Systematic Review of the Relationships between 24-Hour Movement Behaviours and Health Indicators in School-Aged Children from Arab-Speaking Countries

The Australian and Canadian 24-hour movement guidelines for children and youth synthesized studies in English and French or other languages (if able to be translated with Google translate) and found very few studies published in English from Arabic countries that examined the relationship between objectively measured sedentary behaviour (SB), sleep and physical activity (PA) and health indicators in children aged 5–12 years. The purpose of this systematic review was to investigate the relationships between 24-hour movement behaviours and health indicators in school-aged children from Arab-speaking countries. Online databases MEDLINE, EMBASE, SPORTdiscus, CINAHL, PsycINFO and Scopus were searched for English, French and Arabic studies (written in English), while Saudi Digital Library, ArabBase, HumanIndex, KSUP, Pan-Arab Academic Journal, e-Marefa, Al Manhal eLibrary and Google Scholar were searched for Arabic studies. The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess the risk of bias and the quality of evidence for each health indicator. A total of 16 studies, comprising 15,346 participants from nine countries were included. These studies were conducted between 2000 and 2019. In general, low levels of PA and sleep and high SB were unfavourably associated with adiposity outcomes, behavioural problems, depression and low self-esteem. Favourable associations were reported between sleep duration and adiposity outcomes. SB was favourably associated with adiposity outcomes, withdrawn behaviour, attention and externalizing problems. PA was favourably associated with improved self-esteem and adiposity outcomes. Further studies to address the inequality in the literature in the Arab-speaking countries to understand the role of 24-hour movement behaviours and its positive influence on health outcomes across childhood are urgently needed.


Introduction
For years, movement guidelines for children and adolescents have concentrated on moderate-to vigorous-intensity physical activity (MVPA) [1]. However, focusing on PA per se and omitting other movement behaviours, such as SB and sleep, has reduced our perception of how these daily movement behaviours interact to affect children's health [2].
Hence, an approach that integrates all components of movement behaviours is required to review their combined influence on health and development [2].
In 2016, the Canadian Society for Exercise Physiology released the world's first integrated 24-hour movement guidelines for children and youth (5-17 years) [3]-a new concept describing the integration of PA, SB and sleep over the 24-hour period. This terminology is regarded as a shift in daily movement behaviour research and illustrates an evolution in PA guidelines [3]. These guidelines were launched based on the results of four systematic reviews, investigating associations between PA, SB, sleep, and movement combinations, each one with health indicators [3]. The authors found that children's total PA was favourably associated with physical, psychological/social, and cognitive health indicators [4]. Higher levels of TV and screen time viewing were associated with unfavourable body composition, cardio-metabolic disease risk scores, hostile behavioural conduct/pro-social behaviour indicators, lower fitness and self-esteem in children [5]. Shorter sleep duration was associated with poorer health outcomes [6]. Children who had higher levels of PA and sleep and less SB had more desirable measures of adiposity and cardiometabolic health when compared with those with a combination of low PA and low sleep and high SB. Similarly, those with high PA and high sleep or high PA and low SB profiles demonstrated favourable health indicators compared with low PA and low sleep, or low PA and high SB profiles [7].
In 2018, the literature on 24-hour movement guidelines was updated as part of the development of Australian 24-Hour Movement Guidelines for Children and Young People [8]. These guidelines were launched as evidence-based guidelines to address movement behaviours observed over the whole day instead of focusing on these behaviours in isolation. Previous studies only captured specific movement behaviours (e.g., MVPA) during waking hours-which accounts for a small portion of children's daily activity (<5%) in the 24-hour period; while sleep (~40%), SB (~40%) and LPA (~15%) make up nearly 95% of the day [2]. Furthermore, these guidelines were launched based on the results of systematic reviews that synthesized studies in English and French or other languages if able to be translated with Google translate, and found very few studies published in English or French from Arabic countries that examined the relationship between objectively measured SB, sleep and PA and health indicators in children aged 5-12 years. The search criteria did not elicit any studies published in Arabic from Arab countries.
Even though more than 140 million children live in the 22 Arabic countries [9], where there are high and increasing levels of childhood obesity and sedentary behaviour [10,11], the lack of evidence from these countries confirms that research is needed to address this gap in the literature, to understand the role of 24-hour movement behaviours and its influence on important health outcomes (obesity, executive functions, motor development and bone health) across the years of primary school. Moreover, it is likely there may be cultural differences in 24-hour movement behaviours in Arabic countries compared to Western countries, necessitating a separate review. Therefore, the purpose of this systematic review was to investigate the relationship between 24-hour movement behaviours and health indicators in school-aged children in Arabic countries.

Methods
This systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO; Registration no. CRD42020143101). It was conducted and reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews and meta-analyses [12]. The protocol of this study was adopted partly from the systematic review performed by Saunders et al. [7].

Eligibility Criteria
Eligible participants included apparently healthy children aged 5 to 12 years old. Overweight and/or obese children were also included. Studies where the sample were aged above 12 years or below 5 years were included if the mean age was between 5-12 years. To be included, studies had to be peer-reviewed, published, written in Arabic, English or French and reported subjective or objective measurement of PA or SB or sleep or their combination. Grey literature, student dissertations or conference abstracts were excluded. The main outcomes were adiposity, cardiometabolic biomarkers, fitness, behavioural conduct/pro-social behaviour, emotional regulation/psychological distress, cognition (academic achievement), quality of life and injuries. Secondary outcomes included bone density, motor skill development and self-esteem. The review was limited to full manuscripts. There was no minimum sample size. All study designs were included.
Twenty-four-hour movement behaviours incorporate sleep, SB and PA, which are independently defined as: Sleep: "a naturally recurring state of body and mind characterized by altered consciousness, relatively inhibited sensory activity, inhibition of nearly all voluntary muscles and reduced interactions with surroundings". [13] SB: "any waking behaviour characterized by an energy expenditure ≤1.5 metabolic equivalents (METs), while in a sitting, reclining or lying posture". [14] PA: "any bodily movement produced by skeletal muscles that results in energy expenditure above the resting metabolic rate". [15]

Search Strategy
Six electronic databases were searched from January, 1990 to January, 2021 to identify relevant articles that were written in English or French: MEDLINE, EMBASE, SPORTdiscus, CINAHL, PsycINFO and Scopus. Eight electronic databases were searched for Arabic studies: Saudi Digital Library, ArabBase, Human Index, KSUP, Pan-Arab Academic Journal, e-Marefa, Al Manhal eLibrary and Google Scholar. Search terms can be seen in the Appendix A.

Data Extraction
Studies were imported into Endnote X9 software (Thomson Reuters, San Francisco, CA, USA). After de-duplication, three authors (YA, ESS and KHC) screened titles and abstracts for relevant studies. Full-text copies of the eligible studies were assessed for final inclusion. Any disagreement between the three authors was resolved through a discussion and, when necessary, included a fourth author. The reference lists of all included studies were screened for additional studies not listed in the database search. Data were extracted for each study using an Excel spread sheet; each study included article, author, study design, publication year, location, sample size, age, mean age, gender, outcomes and measures, study instrument and results (Table 1).

Quality Assessment
Three authors (YA, ESS and KHC) independently assessed the risk of bias (ROB) using the GRADE framework (Grading of Recommendations Assessment, Development, and Evaluation), which was also used to assess the quality of evidence for each health indicator. GRADE does not have an official tool for assessing ROB in observational studies but recommends the types of study characteristics to be evaluated [16]. The quality of evidence was assessed for each included study design based on selection bias, attrition bias, detection bias, performance bias, and selective reporting bias. Quality of evidence scores were considered "low" for experimental and observational studies. Scores above 6/8 were considered as having low risk of bias.    Depression and low self-esteem.
One-way ANOVA and post hoc test (Scheffe).
Regular PA was significantly associated with improved self-esteem; differences were seen between those who never exercised and those who exercised regularly (mean square = 358.257; F = 4.787; p = 0.10).

Results
A total of 612 studies were eligible for inclusion. After title and abstract screening, 102 studies were assessed for full-text review. Of those, 86 were excluded for the following reasons: did not contain measures of PA or SB or sleep as an independent variable (n = 21); did not contain a measure of a health indicator and its association with PA or SB or sleep (n = 13); out of range for age (n = 37); dissertation (n = 7); studies conducted in non-Arab countries (n = 4); unavailability of the full article (n = 3); and lack of statistical data (n = 1). After all exclusions, 16 studies met the inclusion criteria (Figure 1). These studies provided results from 15,346 participants from 9 Arabic countries: Saudi Arabia, n = 6, United Arab Emirates, n = 1, Egypt, n = 2, Oman, n = 2, Kuwait, n = 1, Iraq, n = 1, Tunisia, n = 1, Qatar, n = 1 and Palestine, n = 1 ( Table 1). Of all included studies, 12 were cross-sectional, two were case-control, one was longitudinal and one was a pilot study. These studies were conducted between 2000 and 2019 and included children between 3.4 and 14 years of age (mean age 5.19-11.4 years). Sample sizes ranged from 40 to 8317 participants. Out of the 16 included studies, 14 reported data on adiposity [17][18][19][20][21][22][23][24][25][26][27][28][29][30], one on behavioural problems [31], one on depression and low self-esteem [32] and one on fitness [19]. Out of the sixteen studies included in this review, eight studies (50%) were classified as having a low ROB and eight as having a high ROB (50%). All studies had a reliable and/or valid tool to assess movement behaviours and health outcomes. The criteria used to assess ROB can be seen in Table 2. It was not possible to conduct meta-analyses due to heterogeneity of the data, therefore, narrative syntheses were conducted.

Results
A total of 612 studies were eligible for inclusion. After title and abstract screening, 102 studies were assessed for full-text review. Of those, 86 were excluded for the following reasons: did not contain measures of PA or SB or sleep as an independent variable (n = 21); did not contain a measure of a health indicator and its association with PA or SB or sleep (n = 13); out of range for age (n = 37); dissertation (n = 7); studies conducted in non-Arab countries (n = 4); unavailability of the full article (n = 3); and lack of statistical data (n = 1). After all exclusions, 16 studies met the inclusion criteria (Figure 1). These studies provided results from 15,346 participants from 9 Arabic countries: Saudi Arabia, n = 6, United Arab Emirates, n = 1, Egypt, n = 2, Oman, n = 2, Kuwait, n = 1, Iraq, n = 1, Tunisia, n = 1, Qatar, n = 1 and Palestine, n = 1 (Table 1). Of all included studies, 12 were crosssectional, two were case-control, one was longitudinal and one was a pilot study. These studies were conducted between 2000 and 2019 and included children between 3.4 and 14 years of age (mean age 5.19-11.4 y). Sample sizes ranged from 40 to 8317 participants. Out of the 16 included studies, 14 reported data on adiposity [17][18][19][20][21][22][23][24][25][26][27][28][29][30], one on behavioural problems [31], one on depression and low self-esteem [32] and one on fitness [19]. Out of the sixteen studies included in this review, eight studies (50%) were classified as having a low ROB and eight as having a high ROB (50%). All studies had a reliable and/or valid tool to assess movement behaviours and health outcomes. The criteria used to assess ROB can be seen in Table 2. It was not possible to conduct meta-analyses due to heterogeneity of the data, therefore, narrative syntheses were conducted.

Measurement of Movement Behaviours
Sleep was objectively measured by wrist actigraphy in one study [26] and subjectively measured using questionnaires in two studies [17,29]. SB was measured using screen time in eight studies [19,21,22,24,25,28,30,31] and objectively measured using accelerometers in two studies [23,27], and by both methods (wrist actigraphy and a questionnaire) in one study [26].

Behavioural Problems
Behavioural problems were reported in only one cross-sectional study [31] involving 197 subjects (mean age 8.7 ± 2.1), which studied the relationship between SB and behavioural problems in school-aged children. The results showed that watching TV/playing VG for more than two hours were positively associated with withdrawn behaviour, attention and externalizing problems.

Depression and Low Self-Esteem
One study examined the association between PA and depression and low selfesteem [32]; it involved 165 female subjects with age range of 10-13 years. The results indicated that regular PA (number of occurrences and the duration of the practice of PA per week) was significantly associated with improved self-esteem.

Fitness
One study assessed the relationship between SB and fitness and reported null associations [19]. The results showed that the personal activity score had a strong negative correlation with the time to complete the 1.6 km run/walk and the sum of skinfolds. There were no significant associations between TV watching hours and fitness or fatness.
There were no studies investigating the associations with the rest of the primary outcomes, namely cardio metabolic biomarkers, psychological distress, cognition (academic achievement), quality of life, injuries, nor on secondary outcomes including bone density and motor skill development.

Discussion
This study systematically reviewed the relationships between the movement behaviours of physical activity, sedentary behaviours and sleep and health indicators among school-aged children in Arab-speaking countries. Most of the included studies in this review were cross-sectional (75%). The sample sizes ranged from 40 to 8317 participants. These studies reported mostly favourable and some null associations between PA, SB, and sleep and adiposity, behavioural problems, depression and low self-esteem and fitness outcomes. Low levels of PA and sleep and high SB were associated with higher levels of adiposity, behavioural problems, depression and low self-esteem.
Reasons for the small number of studies investigating these movement behaviours in school-aged children in Arab-speaking countries are that this field of research is still in its early stages of development in these countries, with most child health research focusing on more pressing issues such as infectious diseases. In addition, the unstable political environment in some of the Arab countries, has made conducting such research challenging [33]. The availability of funds is another reason that limited the number of these types of studies. For instance, in 2013, the gross domestic expenditure on research and development (GERD) in North America was $427 billion (28.9%) of the worldwide GERD ($1477.7 billion), while Arab countries collectively only spent $15.4 billion (1%) [34]. Finally, although the Arabic databases were searched for relevant studies in this systematic review, there might be some studies that could not be identified due to the small number of Arabic databases available.
Existing Arabic studies assessed movement behaviours in isolation from each other. Of these studies, most used subjective methods to assess PA, sleep and SB. On the other hand, the Canadian [3,4,6,7] and the Australian 24-Hour Movement Guidelines [8] indicated that focusing on movement behaviours across the entire day is more important than focusing on movement behaviours in isolation. For example, a Canadian study investigating the health outcomes associated with meeting the 24-hour movement behaviour guidelines for children and youth showed that meeting none, one and two recommendations were associated with higher BMI z-score, waist circumference, behavioural strengths and difficulties scores and lower aerobic fitness in a gradient pattern (p trend < 0.05), while meeting all the guidelines during a 24-hour period was associated with better health [35].
Furthermore, due to the prior emphasis on MVPA [1] and the common use of subjective assessments of PA [4], no study in the present review examined different PA intensities such as light-intensity physical activity (LPA), although emerging evidence suggests that LPA may provide some important health benefits for children and adolescents [2][3][4]. Moreover, children cannot participate in MVPA during all waking hours. Therefore, engaging in LPA (e.g., walking) is considered achievable and an easier way to reduce SB, that also provides health benefits [2].
Few studies in this systematic review assessed the relationship between sleep and adiposity outcomes. A possible explanation of this gap is that sleep and SB are new areas of research in this region when compared to the PA field as the SB included studies were published between 2005-2019, while sleep studies were published in the last five years. Therefore, the Arab countries are urgently in need to conduct more studies that focus on sleep and SB to better understand their impact on school-aged children's health.
Despite the importance of the weather and its impact on movement behaviours [36], no study in the present review assessed the relationship between 24-hour movement behaviours and climatic factors, although most of the Arab countries have a hot and dry climate [37]. Previous research in other countries indicates that children's PA levels are affected by seasonal periods across the year and this varies between countries, with PA levels decreasing in specific climatic conditions such as winter, summer, sandstorms areas, humidity and rain [38,39]. Moreover, extreme weather conditions (high or low temperatures) increase SB [40] and decrease sleep efficiency [41], therefore, conducting more studies investigating the association between the weather and movement behaviours and potential interventions may help children in these regions to meet movement behaviour recommendations.

Areas for Future Research
The lack of evidence from the Arab countries confirms that research is needed to address the inequality in the literature, especially with the high and still increasing levels of childhood obesity and SB in the 22 countries. Moreover, it is important to use different types of study designs (longitudinal and experimental) with larger sample sizes to better understand the role of 24-hour movement behaviours, to improve health outcomes. Studies included in this review focused on obesity, however, the field of PA is broader than this health outcome, therefore, it is recommended to conduct more studies reflecting on all movement behaviours across the 24-hour period.

Strengths and Limitations
To our knowledge, the present review is the first study investigating current research assessing the association between movement behaviours and health indicators in schoolaged children in the Arab-speaking countries. A lack of Arabic databases is also a potential limitation. Meta-analyses were not possible to conduct due to heterogeneity of the data, therefore, narrative syntheses were conducted.

Conclusions
Most of the included studies reported favourable associations between movement behaviours and health outcomes. Low levels of PA and sleep and high SB were unfavourably associated with adiposity outcomes, behavioural problems, depression and low self-esteem. Further studies to address the inequality in the literature in the Arab-speaking countries to understand the role of 24-hour movement behaviours and its positive influence on health outcomes across the early years of primary school are urgently needed. Based on the differences between societies and their needs, as well as environmental differences, it might be beneficial to also understand associations between weather conditions and children's movement behaviours. Conducting more studies on different types/intensities of PA, SB and sleep for both boys and girls, and using different types of study designs (longitudinal and experimental) with larger sample sizes will improve the quality of future studies.
OR Yemen OR Libya OR Morocco OR Tunisia OR Algeria OR Comoros OR Djibouti OR Mauritania OR Somalia.