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Review
Sedentary behaviour and diet across the lifespan: an updated systematic review
  1. Matthew Hobbs1,
  2. Natalie Pearson2,
  3. Perry J Foster2,
  4. Stuart J H Biddle2,3
  1. 1Carnegie, Leeds Metropolitan University, Leeds, UK
  2. 2School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
  3. 3The NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit [Now at Institute of Sport, Exercise & Active Living, Victoria University, Melbourne, Australia]
  1. Correspondence to Matthew Hobbs, 227 Fairfax Hall, Headingley Campus, Leeds Metropolitan University, Leeds, LS6 3QT, UK; m.hobbs{at}leedsmet.ac.uk

Abstract

Background Sedentary behaviour and its association with dietary intake in young people and adults are important topics and were systematically reviewed in 2011. There is a need to update this evidence given the changing nature of sedentary behaviour and continued interest in this field. This review aims to assist researchers in better interpreting the diversity of findings concerning sedentary behaviour and weight status.

Objective To provide an update of the associations between sedentary behaviour and dietary intake across the lifespan.

Methods Electronic databases searched were MEDLINE, PsychInfo, Cochrane Library, Web of Science and Science Direct for publications between January 2010 and October 2013, thus updating a previous review. Included were observational studies assessing an association between at least one sedentary behaviour and at least one aspect of dietary intake in preschool children (<5 years), school-aged children (6–11 years), adolescents (12–18 years) and adults (>18 years).

Results 27 papers met inclusion criteria (preschool k=3, school-aged children k=9, adolescents k=15, adults k=3). For all three groups of young people, trends were evident for higher levels of sedentary behaviour, especially TV viewing, to be associated with a less healthful diet, such as less fruit and vegetable and greater consumption of energy-dense snacks and sugar sweetened beverages. Data for the three studies with adults were less conclusive.

Conclusions Sedentary behaviour continues to be associated with unhealthy diet in young people in mostly cross-sectional studies. More studies utilising a prospective design are needed to corroborate findings and more studies are needed with adults.

  • Children
  • Adolescent
  • Nutrition
  • Food intake/body weight regulation

https://doi.org/10.1136/bjsports-2014-093754

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    Introduction

    Sedentary behaviour refers to sitting or lying tasks performed in waking hours with low levels of energy expenditure.1 Studies show associations between sedentary behaviour (usually assessed as screen-based behaviours such as TV and computer use) and a range of health outcomes, including all-cause mortality, cardiovascular disease,2 ,3 poor cardiometabolic health4 and obesity.5

    In 2011, Pearson and Biddle6 published the first systematic review to investigate associations between sedentary behaviours and dietary intake. This was predicated on the fact that not all associations between sedentary behaviour and health outcomes were consistent and some associations might be due to the influence of third variables, or coexisting health behaviours, such as diet.

    There are data from adults that show an association between weight status and sedentary behaviour. For example, in a study from New Zealand, watching television between 5 and 15 years predicted body mass index at 26 years of age.5 Moreover, the Nurses’ Health Study, with over 50 000 women,7 reported data showing those normal weight or overweight at baseline had a 23% increased risk of developing obesity at follow-up after 6 years for each 2 h per day increase in TV viewing. In another large study of women, Blanck et al8 showed an elevated risk of weight gain from elevated levels of leisure time sitting. These studies, therefore, show that for adults there are associations between sedentary behaviour and weight status.9 However, not all studies control for confounding factors, such as diet or physical activity. One variable that may co-vary with some sedentary behaviours, and in particular TV viewing, is diet.

    For young people, there has often been an assumption that obesity is associated with too much TV viewing.10 However, a meta-analysis of mainly cross-sectional studies found that this association was very small.11 Also, inconsistent weight loss was reported from a review of sedentary behaviour intervention studies.12 Overall, therefore, sedentary behaviour, often when assessed as screen time, has been suggested as factor contributing to obesity in youth, but findings are less clear than is often claimed.

    Some of the reasons why TV viewing may be coupled with obesity is that little energy is expended,13 and TV viewers are exposed to commercial material for less health foods and drinks.14 ,15 Also, eating in front of the TV may be linked to different eating styles. For example, TV or snack commercials may be a distraction which leads to a lack of awareness of food consumption or makes individuals overlook food cues, and leading to overconsumption.16

    Dietary intake and its association with sedentary behaviour in young people and adults is an important topic that may assist researchers in better interpreting the diversity of findings concerning sedentary behaviour and weight status. However, it is recognised that sedentary pursuits using technology can change very quickly. Computer technology has become more mobile and will this change the way people use and interact with such devices. Moreover, TV channels have increased and the TV viewing experience has changed with greater access to high definition screens and even three-dimensional TV. To this end, it is important to update the review of studies on the association between sedentary behaviour and dietary behaviour. In addition, we feel it is important to differentiate studies with young people into preschool, children and adolescents. This systematic review, therefore, provides an update of the associations between sedentary behaviour and diet across the lifespan.

    Methods

    Search strategy

    A literature search was conducted using electronic databases, sedentary behaviour review papers, manual searches of existing reference lists and personal files. The electronic database searches used MEDLINE, PsychInfo, Cochrane Library, Web of Science and Science Direct for publications between January 2010 and October 2013, thus updating the previous review.6 To ensure a broad search, a comprehensive list of keywords was used to guide the search process that included the most common forms of sedentary behaviour and dietary intake.

    Inclusion and exclusion criteria

    To be included studies had to: (1) be observational in design; (2) report data on preschool children (<5 years), school-aged children (6–11 years), adolescents (12–18 years) and adults (>18 years; or a mean within these ranges) at baseline; (3) measure at least one domain of sedentary behaviour and one aspect of dietary intake; (4) assess an association between at least one sedentary behaviour and one aspect of dietary intake; (5) be published in English between January 2010 and October 2013. Studies that reported physical inactivity (low physical activity) as a measure of sedentary behaviour were excluded. Studies that manipulated a sedentary behaviour and/or aspects of dietary intake were excluded as were studies that did not involve healthy-free living individuals were excluded (ie, chronic illnesses preventing physical activity), although articles that reported risk factors were included.

    Identification of relevant studies

    Titles then abstracts of potentially relevant articles were screened independently by two authors. The full text of any relevant abstracts were then obtained and screened to determine whether they met the full inclusion criteria. Any uncertainty was resolved by consulting a third author in order to determine whether to include the paper in the final sample on reading the full text. Studies that did not meet the inclusion criteria at this stage were excluded.

    Data extraction

    Two authors extracted the data from relevant articles in accordance with a standardised form developed for a previous review.6 The following data were extracted from each paper: (1) author and year; (2) study design and duration of follow-up if prospective; (3) geographical location; (4) age group; (5) sample size and subgroups; (6) sedentary behaviour outcome and primary measure; (7) dietary intake outcome and primary measure; (8) timing, reliability and validity of assessment methods; (8) the analysis and results of an association between sedentary behaviour and dietary intake. Authors were contacted when missing information prevented data extraction. All data extraction was completed by the researchers independently. Any differences or discrepancies (interpretation errors or factual errors, such as transposed information) were discussed and resolved. Finally, inter-rater reliability was calculated and reported for study quality and data extraction (tables 1 and 2).

    View this table:
    Table 1

    Characteristics of early years and child studies included in the review: sample size, gender, study design, nature of sedentary behaviour assessed, assessment and measurement of sedentary behaviour, type of dietary behaviours assessed, assessment and measurement of dietary behaviour and country of study

    View this table:
    Table 2

    Characteristics of adolescent and adults studies included in systematic review: sample size, gender, study design, nature of sedentary behaviour assessed, assessment and measurement of sedentary behaviour, type of dietary behaviours assessed, assessment and measurement of dietary behaviour and country of study

    Study quality

    The quality of the studies included in this review was assessed with a previously used scale.6 Studies were given a score based on sampling procedure, sample size, response rates, the validity and reliability of the measures used to assess sedentary behaviour and dietary intake and whether confounders had been considered in the analysis. Each included paper was given a score out of 16 with a higher score meaning higher study quality. Studies were categorised as high (scoring 12+), moderate (scoring 6–11) and poor (scoring 0–5) quality. There was good initial agreement for study quality (91% r=0.98) between authors.

    Results

    Flow of studies included

    The literature search identified 13 883 articles from which 209 were identified as potentially relevant on reviewing the title. Following the screening of the full text of the article, 27 were identified that sufficiently examined the association between sedentary behaviour and dietary intake. Figure 1 presents the flow of papers from citations retrieved. The results are reported separately for preschool children, school-aged children, adolescents and adults.

    Figure 1
    Figure 1

    The flow of papers throughout the study selection process.

    Study quality

    Study quality for studies including children of preschool age ranged from 2/16 to 6/16, median=6 (individual scores 6: n=217 ,18; 2: n=119). Study quality in studies including children ranged from 4/16 to 8/16, median=6 (individual scores 6: n=417 ,18 ,20 ,21; 7: n=222 ,23; 8: n=124; 4: n=125; 5: n=126).

    Adolescent study quality ranged from 4/16 to 15/16, median=8 (scores 19: n=127; 10: n=428–31; 8: n=232 ,33; 7: n=134; 6: n=518 ,35–38; 5: n=139; 4: n=140). Study quality scores in adults for studies ranged from 5/16 to 7/16, median=6 (scores 7: n=141; 6: n=118; 5: n=142).

    Associations between sedentary behaviour and diet in preschool children

    Three studies (three samples) including preschool children were eligible for review (table 3). Two studies were conducted in Australia and one in the USA. Two studies examined associations between sedentary behaviour and dietary outcomes for boys and girls combined, one study examined associations separately for boys and girls. The majority used a cross-sectional research design (n=2), two of the studies assessed sedentary behaviour through parental report and one through interview. Dietary behaviour was also assessed through parental report (n=2) and interview (n=1). In this one instance, the dietary behaviour (based on the Healthy Eating Index (HEI) 2005) was collected from two, averaged interview-administered 24 h dietary recalls. The sedentary behaviour information was also collected as part of this interview. TV viewing was the most commonly assessed sedentary behaviour in association with dietary intake, studied in all three studies. In studies including children of preschool age, five dietary behaviours were identified.

    View this table:
    Table 3

    Associations between sedentary behaviour and diet in preschoolchildren (aged <5 years)

    Average weekday and weekend TV viewing, weekday and weekend non-commercial and weekday commercial TV viewing were inversely associated with fruit and vegetable consumption in one sample. However, weekday commercial TV viewing was positively associated with fruit and vegetable consumption in one sample. Finally, TV viewing was inversely associated with the HEI in both boys and girls in one sample and with vegetable intake in one other sample.

    TV viewing was positively associated with energy-dense food in two of two samples and positively associated with fast food in one sample. There was one longitudinal study17 which scored well on study quality and had a large sample size (n=4983). This study corroborates the results from the limited cross-sectional studies showing that TV viewing is positively associated with energy-dense food. Overall, sedentary behaviour in preschool children seems to be trending towards an association with elements of an unhealthy diet, yet caution is required when interpreting results due to the paucity of studies. That said, these results are confirmed in a large high-quality longitudinal study.

    Associations between sedentary behaviour and diet in children

    Nine studies (nine samples) of school-age children were eligible for review (table 4). Three studies were conducted in Australia and two in Norway. The remaining four were carried out in Canada, Netherlands, USA and Belgium. Eight studies examined associations between sedentary behaviour and dietary outcomes for boys and girls combined whilst one study examined associations separately for boys and girls. The majority of studies used a cross-sectional design (n=6), six assessed sedentary behaviour through self-report and three by parental report. One used an objective measure of accelerometry, yet specific methodological information on cut-points was withheld. Dietary behaviour was assessed through 24 h recall (n=3), food diary (n=4) and questionnaire (n=3). TV viewing was the most commonly assessed sedentary behaviour in association with dietary intake (n=6). Nine dietary behaviours were identified and tabulated, the most common being energy-dense food.

    View this table:
    Table 4

    Associations between sedentary behaviour and diet in school age children (aged ≥5–11 years)

    Sedentary behaviour was inversely associated with vegetable intake in two samples (one assessed TV viewing and the other both computer use and screen time), yet computer use was positively associated with vegetable intake in one sample. Sedentary behaviour was inversely associated with fruit intake in two samples (one assessed TV viewing and the other both computer use and screen time), yet computer use had no association with fruit intake in one sample. Finally, homework was positively associated with the HEI (one sample) and TV viewing in boys and girls and computer use was inversely associated with the HEI (two samples).

    Sedentary behaviour was positively associated with energy-dense food in five samples (four assessed TV viewing and the other both screen time and computer use). However, computer use was inversely associated with energy-dense food in one sample. Sedentary behaviour was positively associated with fat, sugar and total calorie intake in three samples (three used self-report and one study objectively assessed sedentary behaviour) and was positively associated with sugar sweetened beverage intake in two samples (one assessed screen time and computer use and the other assessed computer use and TV viewing). Finally, TV viewing was positively associated with diet quality based on fat and sugar intake (one sample).

    Two longitudinal studies assessed the association between sedentary behaviour and diet in children.17 ,24 Both scored at and above the median score on study quality and had moderate-to-large sample sizes (n=908 and n=4464). These studies corroborated findings from the cross-sectional evidence that various sedentary behaviours (TV viewing, screen time and computer use) are positively associated with consumption of energy-dense food and sugar sweetened beverages. Overall, sedentary behaviour in children again seems to be trending towards an association with elements of a less healthy diet. However, the number of comparisons is small, the studies are often diverse in the measurement methods adopted, and are often cross-sectional in design in preschool and children. This makes it difficult to draw meaningful conclusions. That said, two medium-to-large longitudinal studies of moderate-to-good quality did show associations between sedentary behaviour and unhealthy diet.

    Associations between sedentary behaviour and diet in adolescents

    All 15 studies were cross-sectional in design. Data were reported separately for gender in eight studies. The remaining seven studies combined male and female data. Participants were aged between 11 and 19 years. Three studies reported data from the USA and two presented combined data from Europe.

    The majority of studies (60%) measured TV viewing as the sedentary behaviour. Two of these also separately measured computer use and one also measured study time. A further two studies measured internet and video game use alongside TV viewing, two additional studies measured computer use, internet for study, video games and study time alongside TV viewing. One study measured screen time as one outcome (TV+video games+computer use+internet use), another also measured small screen recreation time (TV+/or video+/or DVDs+video games+computer games+computer not for homework) and sedentary education time (reading+homework). Sedentary behaviour was assessed by self-report in the majority of studies; one study used an interview administered technique. Sedentary behaviour was measured using questionnaires in all 15 adolescent studies (table 5).

    View this table:
    Table 5

    Associations between sedentary behaviour and diet in adolescents (aged 12–18 years)

    A total of 18 dietary behaviours were assessed. Eleven studies assessed diet by self-report and the remaining study used a telephone interview technique. Diet was measured using unnamed questionnaires in eight studies, a web-based food behaviour questionnaire in another study, food frequency questionnaire in two studies and using 24 h recall methods in three studies. Finally, one study used a combination of a food frequency questionnaire and 24 h recall.

    Separate measures of TV viewing and various categories of screen time were positively associated with sugar sweetened beverages in five of five samples and inversely associated in one sample. Separate measures of TV viewing and various categories of screen time were also inversely associated with separate measures of fruit and vegetable consumption in three of three studies, and positively associated in another. Further, the inclusion of sedentary behaviours such as ‘internet use for study’ and ‘studying’ evident in one study resulted in a positive association with a separate measure of fruit and vegetable consumption. TV viewing and computer use were also inversely associated with a composite measure of fruit and vegetable consumption in one of one sample.

    Overall, sedentary behaviour in adolescents appears to be associated with elements of an unhealthy diet. However, caution should be expressed when interpreting this association due to the low number of studies reporting the same sedentary and dietary behaviours.

    Associations between sedentary behaviour and diet in adults

    Characteristics of studies concerning adults are shown in table 6. All three studies were cross-sectional in design. Male and female data were reported separately in two studies and one reported only female data. Studies were conducted in the USA in two papers.

    View this table:
    Table 6

    Associations between sedentary behaviour and diet in adults (aged >18 years)

    All three studies assessed self-reported TV viewing as the sedentary behaviour using questionnaires. Dietary intake was measured using food frequency questionnaires, seven-day weighed food records and a 24 h recall. Two studies measured HEI Score, the other measured total energy intake. TV viewing was marginally positively associated with total energy intake in adults and marginally inversely and positively associated with healthy food index scores. Again, caution should be headed when interpreting analyses with fewer than five studies, as estimates of an association may be imprecise.

    Based on the lack of evidence, it is difficult to provide a clear conclusion on the association between TV viewing and dietary behaviour in adults. Although limited, the available evidence tends to suggest that high TV viewing is positively associated with total energy intake and unhealthy diet quality. Similar to findings with adolescents, caution should be taken when interpreting associations regarding adults due to the lack of research.

    Discussion

    This systematic review builds on the published review by Pearson and Biddle.6 An update was attempted because technology-based sedentary behaviours are likely to be changing quickly, and it is timely to examine new papers that were emerging but by differentiating preschool children from children and adolescents. Adults were again included to allow for a lifespan approach. However, studies are failing to provide contextual information about how TV is viewed, thus we were unable to further differentiate results on this basis. For example, we have shown that children multitask while ‘watching’ TV.43 Future research on diet and screen viewing needs to differentiate types of screen viewing as this will inevitably change with time.

    For preschool children, three new studies were found since early 2010. These showed a clear trend for greater time in sedentary behaviour (mainly TV viewing) to be associated with unhealthy eating. This showed in less fruit and vegetable consumption and lower scores on a HEI, as well as higher levels of energy dense food and fast food. In the 2011 review, we combined this age group with older children. The present review, therefore, shows that the coupling of screen time and possibly commercial TV viewing time with an unhealthy diet starts at an early age and leads to the obvious conclusion that parental, family and other interventions are required with children in the first few years of life. However, caution is required at this stage due to the small number of studies and the difficulty of eliciting such information from young children or their carers. Clearly this is an important area of research development.

    For children aged 5–11 years, results across nine studies showed a clear trend for sedentary behaviour to be associated with a less healthy diet. With 19 studies reported by Pearson and Biddle for preadolescent children, including preschool children, this shows a continued interest in diet and sedentary behaviour in this age group. In the current review, sedentary screen time, and mainly TV viewing, is associated with greater consumption of energy-dense food, fat, sugar, sugar sweetened beverages and total caloric intake. It is also associated with consumption of less fruit and vegetables.

    Confidence in these trends is enhanced by two reasonably large longitudinal studies that show that screen time is associated with energy-dense food and sugar sweetened beverage consumption. Sugar sweetened beverages have been implicated in weight gain44 ,45 and might be one mechanism linking screen time with obesity and account for the variable findings in this area. In other words, weight status may be as much to do with energy consumption as it is with low-energy expenditure from sedentary time, thus accounting for inconsistency of findings when just investigating TV and weight status.10 Studies are required that investigate further this association, including availability of food and drinks during different sedentary behaviours, and prompts or cues that encourage or discourage such consumption.

    With 15 studies reported in the current review concerning associations between sedentary behaviour and diet in adolescents, this shows that researchers continue to view this topic and age group as important. In less than 4 years, this represents more than a 50% increase in the number of studies. However, while there is a trend for higher levels of sedentary behaviour to be associated with poorer diet, there are rather few studies assessing the same sedentary behaviour and same diet outcome variable. Future studies need to build on these associations by ensuring that similar measures are taken. It appears that TV and, to a certain extent, computer screen time are implicated in being associated with poorer diet. The dietary outcomes, therefore, need standardising by studies ensuring that they measure at least fruit and vegetable intake, energy-dense snacks and sugar sweetened beverages. That way a more comprehensive picture will emerge for adolescents at an important time of change in this age group.

    Data on adults have not expanded much since the last review. Only 3 studies were reviewed in the present paper, with 11 in 2011. With so few studies, firm conclusions are not possible, although similar trends noted elsewhere in this review are still evident. Future studies need more data on the context of sedentary behaviours and what might be cuing certain dietary behaviours in the presence of screen or other sitting behaviours.

    Conclusion

    In conclusion, sedentary behaviour, mainly in form of screen viewing and especially TV, is associated with indicators of unhealthy dietary intake in preschool children, school-aged children and adolescents in predominantly cross-sectional studies. The results for adults are sparse and less clear. Findings largely confirm and extend the review published in 2011. We have added to knowledge by investigating preschool children separately, and documenting the continued study of sedentary behaviour and diet in young people. Research on adults needs to develop. Future studies need to be longitudinal in design, use standard measures of diet, include a wider variety of sedentary behaviours, as well as document the context that sedentary behaviour may be associated with dietary intake.

    What are the new findings?

    • Sedentary time has been implicated in obesity, yet this could be due to energy intake rather just low-energy expenditure.

    • We provide review-level evidence linking sedentary time and various diet outcomes across the lifespan, including preschool children for the first time.

    • We build on a previous review by providing updated evidence linking sedentary behaviour and elements of an unhealthy diet at a time when sedentary behaviours are continually evolving.

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    View Abstract

    Footnotes

    • MH and NP are joint first authors.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.