Version Changes
Revised. Amendments from Version 1
A reference to the Westrop Systematic review on physical activity and sedentary behaviour in people with an intellectual disability (Westrop et al, 2019) has been included in the introduction section of this protocol. In addition, the National Institute Health (NIH) tools for observational, cohort, cross-sectional and randomised controlled trials have been included in the extended data and the tool for assessing systematic reviews removed. A reference that shows all quality assessment tools by the NIH is also included. Furthermore, the criteria for RCTS has been added to the table. The wording has been changed to highlight that the tools being used for quality assessment are validated tools.
Abstract
Background: Sedentary behaviour contributes to non-communicable diseases, which account for almost 71% of world deaths. Of these, cardiovascular disease is one of the largest causes of preventable death. It is not yet fully understood what level of sedentary behaviour is safe. People with an intellectual disability have poorer health than the general population with higher rates of multi-morbidity, obesity and inactivity. There is a paucity of evidence on whether this poorer health is due to sedentary behaviour or physical inactivity. This systematic review will investigate the sedentary behaviour levels of adults with an intellectual disability.
Method: The PRISMA-P framework will be applied to achieve high-quality articles. An extensive search will be conducted in Medline, Embase, psycINFO and Cinahl and grey literature sources. All articles will be independently reviewed by two reviewers and a third to resolve disputes. Initially, the articles will be reviewed by title and abstract and then the full article will be reviewed using stringent inclusion criteria. All article data will be summarised in a standardised tabular format. The National Institute of Health’s quality assessment tool will be used to assess article quality. GRADE will be used to assess the quality of the evidence. The primary outcome of interest is the prevalence of sedentary behaviour levels for people with an intellectual disability. The definition of sedentary behaviour to be used for the purposes of this study is: ‘low physical activity as identified by metabolic equivalent (MET) or step levels or as measured by the Rapid Assessment of Physical activity questionnaire (RAPA) or the International Physical Activity questionnaire (IPAQ) or sitting for more than 3 hours per day’.
Conclusion: This systematic review will provide a critical insight into the prevalence of sedentary behaviour in adults with an intellectual disability.
Keywords: Intellectual disability, sedentary behaviour, adults
Introduction
Rationale
According to the World Health Organisation ( WHO, 2013), non-communicable diseases account for almost 71% of world deaths. Non-communicable diseases are non-infectious and chronic but can be prevented. Of these, cardiovascular disease (CVD) is one the largest causes of preventable death worldwide with over 17.9 million dying annually. CVD can manifest as increased blood pressure or elevated blood lipid levels, leading to heart attack or stroke. One of the main contributors to CVD is lack of physical activity ( Forouzanfar et al., 2016). Physical activity is any bodily movement which uses skeletal muscles and results in energy expenditure ( WHO, 2019) while a sedentary lifestyle is one which has low levels of physical activity and consequently low levels of energy expenditure. In general, people with intellectual disability (ID) have poorer health than their non-disabled contemporaries ( Emerson et al., 2016) and often experience health disparities ( Krahn & Fox, 2014). However, the real state of the science regarding sedentary behaviour and people with ID is not known. Further investigation is essential to understand if sedentary behaviour contributes to these health differences.
It is necessary to understand some of the known contributors to CVD, obesity and physical inactivity, as well as sedentary behaviours because these are all modifiable and inter-related health risks factors.
Sedentary behaviour. Sedentary comes from the Latin word sedere which means to sit and can describe a wide range of distinct activities which require low levels of energy expenditure in any setting ( Thorp et al., 2011). The first real attempt to define the term ‘sedentary’ was made in 2012 ( Tremblay et al., 2017). This was in an effort to avoid confusion by standardising the terms to refer to sedentary or inactive behaviours used in journals. A metabolic equivalent (MET), known as the resting metabolic rate, is an objective measurement scale used to classify activity types and levels. A MET is the amount of oxygen (O 2) burned at rest and is the equivalent of 3.5ml O 2 per kg body weight per minute ( Jette et al., 1990) or 1kilocalorie per kg of body weight per hour ( Newton et al., 2013). Tremblay et al. (2017) proposed to define sedentary behaviour as ‘any waking behaviour characterized by an energy expenditure of ≤1.5 METs while in a sitting or reclining posture’ for example watching television or working on a computer. Hence sedentary behaviour constitutes too much sitting or stationary activity as opposed to physical inactivity which is too little exercise or physical movement. Tudor-Locke et al. (2013) found a link between reduced steps per day (less than 5,000) and being more sedentary. In addition, sitting for prolonged periods (more than 3 hours per day) has been found to have adverse health effects ( Pinto Pereira et al., 2012).
Sedentary behaviour has been linked to adverse health conditions in older adults, increased cardio metabolic risks, increased obesity and mortality in both men and women, as well as increased cancer risk ( de Rezende et al., 2014; Patel et al., 2010; Same et al., 2016; Thorp et al., 2011). Self-reported studies have shown that high levels of sedentary behaviour, even if minimum exercise guidelines are met, show increased metabolic risk ( Patel et al., 2010). This impact of sedentary behaviour can be mollified by interspersing periods of physical activity throughout the day ( Healy et al., 2008).
An ecological model of sedentary behaviour for older adults without an ID, proposed by Owen et al. (2011), could be used to assess the sedentary behaviours of people with ID. This model classed sedentary behaviour into four categories:
-
-
Household (e.g. watching TV)
-
-
Leisure time (increased screen-based and sitting activities)
-
-
Transport (driving, sitting on public transport to/from work/activities)
-
-
Occupation (e.g. screen-based computer work).
Sedentary behaviour and people with ID
In a systematic review by Melville et al. (2017), it was proposed that studies to determine sedentary behaviour in people with ID did not use enough randomly selected samples and sample sizes were too small, meaning that results could not be generalised for the ID population as a whole. Furthermore, insufficient studies have distinguished between sedentary behaviour and inadequate physical activity. Westrop et al., 2019 in a systematic review investigating physical activity and sedentary behaviour in adults with an intellectual disability deduced that men were more active than women but that results on sedentary behaviour were inconclusive due to insufficient studies. Consequently, it is not clear what the actual sedentary behaviour of people with ID is.
Older people with an intellectual disability have been shown to have higher rates of multi-morbidity, obesity and inactivity than the general population ( Gawlik et al., 2018; McCarron et al., 2013). In 2016 approximately 70,000 people, 1.4% of the overall Irish population ( Census, 2016), were shown to have an ID. In an analysis of secondary data, Harris et al. (2017) deduced that people with ID were sedentary for over 70% a day. According to Graham & Reid (2000), adults with ID are more susceptible to age-related health risks, where sedentary behaviour could be a contributing factor.
While breaking up time spent doing sedentary activity has been shown to increase daily living activities and physical independence in older adults ( Sardinha et al., 2015), there is no similar information on adults with ID. Increased sedentary behaviour has been linked to obesity levels and increased likelihood of multi-morbidity ( Melville et al., 2017), but inconsistent evidence exists on links of sedentary behaviour to level of ID ( Oppewal et al., 2018). Often studies use proxy measures (e.g. watching TV) to determine sedentary behaviour which may be inaccurate, especially with regards to people with ID, as people with a more severe ID may be less likely to watch TV due to sensory or cognitive impairments ( Owen et al., 2011). Level of ID has been shown to be directly related to physical activity but not sedentary behaviour ( Oppewal et al., 2018).
Emerging evidence is highlighting the importance of reducing sedentary behaviour for improving cardio-metabolic health and adopting a holistic public health approach to improve activity levels as well as sedentary behaviour ( van der Ploeg & Hillsdon, 2017).
For the purposes of this systematic review, sedentary behaviour will be defined as:
‘low physical activity as identified by MET or step levels or as measured by the Rapid Assessment of Physical activity questionnaire (RAPA) or the International Physical Activity questionnaire (IPAQ) or sitting for more than 3 hours per day’
Obesity. Globally almost 38% of the world’s population, a greater than 100% increase since 1980, and two-thirds of the American population, are either overweight or obese, with a BMI of greater than 25.0 kg/m 2 ( Fryar et al., 2012; Ng et al., 2014; WHO, 2009). In Ireland, almost 23% of adults are obese with 50% of women and 66% of men being overweight ( Ng et al., 2014. This is a huge concern given the proven link between obesity and cancers, higher rates of type II diabetes, CVD and CVD mortality ( Bhaskaran et al., 2014; Hossain et al., 2007; Ortega et al., 2016).
Obesity and people with ID
A 2017 review found that the prevalence of overweight and obesity in people with ID varies from 28%–71% and 17%–43%, respectively ( Ranjan et al., 2018). The IDS-TILDA study found that overweight and obesity in people with ID increased from 66% in wave2 to 79.7% in wave3 and that 64% of participants considered themselves to be at the right weight ( Burke et al., 2017). According to a US based longitudinal study on people with ID women appear to be at a greater risk of developing morbid obesity while men were more likely to be overweight ( Hsieh et al., 2014)).
According to Fock & Khoo (2013), excessive calorific intake and increased sedentary behaviour are the main contributors to increased obesity levels but obesity levels may be ameliorated by a combination of healthy eating, a reduction in sedentary behaviour and an increase in physical activity
Physical inactivity. Physical inactivity is classified as not meeting the minimum activity requirements. According to the American College of Sports Medicine, moderate-intensity aerobic physical activity (PA) of between 150 and 250 minutes per week is the minimum necessary for health and weight management in adults ( Donnelly et al., 2009; Health Service Executive, 2009; US Department of Health, 2018). Insufficient PA or physical inactivity contributes to adverse health issues like obesity, CVD and cancer as well as increased mortality ( Lee et al., 2012). According to the World Health Organisation ( WHO, 2009), physical inactivity is the fourth leading risk factor for all-cause mortality, with over three million deaths annually. Of concern is that Ireland is one of the least active countries in Europe ( Loyen et al., 2016).
Physical inactivity and people with ID
For People with an ID, the amount of moderate PA done, and the number of hours spent watching TV was found to be significantly associated with obesity level ( Hsieh et al., 2014). A 2016 Australian based study found that over 66% of participants did not meet minimum exercise guidelines ( Koritsas & Iacono, 2016), while another study found that 77% of participants did not meet the minimum exercise recommendations ( Barnes et al., 2013). It must be noted that physical impairments leading to the use of walking aids or wheelchairs may inhibit physical activity for some people with an ID ( Ranjan et al., 2018).
Hence sedentary behaviour and physical inactivity are different and should be addressed separately with distinct guidelines for each. While specific recommendations for movement and physical activity levels in adults have been long established, corresponding recommendations for sedentary behaviour have not. The recommendations from emerging evidence are to minimise the amount of time being sedentary, but no specifics have yet been established for the general population or people with ID ( WHO, 2020).
Developing the question
A focused and well-defined question avoids bias in literature searches, ensures clarity and therefore ensures the identification of the concepts for the focused search. PICO, which is used for quantitative studies is being used to define the question as follows ( Schardt et al., 2007):
P [Population or problem]: Adults aged 18+ with an Intellectual Disability
I [Intervention or exposure]: Sedentary behaviour level (SB in line with the definition of SB defined for this review
C [Comparison]: Individuals with all levels of ID living in residential, community group homes, with family or independently
O [Outcome]: Prevalence of Sedentary behaviour
The research question to be addressed by this systematic review protocol is
‘What are the sedentary behaviour levels of older Adults with an Intellectual Disability?’.
Methods
PRISMA-P, for the reporting and development of systematic review protocols is used as the guide in the writing of this protocol ( Shamseer et al., 2015). The completed PRISMA-P checklist for this protocol is available as extended data ( Lynch, 2020).
Eligibility criteria
The criteria for inclusion in the review are as follows:
Population: adults aged 18+ with an Intellectual Disability
Language: English
Study type: All types of studies including primary studies, peer reviewed, grey literature
Study design: Randomised controlled trials, cohort, cross-sectional
Content: Must reference sedentary behaviours of adults with ID to be eligible for inclusion
Timeframe: no restriction on timeframes up to March 2020.
The criteria for exclusion in the review are as follows:
Population: Children with or without an ID and Adults without ID
Language: Articles that are not available in English
Study design: Any type of reviews
Conference proceedings and published conference abstracts only
Information sources
Databases
The following four databases will be used to perform the search:
In addition, the following sources will be explored for grey literature sources:
Search strategy
The search strategy was refined into two concepts following the application of PICO. Concept 1 is ‘Sedentary behaviour or inactivity’ and Concept 2 is ‘Intellectual Disability’. Each of the two concepts will be searched using MESH terms and keywords and then combined using OR. Then the total results of each concept will be combined using AND (See Figure 1). This search will be repeated for each of the four databases. The resulting article list will be the complete combined database search results. This list will be screened for inclusion.
Figure 1. Search strategy.
Search string. An example of the search string used for the Medline database is shown in Table 1.
Table 1. Medline search string.
| Concept | Index | Keywords |
|---|---|---|
|
Concept 1:
Sedentary behaviour & physical inactivity |
(MH "Sedentary Behavior") | sedentary lifestyle* OR sedentary behavior* OR sedentary behaviour* OR
physical* inactiv* OR inactive lifestyle |
|
Concept 2:
Intellectual disability or learning disability |
(MH "Intellectual
Disability+") OR (MH "Learning Disabilities+") |
((intellectual AND disabilit* OR 'mental retardation'/exp OR 'mental
retardation' OR (mental AND ('retardation'/exp OR retardation)) OR 'learning'/ exp OR learning) AND disabilit* OR developmental) AND disabilit* OR 'learning disabilities'/exp OR 'learning disabilities' OR (('learning'/exp OR learning) AND disabilities) |
Screening process. All identified articles from each database that is searched, as well as all grey literature sources, will be combined and duplicates removed. Endnote software will be used to store all the identified articles. The articles will be stored in folders which are named after the search process used. Using the inclusion criteria as detailed above, all articles will initially be screened by title and then by abstract. The remaining full text articles will be retrieved and read thoroughly. Those that do not meet the inclusion criteria will be omitted. The remaining articles will then be quality assessed using two separate assessors with a third person as an adjudicator should any discrepancies arise.
Quality assessment and risk of bias. The remaining articles will be assessed using two validated quality assessment tools from the National Institute of Health ( National Institute Health, 2020), the first for observational cohort and cross-sectional studies and the second for randomised controlled trials (RCTs). The tools used are available as extended data ( Lynch, 2020).
These tools are used to critically assess the internal validity of each article and identify any issues or sources of potential bias. According to Cochrane, effectively evaluating the quality of a study is done by looking at its design, methodology, results, analysis and reporting, and how they relate to the original research question ( Higgins et al., 2011).
There are different types of study quality assessment tools for the different study types. For Controlled Intervention Studies and Observational Cohort and Cross-sectional studies, 14 criteria are used to evaluate the study quality, while for Case-Control studies 12 criteria are used. 11 criteria are used to determine the study quality of RCTs. This means that a maximum quality score of 11, 12 or 14 can be achieved depending on the study type. This quality score will be used to determine if the study should be included in the review. Quality scores are divided into 3 main categories: Good, Fair or Poor. See Table 2 for details.
Table 2. Quality assessment Scoring System.
| Quality
Rating |
Observational
Cohort & Cross-Sectional Studies |
Case-
Control Studies |
RCTs | Action |
|---|---|---|---|---|
| Good | 9 - 12 | 10 - 14 | 7 - 11 | Data extraction |
| Fair | 6 - 8 | 7 - 9 | 4 - 6 | 2 reviewers
to discuss. Adjudicate with 3rd reviewer if required. |
| Poor | <=5 | <= 6 | <= 4 | 2 reviewers to
discuss. Reject |
| Other | CD, NR, NA * |
* CD = Cannot determine, NR = Not reported, NA = Not applicable
Any studies that are excluded will be tracked with reasons for rejection.
Quality scoring
Scores are attributed to distinct parts of the study design for example type of study, design and blinding, where a ‘yes’ answer gives a score of ‘1’, a ‘no’ answer a score of ‘0’ and could potentially highlight an issue with the article. See Table 3.
Table 3. Study assessment scoring.
| Answer | Score |
|---|---|
| Yes | 1 |
| No | 0 |
| Cannot determine/not reported/not applicable | 0 |
Ethics
This research project is part of the IDS-TILDA project. Full ethical approval for IDS-TILDA has been granted by the Trinity College Dublin Faculty of Health Sciences Research Ethics Committee.
Study records
Data management
All search records will be kept in an excel spreadsheet detailing the database, type of search (keyword or MESH terms) and the resulting search numbers. The articles will be stored in Endnote. Each stage of the search and review will be recorded in excel. For each stage of the search process, articles will be stored in an appropriately named folder in EndNote X9 for windows.
Selection process
The selection process of studies for inclusion, which are identified by the search strategy, will be done by two independent review authors [LL and EB]. The initial screening will be done by title and abstract. If eligibility is inconclusive from the title and abstract, the full text of the article will be assessed. Any articles that do not match the inclusion criteria will be excluded. Any differences on article inclusion between the two authors will be resolved by discussions with the third review author [MMc]. Finally, the full-text article of all potential articles that could be included in the review will be independently assessed by the authors for inclusion as above.
Data collection process
An excel spreadsheet will act as the data extraction tool. This will be used to summarise all the shortlisted studies. The categories to be captured are as in Table 4 ( McKenzie et al., 2019).
Table 4. Article Data Collection Categories.
| Author, title, year |
| - study focus |
| - study type |
| - Intervention type |
| - country |
| - duration |
| - dates |
| - numbers |
| Participants |
| - number |
| - mean age |
| - gender (%) |
| - level of ID |
| - living circumstances |
| - employment type |
| Assessment |
| - type |
| - intervention |
| - Assessment type |
| - measurement device |
| - outcome/data |
| - Statistical results |
| Findings |
| Summary |
| Comment |
Data items
The PICO framework will be used to define what data will be sought from variables as follows:
-
P: Adults with an Intellectual Disability
Age, gender, living circumstance, country, number in study, level of ID
-
I: Sedentary behaviour
Level, types of behaviour, quantify change
-
C: Level of sedentary behaviour or physical inactivity
Level, intensity, types of activity/sedentary behaviour, type of employment
O: Prevalence of sedentary behaviour
Outcomes and prioritisation
The outcomes of this investigation into sedentary behaviour will determine the sedentary behaviour levels of older adults with an intellectual disability.
Primary outcome
Sedentary behaviour levels
Data synthesis
If quantitative studies are homogenous in nature a meta-analysis may be performed and a forest plot produced to summarise results. A narrative synthesis will be used to summarise all the study article data and relevant information. For qualitative studies, a thematic analysis of the semantic and latent topics of the articles using a 6-step process (see Table 5), will guide the derivation of a framework for the analysis of the outcome data ( Braun & Clarke, 2006).
Table 5. 6-step thematic analysis process.
| Step number | Process | Explanation |
|---|---|---|
| 1 | Data familiarisation | Complete data immersion |
| 2 | Generate initial codes | Topics, patterns of data |
| 3 | Search for themes | Broader theme identification |
| 4 | Review of themes | Theme refinement |
| 5 | Define and name themes | Categorise. Include sub-themes if required |
| 6 | Produce report | Complete write-up |
Statistical comparisons of article data will be reviewed on a case-by-case basis.
Confidence in cumulative evidence
The GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach will be used to assess the strength of the body of evidence of the review. In line with the Cochrane methodology, each outcome will be ranked according to whether the quality is high, moderate, low or very low. The GRADE framework will be used to assess each outcome in the following areas: risk of bias, consistency of effect, imprecision, indirectness and publication bias ( Schünemann et al., 2019).
Dissemination of information
The dissemination plan will be to present at conferences for example the THEconf March 2021, Irish Gerontology Society PhD event and other ID or physical activity events or conferences as well as publishing in journals.
Study status
Searches are currently in progress.
Conclusion
This systematic review of the sedentary behaviour levels of older adults with an intellectual disability will provide a critical insight into the sedentary behaviours of this population group.
Data availability
Underlying data
No data are associated with this article
Extended data
Harvard Dataverse: Replication Data for: Sedentary behaviour levels in adults with an intellectual disability: a systematic review protocol. https://doi.org/10.7910/DVN/TPS2HU ( Lynch, 2020)
This protocol contains the following extended data:
PRISMA-P checklist
Study Quality Assessment Tools for observational, cohort, cross-sectional and randomised controlled trials
Reporting guidelines
Harvard dataverse: PRISMA-P checklist for ‘Sedentary behaviour levels in adults with an intellectual disability: a systematic review protocol’ https://doi.org/10.7910/DVN/TPS2HU ( Lynch, 2020)
Funding Statement
Health Research Board Ireland [IDS-TILDA-2018-1]
[version 2; peer review: 2 approved]
References
- Barnes TL, Howie EK, McDermott S, et al. : Physical activity in a large sample of adults with intellectual disabilities. J Phys Act Health. 2013;10(7):1048–1056. 10.1123/jpah.10.7.1048 [DOI] [PubMed] [Google Scholar]
- Burke E, McGlinchey E, Haigh M, et al. : Health, Wellbeing and Social Inclusion: Ageing with an Intellectual Disability in Ireland:Evidence from the First Ten Years of The Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing (IDS-TILDA) Wave 3 IDS-TILDA. 2017; Accessed February 20 th, 2019. Reference Source [Google Scholar]
- Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. 10.1191/1478088706qp063oa [DOI] [Google Scholar]
- Bhaskaran K, Douglas I, Forbes H, et al. : Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5·24 million UK adults. Lancet. 2014;384(9945):755–765. 10.1016/S0140-6736(14)60892-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Census:2016; Accessed February 14 th, 2019. Reference Source [Google Scholar]
- de Rezende LFM, Rey-López JP, Matsudo VKR, et al. : Sedentary behavior and health outcomes among older adults: a systematic review. BMC Public Health. 2014;14(1):333. 10.1186/1471-2458-14-333 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Department of Health and Children, Health Service Executive: The National Guidelines on Physical Activity for Ireland. 2009; ISBN 978-1-906218-27-0. Reference Source [Google Scholar]
- Donnelly JE, Blair SN, Jakicic JM, et al. : American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. 2009;41(2):459–471. 10.1249/MSS.0b013e3181949333 [DOI] [PubMed] [Google Scholar]
- Emerson E, Hatton C, Baines S, et al. : The physical health of British adults with intellectual disability: cross sectional study. Int J Equity Health. 2016;15(1):11. 10.1186/s12939-016-0296-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fock KM, Khoo J: Diet and exercise in management of obesity and overweight. J Gastroenterol Hepatol. 2013;28 Suppl 4:59–63. 10.1111/jgh.12407 [DOI] [PubMed] [Google Scholar]
- Forouzanfar MH, Afshin A, Alexander LT, et al. : Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990– 2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1659–1724. 10.1016/S0140-6736(16)31679-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fryar CD, Carroll MD, Ogden CL: Prevalence of overweight, obesity, and extreme obesity among adults: United States, trends 1960 – 1962 through 2009 – 2010.Hyattsville, MD: National Center for Health Statistics. 2012. Reference Source [Google Scholar]
- Gawlik K, Zwierzchowska A, Celebańska D: Impact of physical activity on obesity and lipid profile of adults with intellectual disability. J Appl Res Intellect Disabil. 2018;31(2):308–311. 10.1111/jar.12406 [DOI] [PubMed] [Google Scholar]
- Graham A, Reid G: Physical fitness of adults with an intellectual disability: A 13-year follow-up study. Res Q Exerc Sport. 2000;71(2):152–161. 10.1080/02701367.2000.10608893 [DOI] [PubMed] [Google Scholar]
- Harris L, McGarty AM, Hilgenkamp T, et al. : Correlates of objectively measured sedentary time in adults with intellectual disabilities. Prev Med Rep. 2017;9:12–17. 10.1016/j.pmedr.2017.11.010 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Health Service Executive: 2009. Accessed March, 2019. Reference Source [Google Scholar]
- Healy GN, Dunstan DW, Salmon J, et al. : Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes care. 2008;31(4):661–6. 10.2337/dc07-2046 [DOI] [PubMed] [Google Scholar]
- Higgins JPT, Altman DG, Gøtzsche PC, et al. : The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. 10.1136/bmj.d5928 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hossain P, Kawar B, El Nahas M: Obesity and diabetes in the developing world—a growing challenge. N Engl J Med. 2007;356(3):213–5. 10.1056/NEJMp068177 [DOI] [PubMed] [Google Scholar]
- Hsieh K, Rimmer JH, Heller T: Obesity and associated factors in adults with intellectual disability. J Intellect Disabil Res. 2014;58(9):851–863. 10.1111/jir.12100 [DOI] [PubMed] [Google Scholar]
- Jette M, Sidney K, Blümchen G: Metabolic equivalents (METS) in exercise testing, exercise prescription, and evaluation of functional capacity. Clin Cardiol. 1990;13(8):555–565. 10.1002/clc.4960130809 [DOI] [PubMed] [Google Scholar]
- Koritsas S, Iacono T: Weight, nutrition, food choice, and physical activity in adults with intellectual disability. J Intellect Disabil Res. 2016;60(4):355–364. 10.1111/jir.12254 [DOI] [PubMed] [Google Scholar]
- Krahn GL, Fox MH: Health disparities of adults with intellectual disabilities: what do we know? What do we do? J Appl Res Intellect Disabil. 2014;27(5):431–446. 10.1111/jar.12067 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lee IM, Shiroma EJ, Lobelo F, et al. : Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229. 10.1016/S0140-6736(12)61031-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Loyen A, Van Hecke L, Verloigne M, et al. : Variation in population levels of physical activity in European adults according to cross-European studies: a systematic literature review within DEDIPAC. Int J Behav Nutr Phys Act. 2016;13(1):72. 10.1186/s12966-016-0398-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lynch L: "Replication Data for: Sedentary behaviour levels in adults with an intellectual disability: a systematic review protocol".Harvard Dataverse, V1.2020. 10.7910/DVN/TPS2HU [DOI] [PMC free article] [PubMed] [Google Scholar]
- McCarron M, Swinburne J, Burke E, et al. : Patterns of multimorbidity in an older population of persons with an intellectual disability: results from the intellectual disability supplement to the Irish longitudinal study on aging (IDS-TILDA). Res Dev Disabil. 2013;34(1):521–527. 10.1016/j.ridd.2012.07.029 [DOI] [PubMed] [Google Scholar]
- McKenzie JE, Brennan SE, Ryan RE, et al. : Chapter 9: Summarizing study characteristics and preparing for synthesis.In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions.version 6.0 (updated July 2019). Cochrane, 2019. 10.1002/9781119536604.ch9 [DOI] [Google Scholar]
- Melville CA, Oppewal A, Elinder LS, et al. : Definitions, measurement and prevalence of sedentary behaviour in adults with intellectual disabilities - a systematic review. Prev Med. 2017;97:62–71. 10.1016/j.ypmed.2016.12.052 [DOI] [PubMed] [Google Scholar]
- National Institute Health, 2020.Accessed February 2020. Reference Source [Google Scholar]
- Newton RL, Jr, Han H, Zderic T, et al. : The energy expenditure of sedentary behavior: a whole room calorimeter study. PLoS One. 2013;8(5):e63171. 10.1371/journal.pone.0063171 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ng M, Fleming T, Robinson M, et al. : Global, regional, and national prevalence of overweight and obesity in children and adults during 1980–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9945):766–781. 10.1016/S0140-6736(14)60460-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Oppewal A, Hilgenkamp TIM, Elinder LS, et al. : Correlates of Sedentary Behaviour in Adults with Intellectual Disabilities—A Systematic Review. Int J Environ Res Public Health. 2018;15(10):2274. 10.3390/ijerph15102274 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ortega FB, Lavie CJ, Blair SN: Obesity and cardiovascular disease. Circ Res. 2016;118(11):1752–1770. 10.1161/CIRCRESAHA.115.306883 [DOI] [PubMed] [Google Scholar]
- Owen N, Sugiyama T, Eakin EE, et al. : Adults' sedentary behavior determinants and interventions. Am J Prev Med. 2011;41(2):189–196. 10.1016/j.amepre.2011.05.013 [DOI] [PubMed] [Google Scholar]
- Patel AV, Bernstein L, Deka A, et al. : Leisure time spent sitting in relation to total mortality in a prospective cohort of US adults. Am J Epidemiol. 2010;172(4):419–429. 10.1093/aje/kwq155 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Pereira SMP, Ki M, Power C: Sedentary behaviour and biomarkers for cardiovascular disease and diabetes in mid-life: the role of television-viewing and sitting at work. PLoS One. 2012;7(2):e31132. 10.1371/journal.pone.0031132 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ranjan S, Nasser JA, Fisher K: Prevalence and potential factors associated with overweight and obesity status in adults with intellectual developmental disorders. J Appl Res Intellect Disabil. 2018;31 Suppl 1:29–38. 10.1111/jar.12370 [DOI] [PubMed] [Google Scholar]
- Same RV, Feldman DI, Shah N, et al. : Relationship between sedentary behavior and cardiovascular risk. Curr Cardiol Rep. 2016;18(1):6. 10.1007/s11886-015-0678-5 [DOI] [PubMed] [Google Scholar]
- Sardinha LB, Ekelund U, dos Santos L, et al. : Breaking-up sedentary time is associated with impairment in activities of daily living. Change as Exp Gerontol. 2015;72: 57–62. 10.1016/j.exger.2015.09.011 [DOI] [PubMed] [Google Scholar]
- Schardt C, Adams MB, Owens T, et al. : Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007;7:16. 10.1186/1472-6947-7-16 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Schünemann HJ, Higgins JPT, Vist GE, et al. : Chapter 14: Completing ‘Summary of findings’ tables and grading the certainty of the evidence.In: Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions.version 6.0 (updated July 2019). Cochrane,2019. 10.1002/9781119536604.ch14 [DOI] [Google Scholar]
- Shamseer L, Moher D, Clarke M, et al. : Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. BMJ. 2015;350:g7647. 10.1136/bmj.g7647 [DOI] [PubMed] [Google Scholar]
- Thorp AA, Owen N, Neuhaus M, et al. : Sedentary behaviors and subsequent health outcomes in adults a systematic review of longitudinal studies, 1996–2011. Am J Prev Med. 2011;41(2):207–215. 10.1016/j.amepre.2011.05.004 [DOI] [PubMed] [Google Scholar]
- Tremblay MS, Aubert S, Barnes JD, et al. : Sedentary behavior research network (SBRN) – terminology consensus project process and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75. 10.1186/s12966-017-0525-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Tudor-Locke C, Craig CL, Thyfault JP, et al. : A step-defined sedentary lifestyle index: <5000 steps/day. Appl Physiol Nutr Metab. 2013;38(2):100–114. 10.1139/apnm-2012-0235 [DOI] [PubMed] [Google Scholar]
- US Department of Health: 2018; Accessed February 4th, 2019. Reference Source [Google Scholar]
- van der Ploeg HP, Hillsdon M: Is sedentary behaviour just physical inactivity by another name? Int J Behav Nutr Phys Act. 2017;14(1):142. 10.1186/s12966-017-0601-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Westrop SC, Melville CA, Muirhead F, et al. : Gender differences in physical activity and sedentary behaviour in adults with intellectual disabilities: A systematic review and meta-analysis. J Appl Res Intellect Disabil. 2019;32(6):1359–1374. 10.1111/jar.12648 [DOI] [PubMed] [Google Scholar]
- World Health Organisation:2009; Accessed February 14, 2019. Reference Source [Google Scholar]
- World Health Organisation:2013; Accessed February 14, 2019. Reference Source [Google Scholar]
- World Health Organisation: 2019; Accessed February 14th, 2019. Reference Source [Google Scholar]
- World Health Organisation:2020; Accessed June 2020. Reference Source [Google Scholar]