21,22,27,29,33,47,48
Sedentary Behavior and Lipid Profile
The data on lipid profile presented in Table 2 show that the majority
of studies did not demonstrate an association between total sedentary
time and levels of total cholesterol (TC),
18,43,50,56
high-density lipopro-
tein cholesterol (HDL-C),18,25,31,35,36,43,50,52,56,58 low-density lipoprotein
cholesterol (LDL-C),
18,43,50,52,56,58
very low-density lipoprotein cholesterol
(VLDL-C),
43
non-HDL cholesterol,
22,32
TC/HDL-C ratio,
54,57
and triglycerides
(TG).25,31,35,36,40,50,52-54,56-58 However, some studies indicated that children
and adolescents with more sedentary time during the day had higher
levels of TG18,43 and LDL-C53 and lower levels of HDL-C.40,53 The analysis
focusing on patterns of sedentary time showed that in most studies
there was no relationship between bouts22,32,35,40,50 and breaks22,32,35,59,60
in sedentary time with lipid profile. Only one study showed that children
with higher volumes of prolonged bouts of sedentary behavior had
reduced levels of HDL-C.40
Reduced levels of HDL-C25,28,31 and high levels of LDL-C48,52 and TG52
have been observed in children and adolescents who reported higher
screen time, although most studies indicated a lack of association. In
some studies, prolonged TV use was associated with reduced levels of
HDL28 and increased levels of LDL.48 Moreover, high TV use increased
the likelihood of high levels of non-HDL cholesterol in a dose-response
relationship.
22
An association of VG and computer usage with lipid profile
was shown in a few studies, and more time spent using these devices
was found to be related to reduced levels of HDL.35,48 In contrast, in one
study, there was a positive association between the combined use of
computers and VGs and HDL levels.39 Increasing levels of LDL-C,47 TG,29
and TC/HDL-C24 were also detected with increasing VG usage.
Sedentary Behavior and Insulin and Glucose Levels
There was no relationship between total sedentary time and levels
of insulin,
35,36,40,43,52,53,56
glucose,
25,31,35,36,40,43,50,52,53,56,58
, and insulin resistan-
ce36,54,57,58 in the analyzed studies (Table 2). Only three studies showed a
positive association between total sedentary time and each individual
parameter (insulin,58 glucose,18 and insulin resistance12). With regard to
the patterns of accumulation of sedentary time, in one randomized study,
Figure 1. Flowchart of study inclusion.
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Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
Chart 1. Characteristics of the included studies.
Study Location Year Age (years) Sample size (F/M) Sedentary
behavior
Method of
assessment Factors of cardiovascular risk AF
Cross-sectional
Ekelund11 Europe 2006 9 to 10
15 to 16 1921 (1010/911) TV Questionnaire BF, HDL-C, TG, Insulin, Glucose,
SBP, DBP, and CR S
Sardinha12 Portugal 2008 9 to 10 308 (147/161) TS Accelerometry HOMA-IR N
Torres13 Spain 2008 3 to 13 373 (169/204) Screen Questionnaire BMI N
Wells14 Brazil 2008 10 to 12 4452 (2258/2193) TV Questionnaire BMI, BF, SBP, and DBP S
Martinez-Gomez15 USA 2009 3 to 8 111 (54/57) TS, Screen, TV, CP Accelerometry
Questionnaire SBP and DBP N
Hardy16 Australia 2010 14 to 17 496 (206/290) Screen Questionnaire HDL-C, LDL-C, TG, Insulin, Glucose,
HOMA-IR, SBP, and DBP N
Kang17 Korea 2010 10 to 18 845 (396/449) Screen Questionnaire SM N
Martinez-Gómez18 Spain 2010 13 to 17 201 (99/102) TS Accelerometry BMI, BF, WC, TC, HDL-C, LDL-C,
TG, Glucose, SBP, DBP, and CR N
McCrindle19 Canada 2010 14 to 15 20719
(10300/10419) TV+VG, CP Questionnaire BMI, TC, SBP, DBP, and CR N
Rivera20 Brazil 2010 7 to 17 1253 (706/547) TV Questionnaire BMI and BF N
Alvarez Caro21 Spain 2011 6 to 12 459 (213/246) TS, TV+VG, CP Questionnaire BMI N
Carson22 EUA 2011 6 to 19 2527 (1243/1284) TS, Bout, Breaks,
TV, CP
Accelerometry
Questionnaire WC, non-HDL, SBP, and CR S
Danielsen23 Norway 2011 7 to 13 86 (38/48) Screen Questionnaire TC, HDL-C, LDL-C, TG, and HOMA-IR S
Goldfield24 Canada 2011 14 to 18 282 (196/86) Screen, TV, VG, CP Questionnaire WC, HDL-C, LDL-C, TG, CTC/
HDL-C, SBP, and DBP S
Hsu25 US 2011 13 105 (79/26) TS, Screen Accelerometry
Questionnaire WC, HDL-C, TG, Glucose, SBP, DBP, and MS N
Lehto26 Finland 2011 9 to 11 604 (312/292) TV, CP+VG Questionnaire WC and WHR S
Altenburg27 Netherlands 2012 12 to 18 125 (71/54) Screen, TV, CP Questionnaire BMI, GC, TC, HDL-C, LDL-C, TG,
Insulin, Glucose, SBP, DBP, and CR S
Byun28 Korea 2012 12 to 18 577 (261/316) Screen, TV, CP+VG Questionnaire BMI, WC, TC, HDL-C, LDL-C, TG, SBP, and DBP S
Martinez-Gomez29 Spain 2012 13 to 17 181 (88/93) CP, VG Questionnaire WC, TC, HDL-C, LDL-C, TG, Insulin,
Glucose, SBP, SBP, MBP, and CR S
Camhi30 US 2013 12 to 18 225 (118/107) Screen, TV, CP Questionnaire CR N
Chaput31 Canada 2013 8 to 10 536 (244/292) TS, Screen Accelerometry
Questionnaire WC, HDL-C, TG, Glucose, SBP, and DBP S
Colley32 Canada 2013 6 to 19 1608 (799/809) TS, Bout, Breaks Accelerometry BMI, WC, non-HDL, SBP, and DBP S
Govindan33 US 2013 10 to 12 1714 (906/808) TV, CP, VG Questionnaire BMI N
Rey-Lopez34 Europe 2013 12 to 17 769 (393/376) TV, VG Questionnaire CR S
Saunders35 Canada 2013 8 to 11 522 (236/286) TS, Bout, Breaks,
TV, CP+VG
Accelerometry
Questionnaire BMI, WC, HDL-C, TG, Insulin, Glucose, and CR S
Sisson36 US 2013 12 to 20 394 (193/201) TS Questionnaire BMI, WC, HDL-C, TG, Insulin, Glucose,
HOMA-IR, MBP, CR, and MS S
Stamatakis37 Portugal 2013 2 to 12 2515 (1427/1088) TV, CP, VG Questionnaire SBP, DBP, and CR Y
Berentzen38 Netherlands 2014 11 to 14 1447 (744/703) Screen, TV, CP Questionnaire BMI, WC, WHR, TC/HDL-C, SBP, and DBP N
Chinapaw39 Netherlands 2014 5 to 6 1961 (961/1000) TV, CP+VG Questionnaire WC, HDL-C, LDL-C, TG, Glucose, MBP, and CR Y
Cliff40 Australia 2014 5 to 9 120 (74/46) TS, Bout Accelerometry HDL, TG, Insulin, Glucose, SBP, DBP, CR Y
Crispim41 Brazil 2014 2 to 5 276 (131/145) TV Questionnaire SBP and DBP N
Flynn42 EUA 2014 10 to 12 1104 (565/539) Screen Questionnaire HDL-C N
Väistö43 Finland 2014 6 to 8 468 (225/243) TS, Screen, TV Questionnaire BF, WC, TC, HDL-C, LDL-C, VLDL-C, TG,
Insulin, Glucose, SBP, DBP, and CR Y
do Prado Junior44 Brazil 2015 10 to 19 676 (378/298) Screen Questionnaire TC, LDL-C, HDL-C, TG, SBP, and DBP N
Herman45 Canada 2015 8 to 10 534 (248/286) TS, Screen, TV Accelerometry
Questionnaire BMI and WC N
Rendo-Urteaga46 Europe 2015 12 to 17 769 (404/365) Screen Questionnaire BF, TC/HDL-C, TG, HOMA-IR, SBP, and CR N
Robinson47 Australia 2015 7 to 10 264 TV, CP, VG, Screen Questionnaire BMI, WC, TC, HDL-C, LDL-C,
TG, SBP, DBP, and CR Y
Safiri48 Iran 2015 10 to 18 5625 (2801/2824) TV, CP, Scree Questionnaire BMI, WHR, TC, HDL-C, LDL-C, TG,
Glucose, SBP, DBP, and MS N
Vaccaro49 US 2016 6 to 12 614 Screen Questionnaire BMI N
Batalau50 Portugal 2017 7 to 10 77 (31/46) TS, Bout, Screen Accelerometry
Questionnaire TC,HDL-C, LDL-C, TG, Glucose,SBP, and DBP N
Katzmarzyk51 US 2017 5 to 18 357 TV Questionnaire BMI, BF, WC, HDL-C, TG,
Glucose, SBP, DBP, and CR Y
Norman52 US 2017 11 to 13 106 (54/52) TS, Screen Accelerometry
Questionnaire
BMI, GC, WC, HDL-C, LDL-C, TG,
Insulin, Glucose, SBP, and DBP Y
Hansen53 ICAD* 2018 4 to 18 18200 (9207/8993) TS Accelerometry WC, HDL-C, LDL-C, TG, Insulin, Glucose, SBP N
Cristi-Montero54 Europe 2019 12 to 17 548 (289/259) TS Accelerometry BF, TC/HDL-C, TG, HOMA-IR, SBP, and CR Y
Longitudinal
de Moraes55 Europe 2015 2 to 9 5061 (2576/2485) Screen Questionnaire SBP and DBP N
Stamatakis56 England 2015 11 to 12 4639 (2459/2180) TS Accelerometry BMI, BF, WC, TC, HDL-C, LDL-C, TG,
Insulin, Glucose, SBP, DBP, and CR Y
Norman52 US 2017 11 to 13 106 (54/52) TS, Screen Accelerometry
Questionnaire
IMC, GC, PC, HDL, LDL, TG,
Insulin, Glucose, PAS e PAD Y
Skrede57 Norway 2017 10 700 (356/344) S Accelerometry WC, TC/HDL-C, TG, HOMA-IR, SBP, and CR N
Väistö58 Finland 2019 6 to 8 258 (140/118) TS Accelerometry BF, WC, HDL-C, LDL-C, TG, Insulin,
Glucose, HOMA-IR, SBP, DBP, and CR N
Randomized
Saunders59 Canada 2013 10 to 14 19 (8/11) Breaks Observation HDL-C, LDL-C, TG, Insulin, and Glucose Y
Belcher60 USA 2015 7 to 11 28 (15/13) Breaks Observation TG, Insulin, and Glucose N
F = Female. M = Male. AF = Analysis adjusted for physical activity. Y = Yes. N = No. TS = Total sedentary time. Bout = A period of continuous sedentary time. Breaks = Interruptions in prolonged sedentary time. Screen =
Screen time. TV = Time spent watching television. VG = Time spent using video games. CP = Time spent using the computer. BF = Body fat. BMI = Body mass index. WC = Waist circumference. WHR = Waist/height ratio. TC =
Total cholesterol. HDL = High-density lipoprotein. LDL = Low-density lipoprotein. TG = Triglycerides. VLDL = Very low-density lipoprotein. Non-HDL-C = (Total cholesterol – HDL-C). TC/HDL-C = Total cholesterol /HDL-C ratio.
SBP = Systolic blood pressure. DBP = Diastolic blood pressure. HOMA-IR = Insulin resistance index. MS = Metabolic syndrome. CR = Cardiovascular risk. US = United States. *ICAD = International Children’s Accelerometry
Database (Australia, Brazil, US, and Europe).
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Table 1. Sedentary behavior and body adiposity
Sedentary
behavior Adiposity Positive
association
Negative
association
Lack of
association
TS BMI 36,45 18,21,32,35,52,
52L,56
BF% (DEXA) 58 43,52,52L,56
Skin folds 18,54
WC 45,53,58 18,22,25,31,32,35,3
6,43,52,52L,56,57
Bout of ST BMI 32,35
WC 32,35 22
Breaks in ST BMI 35 32
WC 32,35 22
Screen BMI 13,28,38,45,47,
49,52,52L 27,48
BF% (DEXA) 27,43,52,52L
Skin folds 46
WC 28,31,38,45 25,43,47,52,52L
RCE 38 48
Television BMI 14,28,33,35,47 20,27,45,48,51
BF% (DEXA) 43,51 27
Skin folds 11,14,20
WC 22,26,28,35,39,
43, 47,51 45
RCE 26,48
Computer BMI 19 21,27,33,47,48
BF% (DEXA) 27
WC 22,29,47
RCE 48
Vídeo Game BMI 33,47
WC 29,47
ST = Sedentary time; BMI = Body mass index; %GC (DEXA) = Total body fat percentage determined by bone den-
sitometry; WC = Waist circumference; WHR = Waist/height ratio. 52L = R eference 52 with the longitudinal analysis.
Table 2. Sedentary behavior associated with lipid profile, insulin, and glucose.
Sedentary
behavior
Biochemical
parameters
Positive
association
Negative
association
Lack of
association
ST Total cholesterol 18,43,50,56
HDL-C 40,53 18,25,31,35,36,43
,50,52,52L,56,58
LDL-C 53 18,43,50,52,52L,56,58
Non-HDL-C 22,32
TC/HDL-C 54,57
VLDL-C 43
Triglycerides 18,43 25,31,35,36,40,50,52-
54,56-58
Insulin 58 35,36,40,43,52,52L,
53,56
Glucose 18 25,31,35,36,40,43,5
0,52,52L,53,56,58
HOMA-IR 12 36,54,57,58
Bout of ST Total cholesterol 50
HDL-C 40 35,50
LDL-C 50
Non-HDL-C 22,32
Triglycerides 35,40,50
Insulin 35,40
Glucose 35,40,50
Breaks in ST HDL-C 35,59
LDL-C 59
Non-HDL-C 22,32
Triglycerides 35,59,60
Insulin 60 35,59
Glucose 60 35,59
Screen Total cholesterol 23,24,27,28,43,44,47,
48,50
HDL-C 25,28,31 16,23,24,27,42-
44,47,48,50,52,52L
LDL-C 48,52L 16,23,24,27,28,43,44,
47,50,52
TC/HDL-C 24,38,46
VLDL-C 43
Triglycerides 52L
16,23-
25,27,28,31,43,44,46-
48,50,52
Insulin 16 27,43,52,52L
Glucose 16,25,27,31,43,48,50,
52,52L
HOMA-IR 16,23 46
Television Total cholesterol 24,27,28,43,47,48
HDL-C 28 11,24,27,35,39,43,47,
48,51
LDL-C 48 24,27,28,39,43,47
Non-HDL-C 22
TC/HDL-C 24,38
VLDL-C 43
Triglycerides 51 11,24,27,28,35,39,43,
47,48
Insulin 11,27,35,43
Glucose 51 11,27,35,39,43,48
Computer Total cholesterol 27 19,24,29,47,48
HDL-C 48 24,27,29,47
LDL-C 27 24,29,47,48
Non-HDL-C 22
TC/HDL-C 24,38
Triglycerides 24,27,29,47,48
Insulin 27,29
Glucose 27,29,48
Vídeo Game Total cholesterol 24,29,47
HDL-C 24,29,47
LDL-C 47 24,29
TC/HDL-C 24
Triglycerides 29 24,47
Insulin 29
Glucose 29
ST = Sedentary time; HDL = High-density lipoproteins; LDL = low-density lipoproteins; Non-HDL-C = Total choles-
terol– HDL-C; TC/HDL-C = Total cholesterol /HDL-C ratio; VLDL = very low-density lipoproteins; HOMA-IR = Insulin
resistance index. 52L = Reference 52 with the longitudinal analysis.
the levels of insulin and glucose were reduced after a period of sedentary
time with breaks compared with the same period without breaks.60
The analysis of the type of sedentary behavior showed that adoles-
cents with a screen time of 2 or more hours per day were at a higher risk
of abnormal levels of insulin.16 In addition, greater exposure to screen
time was associated with elevated insulin resistance.16,23 However, the
majority of studies did not indicate an association between screen
time and levels of insulin, glucose, and insulin resistance.25,27,31,43,46,48,50,52
Sedentary Behavior and Blood Pressure
The observed relationships between sedentary behavior and BP
are shown in Table 3. Only two studies demonstrated an association
between total sedentary time and systolic blood pressure (SBP), in
which adolescents with longer total sedentary time had higher levels of
SBP,18,53 a finding that contrasts most studies reporting a lack of associa-
tion.
15,22,31,32,40,43,50,52,54,56-58
Prolonged bouts of sedentary time
22,32,40,50
and
breaks
32
were not associated with BP. However, there were associations
with specific indicators of sedentary behavior. Children and adolescents
with prolonged screen exposure had higher values of BP.15,25,52,55 After
a 2-year follow-up, children with screen time of 2 or more hours per
438
Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
with higher CR.22,35,37,43 Prolonged VG use29,34 was also associated
with increased CR. Moreover, higher CR was observed in children
and adolescents who spent more time on combined screen activities
(computer+VG35 and TV+VG19).
DISCUSSION
The present study demonstrated that sedentary behavior is associated
with risk factors for cardiovascular disease in children and adolescents.
Moreover, the frequency of this association appeared to depend on the
assessed behavior indicator and the analyzed risk factor. These observa-
tions have been confirmed by the growing number of studies on the
subject in recent years. This reflects the recognition that sedentariness as
a health behavior is an important and necessary area of study.
2
Although
there are numerous studies with adults, those involving the pediatric
population are still scarce.4
In addition to total sedentary time, screen time and TV time were
the most used indicators to determine sedentary behavior. Although
the use of electronic media is a popular and frequent sedentary activity,
the overlap of these daily activities is a reality that makes sedentary
behavior a complex issue, which indicates that it cannot be limited to
a single component.1
It is important to consider that TV time and computer time, among
other screen activities, are indicators and determinants of sedentary
behavior that have been studied using subjective methods. On the
other hand, the assessment of total sedentary time provides a glo-
bal measure of this behavior. This measurement can be performed
using objective and subjective methods such as accelerometry and
activity diaries, respectively. These are distinct indicators of sedentary
behavior, both of which have limitations.
61
Using subjective measures
incorporates the risk of biases related to response, memory, and social
desirability, which are characteristic of assessment questionnaires.
62
Accelerometry, an objective measure, does not provide information
about context and type of activities,
61
and the use of different methods
(including definitions of usage days and usage time) may hinder the
comparison of results.
63
In this sense, the measures provide important
information on sedentary behavior and the use of both approaches,
whenever possible, has been recommended.61
Several studies have demonstrated the association between seden-
tary activities and CR factors in children and adolescents using different
indicators, which points to the deleterious impact of sedentary behavior
on health. Lipase lipoprotein activity suppression may occur as a result
of sustained inactivity of the major muscle groups of legs and trunk
inherent to sedentary activities,
64
in addition to changes in the response
of myosin in skeletal muscle that promote endothelial dysfunction of
the cardiovascular system through the increase in pro-inflammatory
adipokines.65 Consequently, these changes may occur in the early stages
of the pathological process of atherosclerosis, leading to the gradual
development of cardiovascular diseases.65
The qualitative analysis of the studies showed that sedentary
behavior, indicated primarily by prolonged exposure to screen
time, was frequently associated with higher adiposity indi-
ces,13,28,31,38,45-47,49,52 elevated BP,15,25,52,55 low values of HDL choleste-
rol,
25,28,31
elevated levels of serum insulin
16
and insulin resistance,
16,23
increased risk of metabolic syndrome
1,7,25
and higher CR.
43
When TV
time was analyzed individually as an indicator of sedentary behavior,
the results showed that prolonged time spent watching TV was
associated with increased body adiposity,11,14,20,22,26,28,33,35,39,43,47,48,51
elevated SBP
14,15,37,43,47,48
and DBP,
14,15,37,38
reduced levels of HDL-C,
28
and increased CR.22,35,37,43,51 These results indicate the importance
of promoting the reduction in sedentary behavior by reducing the
Table 3. Sedentary behavior associated with blood pressure and cardiovascular risk.
Sedentary
behavior
BP and
CR
Positive
association
Negative
associatio
Lack of
association
ST SBP 18,53 15,22,25,31,32,40,43,50,52,52L,
54,56-58
DBP 15,18,25,31,32,40,43
,50,52,52L,56,58
MBP 36
CR 18,54,58 22,35,36,40,43,56,57
MS 25,36
Bout of TS SBP 22,32,40,50
DBP 32,40,50
CR 35 22,40
Breaks in ST SBP 22,32
DBP 32
CR 35 22
Screen SBP 15,25,55 16,24,27,28,31,38,43,44,46,
48,50,52,52L
DBP 52,55 15,16,24,25,27,28,31,38
,43,44,47,48,50,52L
CR 43 27,30,46,47
MS 17,25 48
Television SBP 14,15,37,43,47,48 11,22,24,27,28,38,41,51
DBP 14,15,37,48 11,24,27,28,38,41,43,47,51
MBP 39
CR 22,35,37,43,51 11,27,30,34,39,47
MS 48
Computer SBP 15,19,22,24,27,29,37,38,47,48
DBP 15,19,24,27,29,37,38,47,48
MBP 29
CR 19,22,27,29,30,37,47
MS 48
Vídeo Game SBP 24 29,37,47
DBP 29 24,37,47
MBP 29
CR 29,34 37,47
ST = Sedentary time; BP = Blood pressure; SBP = Systolic blood pressure; DBP = Diastolic blood pressure; MBP = Mean
blood pressure; CR = Cardiovascular risk; MS = Metabolic syndrome. 52L = Reference 52 with the longitudinal analysis.
day had a higher incidence of elevated BP.55 Among screen behaviors,
TV time was positively associated with BP,14,15,37,43,47,48 which indicates
that the increase in time spent watching TV is related to increased
SBP
14,15,37,43,47,48
and DPB
14,15,37,48
in children and adolescents. Moreover,
TV viewing for more than 2 hours per day was related to increased
BP compared with TV time limited to one hour per day.37 Two other
studies also reported that VG usage was positively associated with
elevated BP in adolescents.24,29
Sedentary Behavior and Combination of Risk Factors
As presented in Table 3, three studies showed higher CR among
adolescents with longer sedentary time.18,54,58 One study on the pat-
terns of sedentary time accumulation showed that a frequent breaks
and short sedentary bouts was associated with reduced CR among
children and adolescents.
35
Some authors reported that increased
screen time was associated with increased CR
43
and prevalence of
metabolic syndrome.
17,25
A longer exposure to TV was associated
439
Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
exposure of children and adolescents to screen and TV time. This
strategy is essential because of the high and increasing prevalen-
ce of sedentary activities among this population.
7
Moreover, it is
important to consider that individuals tend to increase their total
energy intake (including unhealthy foods) during TV viewing, which
affects the energy balance and increases health risks.66
Considering that sedentary behavior and physical inactivity are distinct
terms and behaviors, their quantification and related recommendations
should also be specific.
3
Guidelines on sedentary behavior intended for the
pediatric population recommend the limitation of screen time, especially
TV time, to 2 hours per day.
67
The studies analyzing screen time of children
and adolescents reported that exceeding the recommended time was
associated with increased adiposity,
38
elevated BP,
37,55
increased insulin
levels,16 increased HOMA-IR,16 and elevated CR.37 After a 2-year follow-up
of children aged 2 to 9 years, the incidence of elevated BP was higher in
those with a screen time of 2 or more hours per day than in those who
reduced it to less than 2 hours per day.55 It should be noted that despite
the obtained results, the recommendation to limit TV time to 2 hours per
day is based on a single and exclusive determinant. This means that a limit
of 2 hours does not account for the complexity and potential interactions
between the multiple determinants of sedentary behavior, such as com-
bined TV and VG time or combined TV and computer time. Moreover,
more recent studies suggest that the limitation of screen time to 1 to 1.5
hours daily may be more effective in avoiding obesity.68
Although the current recommendations also include the reduction
in time spent in sedentary transportation and prolonged sitting time,5
cut-off points have not yet been established for the limitation of total
sedentary time. Several authors have assessed the total sedentary time
per day and reported mean values varying from 241 to 549 minutes per
day. Although with a lower level of evidence in the studies, the results
indicated that children and adolescents with higher sedentary time
were more likely to be overweight or obese36,45 and had higher SBP,18,53
insulin,58 glucose,18 insulin resistance,12 triglycerides,18,43 LDL-C,53 and
CR
18,54,58
and reduced levels of HDL-C.
40,53
This suggests that the dele-
terious effect of prolonged total sedentary time on health stems from
childhood. In a 2-year follow-up study, a reduction in total sedentary
time was associated with a reduction in BF, WC, levels of insulin, and
cardiometabolic risk among children.58
Regarding the impact that sedentary behavior may have on health, in
addition to total sedentary time and other related activities, the patterns
of sedentary time accumulation were also investigated.
22,32,35,40,50,59,60
Some
authors analyzed bouts of sedentary time over a continuous period of
sedentary time, as well as breaks in prolonged sedentary time. Prolonged
bouts of sedentary time have been associated with overweight
32
and lower
levels of HDL-C.40 On the contrary, short bouts of sedentary time mitigated
CV.
35
Moreover, a higher frequency of breaks in sedentary time was associa-
ted with low BMI,35 reduction in insulin and glucose levels,60 and low CR.35
Short bouts of sedentary behavior and breaks in sedentary beha-
vior may be related to CR reduction, which suggests that children and
adolescents who frequently interrupt sedentary time are at a lower risk
than those who spend long periods of time sitting.32,35,40,60 In a rando-
mized study, lower levels of insulin and blood glucose were detected
when 3-minute breaks in sitting time were taken every 30 minutes
during a 3-hour sedentary bout,60 which indicated an effect on glucose
homeostasis and lower endogenous insulin production. These results
suggest that the acute metabolic effect of sedentary time interruption
is a potential strategy for the prevention of CR, although the long-term
consequences of the accumulation patterns of sedentary time have
not been determined.
In some studies, sedentary behavior was analyzed separately, i.e., on
weekdays and weekends.16,17,26,31,32,34 Some authors reported a positive
association between prolonged TV and VG time on weekends with
the assessed risk factors.17,34 Considering that the amount of sedentary
activities of children and adolescents may be higher in certain periods
of the day and the week69 and may be associated with other determi-
nants,70 data on the latter are relevant for understanding and proposing
interventions related to sedentary behavior reduction.
According to the findings of the present review, total sedentary time,
type of activity, and pattern of sedentary time accumulation appear to
be associated with cardiovascular health. However, the study had the
following limitations: because of the heterogeneity of the analyzed
studies regarding participants and measures of outcomes, a qualitative
synthesis describing the studies and their findings was conducted rather
than a meta-analysis. In addition, the fact that the majority were cros-
s-sectional studies hindered the establishment of a causal relationship
between sedentary behavior and CR.
Additionally important is the fact that, in general, the studies showed
an association between a single indicator of sedentary behavior and
the analyzed CR factors, which indicates the limitations of the findings.
Considering the multiple components, complexity, and potential inte-
ractions between the multiple determinants of sedentary behavior, it
is necessary to use methods that allow for the evaluation of sedentary
behavior as a construct. Alternative methods have recently been used
to evaluate the lifestyle of adolescents,71 in which the approach with
a latent variable allows concomitant analysis through the iteration of
manifesting variables.
CONCLUSION
Although not all studies support this relationship, a growing body
of evidence indicates that sedentary behavior is associated with adverse
effects on health and is a risk factor for the development of cardiovascular
disease in children and adolescents. Prolonged sedentary time, espe-
cially prolonged exposure to screen and TV time, is associated with CR
factors. In addition, prolonged sedentary bouts and infrequent breaks
in sedentary time appear to compromise the cardiometabolic profile.
Therefore, it is important to individually consider the distinct indicators
and patterns of this behavior and their influence on health.
Currently, understanding the complex relationships between
sedentary behavior determinants and the health of the pediatric
population is an extremely important need, especially because this
childhood behavior tends to persist into adulthood, more so than
physical activity habits. Thus, new studies should be conducted for
the development of proposals for interventions that enable the mi-
tigation of the adverse effects of sedentary behavior on health and
a better understanding of the multiple and overlapping aspects of
this behavior and its influence on health. The aim is to promote the
creation of guidelines for this population.
All authors declare no potential conflict of interest related to this article
AUTHORS’ CONTRIBUTIONS: Each author made signicant individual contributions to this manuscript. KLRC (0000-0002-9117-6129)*: conception of the work, acquisition,
analysis and interpretation of data, writing; PRSA (0000-0002-4327-9190)*: analysis and interpretation of data for the work, critical review of its intellectual content; VPNM (0000-
0002-2037-0573)*: analysis and interpretation of data for the work, writing; SEP (0000-0003-0656-1485)*: interpretation of data for the work, critical review of its intellectual
content; SCCF (0000-0001-7934-4558)*: conception of the work, critical review of its intellectual content. All authors approved the nal version of the manuscript. *ORCID (Open
Researcher and Contributor ID).
440
Rev Bras Med Esporte – Vol. 25, No 5 – Set/Out, 2019
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