Journal supplement

Resources to support the Guidelines

Evidence to support the 24-Hour Movement Guidelines for Adults aged 18-64 and Adults 65 years and older has been published in a special supplement of Applied Physiology, Nutrition, and Metabolism (APNM).

Volume 45 • Number 10 (Suppl. 2) • October 2020
CSEP Special Supplement: Canadian 24–Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older (online only) / Supplément spécial de la SCPE : Directives canadiennes en matière de mouvement sur 24 heures pour les adultes âgés de 18 à 64 ans et les adultes âgés de 65 ans et plus (électronique seulement)

Guest Editor

Christine Friedenreich, PhD, FCAHS, FRSC

Scientific Director, Cancer Epidemiology and Prevention Research

Cancer Care Alberta, Alberta Health Services

Adjunct Professor and Division Head, Preventive Oncology

Departments of Oncology, Community Health Sciences

Interim Scientific Director, O’Brien Institute of Public Health

Cumming School of Medicine and Faculty of Kinesiology

University of Calgary

Introduction

Introduction to the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep

Robert Ross and Mark Tremblay

Vol. 45 No. 10 (Suppl. 2) pp. v–xi

Articles

Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep

Robert Ross, Jean-Philippe Chaput, Lora M. Giangregorio, Ian Janssen, Travis J. Saunders, Michelle E. Kho, Veronica J. Poitras, Jennifer R. Tomasone, Rasha El-Kotob, Emily C. McLaughlin, Mary Duggan, Julie Carrier, Valerie Carson, Sebastien F. Chastin, Amy E. Latimer-Cheung, Tala Chulak-Bozzer, Guy Faulkner, Stephanie M. Flood, Mary Kate Gazendam, Genevieve N. Healy, Peter T. Katzmarzyk, William Kennedy, Kirstin N. Lane, Amanda Lorbergs, Kaleigh Maclaren, Sharon Marr, Kenneth E. Powell, Ryan E. Rhodes, Amanda Ross-White, Frank Welsh, Juana Willumsen, and Mark S. Tremblay

Vol. 45 No. 10 (Suppl. 2) pp. S57–S102

The Canadian Society for Exercise Physiology assembled a Consensus Panel representing national organizations, content experts, methodologists, stakeholders, and end-users and followed an established guideline development procedure to create the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: An Integration of Physical Activity, Sedentary Behaviour, and Sleep. These guidelines underscore the importance of movement behaviours across the whole 24-h day. The development process followed the strategy outlined in the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A large body of evidence was used to inform the guidelines including 2 de novo systematic reviews and 4 overviews of reviews examining the relationships among movement behaviours (physical activity, sedentary behaviour, sleep, and all behaviours together) and several health outcomes. Draft guideline recommendations were discussed at a 4-day in-person Consensus Panel meeting. Feedback from stakeholders was obtained by survey (n = 877) and the draft guidelines were revised accordingly. The final guidelines provide evidence-based recommendations for a healthy day (24-h), comprising a combination of sleep, sedentary behaviours, and light-intensity and moderate-to-vigorous-intensity physical activity. Dissemination and implementation efforts with corresponding evaluation plans are in place to help ensure that guideline awareness and use are optimized. Novelty First ever 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older with consideration of a balanced approach to physical activity, sedentary behaviour, and sleep Finalizes the suite of 24-Hour Movement Guidelines for Canadians across the lifespan.

Knowledge translation of the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older: a collaborative movement guideline knowledge translation process

Jennifer R. Tomasone , Stephanie M. Flood , Amy E. Latimer-Cheung , Guy Faulkner , Mary Duggan , Rebecca Jones , Kirstin N. Lane , Frances Bevington , Julie Carrier , Matt Dolf , Kevin Doucette , Emma Faught , Madelaine Gierc , Nicole Giouridis , Reut Gruber , Nora Johnston , Kaitlyn D. Kauffeldt , William Kennedy , Amanda Lorbergs , Kaleigh Maclaren , Robert Ross , Kim Tytler , Alexandra J. Walters , Frank Welsh , and Melissa C. Brouwers
Vol. 45 No. 10 (Suppl. 2) pp. S103–S124

Establishing a step-by-step process that provides practitioners with a blueprint for translating movement guidelines into action stands to optimize the investment in guideline development, improve guideline promotion and uptake, and ultimately enhance population health. The purpose of this paper is to describe how the Knowledge-to-Action framework and integrated knowledge translation were operationalized to systematically inform our knowledge translation (KT) efforts for the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older. In October 2018, the need for a KT Process, operating in tandem with the Guideline Development Process, led to the establishment of a KT team with a specific structure and terms of reference. The KT team collaboratively agreed on decision-making principles prior to selecting target audiences to focus their efforts. We undertook formative research to assess the local context and determinants of guideline dissemination and implementation efforts among target audiences. Plans for the subsequent steps and research are outlined. We highlight recommendations and lessons learned for applying the process in other settings. Novelty We outline a collaborative and systematic process and research program for the knowledge translation of movement guidelines. This paper provides an innovative and replicable blueprint to optimize future movement guideline knowledge translation efforts.

Optimal messaging of the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years and older

Emma Faught, Alexandra J. Walters, Amy E. Latimer-Cheung, Guy Faulkner, Rebecca Jones, Mary Duggan, Tala Chulak-Bozzer, Kirstin N. Lane, Melissa C. Brouwers, and Jennifer R. Tomasone
Vol. 45No. 10 (Suppl. 2)pp. S125–S150

The Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years and older (“Guidelines”) integrate recommendations for physical activity, sedentary, and sleep behaviours. Given the novelty of these integrated Guidelines, it was important to consider messaging strategies that would be most effective in reaching Canadian adults. The purpose of this study was to examine optimal messaging of the Guidelines as it pertains to communication channels and messages. Representative samples of Guideline end-users (N = 1017) and stakeholders (N = 877) each completed a cross-sectional survey. Descriptive statistics were calculated along with tests of statistical significance. Inductive content analysis was used to code stakeholders’ comments (i.e., suggestions, concerns) on a draft version of the Guidelines. Most end-users had recently referred to online medical resources; family, friends, and co-workers; and physicians as communication channels for information regarding the movement behaviours. End-users and stakeholders felt that generic messages would foster self-efficacy to meet the Guidelines. Stakeholders highlighted a variety of considerations to ensure the Guidelines are inclusive towards diverse groups within the Canadian population. Findings will inform Guideline messaging. Novelty Most end-users referred to online medical resources; family, friends, and co-workers; and physicians as communication channels. End-users and stakeholders indicated that generic messages would foster self-efficacy to meet the Guidelines. Stakeholders expressed concerns about the inclusivity of the Guidelines for diverse socioeconomic groups.

Development and application of an outcome-centric approach for conducting overviews of reviews

Michelle E. Kho, Veronica J. Poitras, Ian Janssen, Jean-Philippe Chaput, Travis J. Saunders, Lora M. Giangregorio, Jennifer R. Tomasone, Amanda Ross-White, and Robert Ross
Vol. 45 No. 10 (Suppl. 2) pp. S151–S164

There are gaps in current guidance concerning how to conduct overviews of systematic reviews in an outcome-centric manner. Herein we summarize the methods and lessons learned from conducting 4 outcome-centric overviews to help inform the Canadian 24-Hour Movement Guidelines for Adults aged 18–64 years and Adults aged 65 years or older on the topics of resistance training, balance and functional training, sedentary behaviour, sleep duration. We defined “critical” and “important” outcomes a priori. We used AMSTAR 2 to assess review quality and sought 1 systematic review per outcome. If multiple reviews were required to address subgroups for an outcome, we calculated the corrected covered area (CCA) to quantify overlap. We report our methodology in a PRISMA table. Across the 4 overviews, authors reviewed 1110 full texts; 45 were retained (low to high quality per AMSTAR 2), representing 950 primary studies, enrolling over 5 385 500 participants. Of 46 outcomes, we identified data for 35. Nineteen outcomes required >1 review (CCA range: 0% to 71.4%). Our outcome-centric overviews addressed unique aspects of overviews, including selection and quality assessment of included reviews, and overlap. Lessons learned included consistent application of methodological principles to minimize bias and optimize reporting transparency. Novelty Overviews of reviews synthesize systematic reviews in a rigorous and transparent manner. Outcome-centric systematic reviews assess the quality of evidence for primary studies contributing to an outcome. This manuscript describes the development and application of extending the concept of outcome-centric systematic reviews to the design and conduct of outcome-centric overviews.

Reviews

Resistance training and health in adults: an overview of systematic reviews

Rasha El-Kotob, Matteo Ponzano, Jean-Philippe Chaput, Ian Janssen, Michelle E. Kho, Veronica J. Poitras, Robert Ross, Amanda Ross-White, Travis J. Saunders, and Lora M. Giangregorio
Vol. 45 No. 10 (Suppl. 2) pp. S165–S179

The objective of this overview of systematic reviews was to determine the benefits and harms of resistance training (RT) on health outcomes in adults aged 18 years or older, compared with not participating in RT. Four electronic databases were searched in February 2019 for systematic reviews published in the past 10 years. Eligibility criteria were determined a priori for population (community dwelling adults), intervention (exclusively RT), comparator (no RT or different doses of RT), and health outcomes (critical: mortality, physical functioning, health-related quality of life, and adverse events; important: cardiovascular disease, type 2 diabetes mellitus, mental health, brain health, cognitive function, cancer, fall-related injuries or falls, and bone health). We selected 1 review per outcome and we used the GRADE process to assess the strength of evidence. We screened 2089 records and 375 full-text articles independently, in duplicate. Eleven systematic reviews were included, representing 364 primary studies and 382 627 unique participants. RT was associated with a reduction in all-cause mortality and cardiovascular disease incidence, and an improvement in physical functioning. Effects on health-related quality of life or cognitive function were less certain. Adverse events were not consistently monitored or reported in RT studies, but serious adverse events were not common. Systematic reviews for the remaining important health outcomes could not be identified. Overall, RT training improved health outcomes in adults and the benefits outweighed the harms. (PROSPERO registration no.: CRD42019121641.) Novelty This overview was required to inform whether there was new evidence to support changes to the recommended guidelines for resistance training.

Balance and functional training and health in adults: an overview of systematic reviews

Emily Claire McLaughlin, Rasha El-Kotob, Jean-Philippe Chaput, Ian Janssen, Michelle E. Kho, Veronica J. Poitras, Robert Ross, Amanda Ross-White, Travis J. Saunders, Catherine Sherrington, and Lora M. Giangregorio
Vol. 45No. 10 (Suppl. 2)pp. S180–S196

This overview of systematic reviews examined the effect of balance and functional strength training on health outcomes in adults aged 18 years or older, to inform the Canadian 24-hour Movement Guidelines. Four electronic databases were searched for systematic reviews published between January 2009 and May 2019. Eligibility criteria were determined a priori for population (community-dwelling adults), intervention (balance and functional training), comparator (no intervention or different types/doses), and outcomes (critical: falls and fall-related injuries; adverse events; important: physical functioning and disability; health-related quality of life; physical activity; and sedentary behaviour). Two reviewers independently screened studies for eligibility and performed AMSTAR 2 assessment. One review was selected per outcome. Of 3288 records and 355 full-text articles, 5 systematic reviews were included, encompassing data from 15 890 participants in 23 countries. In adults 65 years and older, balance and functional training and Tai Chi reduced the rate of falls and the number of people who fell, and improved aspects of physical functioning and physical activity. The effect on health-related quality of life and falls requiring hospitalization was uncertain. While inconsistently monitored, only 1 serious adverse event was reported. No evidence was available in adults under age 65 years. Included systematic reviews and primary evidence reported by review authors ranged in quality. Overall, participation in balance and functional training reduced falls and improved health outcomes in adults 65 years of age and older. PROSPERO registration no.: CRD42019134865. Novelty This overview informs updated guidelines for balance training in adults. Balance and functional training reduced falls and improved health outcomes.

Sedentary behaviour and health in adults: an overview of systematic reviews

Travis J. Saunders, Travis McIsaac, Kevin Douillette, Nick Gaulton, Stephen Hunter, Ryan E. Rhodes, Stephanie A. Prince, Valerie Carson, Jean-Philippe Chaput, Sebastien Chastin, Lora Giangregorio, Ian Janssen, Peter T. Katzmarzyk, Michelle E. Kho, Veronica J. Poitras, Kenneth E. Powell, Robert Ross, Amanda Ross-White, Mark S. Tremblay, and Genevieve N. Healy
Vol. 45 No. 10 (Suppl. 2) pp. S197–S217

The purpose of this overview of systematic reviews was to determine the relationship between different types and patterns of sedentary behaviour and selected health outcomes in adults and older adults. Five electronic databases were last searched in May, 2019, with a 10-year search limit. Included reviews met the a priori population (community-dwelling adults aged 18 years and older), intervention/exposure/comparator (various types and/or patterns of sedentary behaviour), and outcomes criteria. Eighteen systematic reviews were included in the evidence synthesis. High levels of sedentary behaviour are unfavourably associated with cognitive function, depression, function and disability, physical activity levels, and physical health-related quality of life in adults. Reducing or breaking up sedentary behaviour may benefit body composition and markers of cardiometabolic risk. Total sedentary behaviour and TV viewing were most consistently associated with unfavourable health outcomes, while computer and Internet use may be favourably associated with cognitive function for older adults. The quality of evidence within individual reviews (as assessed by review authors) varied from low to high, while the certainty of evidence was low to very low. These findings have important public health implications, suggesting that adults should avoid high levels of sedentary behaviour and break-up periods of prolonged sitting. (PROSPERO registration nos.: CRD42019123121 and CRD42019127157.) Novelty High levels of sedentary behaviour are unfavourably associated with important health outcomes in adults. Reducing or breaking up sedentary behaviour may benefit body composition and markers of cardiometabolic risk. Computer and Internet use may be favourably associated with cognitive function in older adults

Sleep duration and health in adults: an overview of systematic reviews

Jean-Philippe Chaput, Caroline Dutil, Ryan Featherstone, Robert Ross, Lora Giangregorio, Travis J. Saunders, Ian Janssen, Veronica J. Poitras, Michelle E. Kho, Amanda Ross-White, and Julie Carrier
Vol. 45 No. 10 (Suppl. 2) pp. S218–S231

The objective of this overview of systematic reviews was to examine the associations between sleep duration and health outcomes in adults. Four electronic databases were searched in December 2018 for systematic reviews published in the previous 10 years. Included reviews met the a priori determined population (community-dwelling adults aged 18 years and older), intervention/exposure/comparator (various levels of sleep duration), and outcome criteria (14 outcomes examined). To avoid overlap in primary studies, we used a priority list to choose a single review per outcome; reviews that examined the effect of age and those that looked at dose–response were prioritized. A total of 36 systematic reviews were eligible and 11 were included. Reviews included comprised 4 437 101 unique participants from 30 countries. Sleep duration was assessed subjectively in 96% of studies and 78% of studies in the reviews were prospective cohort studies. The dose–response curves showed that the sleep duration that was most favourably associated with health was 7–8 h per day. Modification of the effect by age was not apparent. The quality of the evidence ranged from low to high across health outcomes. In conclusion, the available evidence suggests that a sleep duration of 7–8 h per day is the one most favourably associated with health among adults and older adults. (PROSPERO registration no.: CRD42019119529.) Novelty This is the first overview of reviews that examines the influence of sleep duration on a wide range of health outcomes in adults. Seven to 8 h of sleep per day was most favourably associated with health. Effect modification by age was not evident.

Systematic Reviews

Sleep timing, sleep consistency, and health in adults: a systematic review

Vol. 45 No. 10 (Suppl. 2) pp. S232–S247

The objective of this systematic review was to examine the associations between sleep timing (e.g., bedtime/wake-up time, midpoint of sleep), sleep consistency/regularity (e.g., intra-individual variability in sleep duration, social jetlag, catch-up sleep), and health outcomes in adults aged 18 years and older. Four electronic databases were searched in December 2018 for articles published in the previous 10 years. Fourteen health outcomes were examined. A total of 41 articles, including 92 340 unique participants from 14 countries, met inclusion criteria. Sleep was assessed objectively in 37% of studies and subjectively in 63% of studies. Findings suggest that later sleep timing and greater sleep variability were generally associated with adverse health outcomes. However, because most studies reported linear associations, it was not possible to identify thresholds for “late sleep timing” or “large sleep variability”. In addition, social jetlag was associated with adverse health outcomes, while weekend catch-up sleep was associated with better health outcomes. The quality of evidence ranged from “very low” to “moderate” across study designs and health outcomes using GRADE. In conclusion, the available evidence supports that earlier sleep timing and regularity in sleep patterns with consistent bedtimes and wake-up times are favourably associated with health. (PROSPERO registration no.: CRD42019119534.) Novelty This is the first systematic review to examine the influence of sleep timing and sleep consistency on health outcomes. Later sleep timing and greater variability in sleep are both associated with adverse health outcomes in adults. Regularity in sleep patterns with consistent bedtimes and wake-up times should be encouraged.

Dissemination and implementation of national physical activity, sedentary behaviour, and/or sleep guidelines among community-dwelling adults aged 18 years and older: a systematic scoping review and suggestions for future reporting and research

J. R. Tomasone, K. D. Kauffeldt, T. L. Morgan, K. W. Magor, A. E. Latimer-Cheung, G. Faulkner, A. Ross-White, V. Poitras, M. E. Kho, and R. Ross
Vol. 45 No. 10 (Suppl. 2) pp. S258–S283

Strategies for dissemination (purposive distribution of a guideline to specific audiences) and implementation (actions to support the general public in meeting guideline recommendations/behavioural benchmarks) of national movement guidelines (physical activity (PA), sedentary behaviour, and sleep) have yet to be synthesized. The purpose of this systematic scoping review was to identify strategies for dissemination and implementation of national PA, sedentary behaviour, and/or sleep guidelines among community-dwelling adults (aged >18 years) and/or stakeholders in Canada and analogous countries. Five search approaches (e.g., published literature, grey literature, targeted web-based, custom Google, and content expert consultation) identified records (e.g., empirical studies, organizational reports, website pages, or guideline messages) that discussed and/or evaluated dissemination or implementation strategies for a prespecified list of guidelines. A modified strategy classification system was developed to chart the data. Forty-seven reports met inclusion criteria. Dissemination strategies (n = 42) were more frequently reported than implementation strategies (n = 24). Implementation strategies were more frequently evaluated (n = 13 vs. 7 dissemination strategies) and associated with positive outcomes. The 13 studies that evaluated strategies were at high or serious risk of bias. We identified limited information about the dissemination and implementation of national movement guidelines and identified strategies were rarely evaluated. Greater efforts are required to increase the impact of guidelines among the general public and stakeholders and to build the evidence base in this field. (Open Science Framework registration: https://osf.io/4tyw3.) Novelty An adapted movement guideline dissemination and implementation strategy classification framework is provided. Knowledge translation efforts should be documented and evaluated to advance science and practice in the movement guideline field.