ABSTRACT

OBJECTIVE

To identify and evaluate the effects of community-based interventions on the sedentary behavior (SB) of Latin American children and adolescents.

METHODS

A systematic review on community-based trials to reduce and/or control SB in Latin American countries (Prospero: CRD42017072157). Five databases (PubMed, Web of Science, Scopus, SciELO and Lilacs) and a reference lists were searched.

RESULTS

Ten intervention studies met the eligibility criteria and composed the descriptive synthesis. These studies were conducted in Brazil (n=5), Mexico (n=3), Ecuador (n=1) and Colombia (n=1). Most interventions were implemented in schools (n=8) by educational components, such as meetings, lessons, and seminars, on health-related subjects (n=6). Only two studies adopted specific strategies to reduce/control SB; others focused on increasing physical activity and/or improving diet. Only one study used an accelerometer to measure SB. Seven studies investigated recreational screen time. Eight studies showed statistically significant effects on SB reduction (80%).

CONCLUSIONS

Latin America community-based interventions reduced children and adolescents’ SB. Further studies should: define SB as a primary outcome and implement strategies to reduce such behaviour; focus in different SBs and settings, other than recreational screen time or at-home sitting time; and use objective tools together with questionnaires to measure sedentary behaviour in.

Child; Adolescent; Sedentary Behavior; Evaluation of the Efficacy-Effectiveness of Interventions; Systematic Review

INTRODUCTION

High levels of sedentary behavior (SB) –activities in a seated or reclining position requiring low energy expenditure¹1. Pate RR, O’Neill JR, Lobelo F. The evolving definition of “sedentary”. Exerc Sport Sci Rev. 2008;36(4):173-8. https://doi.org/10.1097/JES.0b013e3181877d1a
https://doi.org/10.1097/JES.0b013e318187... are associated with cardiovascular diseases, diabetes and premature mortality risk²2. Ekelund U, Steene-Johannessen J, Brown WJ, Fagerland MW, Owen N, Powell KE, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016;388(10051):1302-10. https://doi.org/10.1016/S0140-6736(16)30370-1
https://doi.org/10.1016/S0140-6736(16)30... . A study that analyzed over one million people reported that high activity level (60 to 75 minutes per day) attenuate, but does not eliminate, the increased mortality risk associated with high TV-viewing time ( ≥ 3 hours per day)²2. Ekelund U, Steene-Johannessen J, Brown WJ, Fagerland MW, Owen N, Powell KE, et al. Does physical activity attenuate, or even eliminate, the detrimental association of sitting time with mortality? A harmonised meta-analysis of data from more than 1 million men and women. Lancet. 2016;388(10051):1302-10. https://doi.org/10.1016/S0140-6736(16)30370-1
https://doi.org/10.1016/S0140-6736(16)30... . This type of SB is very common among children and adolescents³3. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011;41(2):197-206. https://doi.org/10.1016/j.amepre.2011.05.001
https://doi.org/10.1016/j.amepre.2011.05... .

SB in childhood and adolescence is related to overweight and obesity, insufficient levels of physical activity (PA), unhealthy food consumption, and poor academic performance and perceptions of well-being⁴4. Matthews CE, Chen KY, Freedson PS, Buchowski MS, Beech BM, Pate RR, et al. Amount of time spent in sedentary behaviors in the United States, 2003-2004. Am J Epidemiol. 2008;167(7):875-81. https://doi.org/10.1093/aje/kwm390
https://doi.org/10.1093/aje/kwm390... . A systematic review reported that SB also plays a role in weight gain from childhood to adulthood⁸8. Thorp AA, Owen N, Neuhaus M, Dunstan DW. Sedentary behaviors and subsequent health outcomes in adults: a systematic review of longitudinal studies, 1996-2011. Am J Prev Med. 2011;41(2):207-15. https://doi.org/10.1016/j.amepre.2011.05.004
https://doi.org/10.1016/j.amepre.2011.05... .

Among children and adolescents, SB is usually assessed by self-reported recreational screen time (e.g., TV-viewing, using computer, tablet or smartphone for non-school work, or playing electronic games) or objective measurements (e.g., accelerometers as ActiGraph and ActivPAL)⁹9. Tremblay MS, LeBlanc AG, Kho ME, Saunders TJ, Larouche R, Colley RC, et al. Systematic review of sedentary behaviour and health indicators in school-aged children and youth. Int J Behav Nutr Phys Act. 2011;8(1):98. https://doi.org/10.1186/1479-5868-8-98
https://doi.org/10.1186/1479-5868-8-98... , which provide information on total SB time but does not discriminate the type of activity and its context. The contexts in which young people are usually sedentary are little explored, such as sitting time at home, at school, and during transportation³3. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011;41(2):197-206. https://doi.org/10.1016/j.amepre.2011.05.001
https://doi.org/10.1016/j.amepre.2011.05... .

Guidelines from several countries state that children and adolescents should spend less than two hours a day in recreational screen time¹⁰10. Tremblay MS, LeBlanc AG, Janssen I, Kho ME, Hicks A, Murumets K, et al. Canadian sedentary behaviour guidelines for children and youth. Appl Physiol Nutr Metab. 2011;36(1):59-64. https://doi.org/10.1139/H11-012
https://doi.org/10.1139/H11-012... ,¹¹11. Council on Communication and Media. Children, adolescents, and the media. Pediatrics. 2013;132(5):958-61. https://doi.org/10.1542/peds.2013-2656
https://doi.org/10.1542/peds.2013-2656... , as well as limit sedentary transport, sitting time, and indoors time during the day¹⁰10. Tremblay MS, LeBlanc AG, Janssen I, Kho ME, Hicks A, Murumets K, et al. Canadian sedentary behaviour guidelines for children and youth. Appl Physiol Nutr Metab. 2011;36(1):59-64. https://doi.org/10.1139/H11-012
https://doi.org/10.1139/H11-012... . Yet, studies conducted in high-income countries showed that youth spend from two to four hours a day in recreational screen time and are sedentary from five to ten hours daily³3. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011;41(2):197-206. https://doi.org/10.1016/j.amepre.2011.05.001
https://doi.org/10.1016/j.amepre.2011.05... .

In Latin America, over 50% of children and adolescents do not follow the recommendation of < 2 hours a day using electronic media for recreational purposes¹²12. Ministério da Saúde (BR); Ministério do Planejamento, Orçamento e Gestão, Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016.. Higher levels of recreational screen time appear to be more prevalent among girls, adolescents, urban area residents, and less active individuals¹³13. Ferreira RW, Rombaldi AJ, Ricardo LIC, Hallal PC, Azevedo MR. Prevalence of sedentary behavior and its correlates among primary and secondary school students. Rev Paul Pediatr. 2016;34(1):56-63. https://doi.org/10.1016/j.rpped.2015.06.005
https://doi.org/10.1016/j.rpped.2015.06.... . Tracking shows that SB increases with age, and that childhood and adolescence lifestyles are maintained during adulthood¹³13. Ferreira RW, Rombaldi AJ, Ricardo LIC, Hallal PC, Azevedo MR. Prevalence of sedentary behavior and its correlates among primary and secondary school students. Rev Paul Pediatr. 2016;34(1):56-63. https://doi.org/10.1016/j.rpped.2015.06.005
https://doi.org/10.1016/j.rpped.2015.06.... ,¹⁷17. Jones RA, Hinkley T, Okely AD, Salmon J. Tracking physical activity and sedentary behavior in childhood: a systematic review. Am J Prev Med. 2013;44(6):651-8. https://doi.org/10.1016/j.amepre.2013.03.001
https://doi.org/10.1016/j.amepre.2013.03... . Such findings indicate that preventive efforts need to commence as soon as possible to educate and support children in maintaining healthy levels of recreational screen time and overall sitting time.

Intervention studies are key to identify effective strategies in reducing high SB levels. Regarding children and adolescents, most interventions are implemented in schools and communities. Systematic reviews have shown the potential of strategies in reducing recreational screen time among children and adolescents, such as classroom sessions, educational newsletter, homework assignments for parents, counseling practices, and TV-viewing time reduction²¹21. Wu L, Sun S, He Y, Jiang B. The effect of interventions targeting screen time reduction: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4029. https://doi.org/10.1097/MD.0000000000004029
https://doi.org/10.1097/MD.0000000000004... . However, most of these studies were conducted in high-income countries²⁰20. Schmidt ME, Haines J, O’Brien A, McDonald J, Price S, Sherry B, et al. Systematic review of effective strategies for reducing screen time among young children. Obesity (Silver Spring). 2012;20(7):1338-54. https://doi.org/10.1038/oby.2011.348
https://doi.org/10.1038/oby.2011.348... ,²¹21. Wu L, Sun S, He Y, Jiang B. The effect of interventions targeting screen time reduction: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4029. https://doi.org/10.1097/MD.0000000000004029
https://doi.org/10.1097/MD.0000000000004... , hampering the generalization of their findings into low-, middle- and upper-middle- income countries, as they differ in potential correlates of SB and acquire less available resources to support potential interventions²²22. Mielke GI, Brown WJ, Nunes BP, Silva ICM, Hallal PC. Socioeconomic correlates of sedentary behavior in adolescents: systematic review and meta-analysis. Sports Med. 2017;47(1):61-75. https://doi.org/10.1007/s40279-016-0555-4
https://doi.org/10.1007/s40279-016-0555-... .

Reducing SB is a global goal and Latin America low-, middle- and upper-middle-income countries, as Brazil and Mexico, are testing strategies to achieve it, but the results of these interventions have not yet been summarized. This study aimed to identify and evaluate the effects of community-based interventions to reduce or control SB among children and/or adolescents in Latin American countries.

METHODS

Study Design

This systematic literature review followed the Prisma (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) protocol and was registered in Prospero (CRD42017072157).

The following databases were searched: PubMed, Web of Science, Scopus, SciELO and Lilacs. Systematic searches combined keywords for type of study, SB and population: (((intervention[Text Word]) OR strategy[Text Word])) AND ((((((sedentary behavior[Text Word]) OR sitting time[Text Word]) OR screen time[Text Word]) OR television[Text Word]) OR computer[Text Word]) OR videogame[Text Word]). Activated filters: Clinical Trial; Controlled Clinical Trial; Pragmatic Clinical Trial; Randomized Controlled Trial; Humans; Child: birth-18 years. The document detailing all strategies applied can be requested by email to the corresponding author. Searches were filtered and/or performed in English, Portuguese and Spanish. To avoid potential losses, articles that were assessed by its full-texts had their reference lists checked (manual search). Searches in Google Scholar were also performed.

Selection process and data extraction

Inclusion criteria were: (i) intervention studies (experimental and quasi-experimental); (ii) implemented in community settings (e.g.: school, public clubs/parks, primary health care centers); (iii) in which primary or secondary objective was reducing SB; (iv) conducted with children and adolescents (< 18 years old); (v) in Latin American countries and; (vi) published until May 2019.

Three researchers, organized in two pairs (EHCR–ACMO; EHCR–PCS), assessed titles, abstracts, full texts and data collection. A senior reviewer (PHG) solved doubts and disagreements.

Data were collected in a structured spreadsheet, organized as follows: (i) sample characterization, study site (city/country) and primary object; (ii) study type, number and type of settings (school, church, home), duration and description of the intervention and control group; (iii) SB assessment method and number of individuals included in the analyzes; and (iv) description of SB results. When available, study protocols were consulted.

Two reviewers independently assessed the risk of bias using an adapted version of the Effective Public Health Practice Project (EPHPP) instrument²³23. Guerra PH, Nobre MRC, Silveira JAC, Taddei JAAC. School-based physical activity and nutritional education interventions on body mass index: a meta-analysis of randomised community trials - Project PANE. Prev Med. 2014;61:81-9. https://doi.org/10.1016/j.ypmed.2014.01.005
https://doi.org/10.1016/j.ypmed.2014.01.... ,²⁴24. Thomas BH, Ciliska D, Dobbins M, Micucci S. A process for systematically reviewing the literature: providing the research evidence for public health nursing interventions. Worldviews Evid Based Nurs. 2004;1(3):176-84. https://doi.org/10.1111/j.1524-475X.2004.04006.x
https://doi.org/10.1111/j.1524-475X.2004... . This instrument analyzes important domains of intervention studies (selection, study design, confounders, blinding of assessors, data collection methods, withdrawals and drop-outs, analyses) and ranks the information as low, moderate and high risk of bias. The adjusted EPHPP can be requested by contacting the corresponding author.

RESULTS

Figure 1 shows the flowchart. Of the 4,148 potential references, 709 duplicates were removed and 3,439 selected for title and abstract screening. After screening, 27 studies were referred for full text assessment, of which 17 were removed (reasons: outcome [n=3], study design [n=3], country [n=10], incomplete data [n=1]) and 10 selected for the descriptive syntheses. All included studies were cluster randomized controlled trials.

Interventions were implemented in Brazil (n=5)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... , Mexico (n=3)³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... , Ecuador (n=1)³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... , and Colombia (n=1)³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... . Most studies involved adolescents and were focused more on girls than boys²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1...

26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... -²⁷27. Guimarães RF, Silva MP, Martini MCS, Guerra-Júnior G, Gonçalves EM. The effects of an after-school intervention program on physical activity level, sedentary time, and cardiovascular risk factors in adolescents. Motriz. 2017;23 Spec N°2:e101769. https://doi.org/10.1590/s1980-6574201700si0069
https://doi.org/10.1590/s1980-6574201700... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... . Five studies had SB as primary objective²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... (Table 1).

Description of the interventions

Most interventions were school-based (n=8)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... and their lengths ranged from five days to 28 months. Five studies lasted at least six months²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... . Most studies (n=9) allocated participants into control and intervention groups. Rauber et al. (2018)²⁹29. Rauber SB, Castro HO, Marinho A, Vicent JB, Ribeiro HL, Monteiro LZ, et al. Effects of a physical activity and nutritional intervention in overweight and obese children trhough an educational and recreational camp. Nutr Health. 2018;24(3):145-52. https://doi.org/10.1177/0260106018771519
https://doi.org/10.1177/0260106018771519... allocated into the intervention group participants who answered to advertisements on a regional television channel. Other study applied the same protocol of the intervention group to participants allocated at baseline to the control group, due to the benefits of the intervention³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... . One study measured SB by an accelerometer (GT3x+, ActiGraph)³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... , but the others applied questionnaires. Recreational screen time was the most investigated behavior (television, computer and videogame)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... . In five studies, over 70% of participants (intervention and control group) completed the intervention²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... . Six studies performed their analyses following intention-to-treat principles²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... ,³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... .

Educational components (meetings/lessons/seminars on health-related subjects) (n=7)²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... and parents involvement (n=7)²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... were the most applied strategies, followed by information (posters, newsletters, guidelines) (n=4)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... and extra physical education/PA sessions (n=5)²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... (Table 3). In Martinez-Andrade et al. (2014)³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... , the intervention protocol boiled down to workshops with parents to modify their children PA behavior and dietary habits (aged from 2 to 5). The least applied strategies were: sending healthy messages to mobile phones (n=2)²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... , providing exercise breaks in the classroom (n=1)³3. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011;41(2):197-206. https://doi.org/10.1016/j.amepre.2011.05.001
https://doi.org/10.1016/j.amepre.2011.05... , and offering PA/sports events on weekends (n=1)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... .

Schools promoted environmental modification by building bike racks²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... and a walking trail³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... and buying simple sports equipment for Physical Education classes²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... . (Table 3)

All interventions applied strategies to increase PA, and seven also focused on improving diet. Three studies proposed specific strategies to reduce SB: 1) a textbook for teachers and a workbook for adolescents, containing topics related to PA and screen time behavior (i.e. being active for at least 60 min/day and watching television for < 2 hours a day), to be used on classes³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... ; 2) recommendations, handed to parents, including decreasing SB-activities time, like TV-viewing, using a computer, or playing videogames³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ; 3) pamphlets on screen time and health for both students and parents²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... . Four studies relied in professionals and students of both Physical Education/Activity and Nutrition for implementing the intervention strategies²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁷27. Guimarães RF, Silva MP, Martini MCS, Guerra-Júnior G, Gonçalves EM. The effects of an after-school intervention program on physical activity level, sedentary time, and cardiovascular risk factors in adolescents. Motriz. 2017;23 Spec N°2:e101769. https://doi.org/10.1590/s1980-6574201700si0069
https://doi.org/10.1590/s1980-6574201700... ,²⁹29. Rauber SB, Castro HO, Marinho A, Vicent JB, Ribeiro HL, Monteiro LZ, et al. Effects of a physical activity and nutritional intervention in overweight and obese children trhough an educational and recreational camp. Nutr Health. 2018;24(3):145-52. https://doi.org/10.1177/0260106018771519
https://doi.org/10.1177/0260106018771519... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... .

Results for Sedentary Behavior

Eight interventions reported a positive effect in total SB or recreational screen time reduction²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... . Three effectively reduced the mean time spent in screen based activities to minutes per day (Table 4). One reduced the proportion of adolescents involved in recreational screen time for ≥ 2 hours per day (TV: boys = -8.9%; girls = -7.2%)²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... . The effect size for total SB ranged from -298.9 to -177.1 min/week, and -22.3 to -21.2 min/day (Table 4).

Andrade et al. (2015)³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... observed that the intervention group showed smaller increases in screen time compared to the control group for the mean total on a weekend day (intervention: 88.1; control: 112.3 minutes a day) and for the proportion of adolescents with screen time behaviors of > 3 hours a day (intervention: 17.4%; control: 22.7%) after 18 months. Changes were not maintained after 28 months.

Hardman et al. (2014)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... observed the benefit of the program Saúde na Boa on the proportion of adolescents in the intervention group exposed to videogame/computer on weekend days for > 2 hours compared to the control group (intervention: 29.8%; control: 35.6%), which was not maintained after adjusting for potential confounding factors.

Risk of Bias

Most studies included in the syntheses were classified as low risk of bias in the domains: study design (n = 5)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... , data collection methods (n = 10), analyses (n = 10), and the use of intention-to-treat (n = 6)²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... ,³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... approaches. A higher proportion of studies were scored as moderate risk of bias in the domains of selection²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... , blinding of assessors²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... , and withdrawals and drop-outs²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁷27. Guimarães RF, Silva MP, Martini MCS, Guerra-Júnior G, Gonçalves EM. The effects of an after-school intervention program on physical activity level, sedentary time, and cardiovascular risk factors in adolescents. Motriz. 2017;23 Spec N°2:e101769. https://doi.org/10.1590/s1980-6574201700si0069
https://doi.org/10.1590/s1980-6574201700... ,³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... ,³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... . For the domain of confounders, four studies presented low risk of bias²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... , four presented moderate²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁷27. Guimarães RF, Silva MP, Martini MCS, Guerra-Júnior G, Gonçalves EM. The effects of an after-school intervention program on physical activity level, sedentary time, and cardiovascular risk factors in adolescents. Motriz. 2017;23 Spec N°2:e101769. https://doi.org/10.1590/s1980-6574201700si0069
https://doi.org/10.1590/s1980-6574201700... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ,³⁴34. Gutiérrez-MartínezI L, Martínez RG, GonzálezI SA, Bolívar MA, EstupiñanI OV, SarmientoI OL. Efectos de una estrategia de promoción de actividad física en escolares de Bogotá. Rev Saude Publica. 2018;52:79. https://doi.org/10.11606/S1518-8787.2018052017173
https://doi.org/10.11606/S1518-8787.2018... and one high risk²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... . Other studies scored high risk of bias for the domains of withdrawals and drop-outs²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,²⁹29. Rauber SB, Castro HO, Marinho A, Vicent JB, Ribeiro HL, Monteiro LZ, et al. Effects of a physical activity and nutritional intervention in overweight and obese children trhough an educational and recreational camp. Nutr Health. 2018;24(3):145-52. https://doi.org/10.1177/0260106018771519
https://doi.org/10.1177/0260106018771519... , and selection³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... .

DISCUSSION

Based on the results of ten community-based trials, the descriptive syntheses showed that the most effective community-based interventions were implemented in schools, adopted educational strategies, such as meetings, lessons or seminars on health-related subjects, targeted increasing PA, and were applied by a Physical Education/PA professional.

We found that effective interventions targeted changes in multiple health behaviors, corroborating Grieken et al. (2012)³⁹39. Grieken A, Ezendam NPM, Paulis WD, Wouden JC, Raat H. Primary prevention of overweight in children and adolescents: a meta-analysis of the effectiveness of interventions aiming to decrease sedentary behaviour. Int J Behav Nutr Phys Act. 2012;9:61. https://doi.org/10.1186/1479-5868-9-61
https://doi.org/10.1186/1479-5868-9-61... , which reported no difference in the positive effects of interventions of single or multiple health behavior on SB. In this review, the combination of strategies to increase PA, reduce SB, and improve diet were beneficial for SB.

Only a few studies aimed specifically at reducing SB and applied strategies focused on it²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... . The main strategies were: (1) recommending for parents a more active lifestyle and decreasing SB time spent on television, computer or videogame³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ; and (2) discussing SB and its guidelines in the classroom by a school teacher guided by a didactic material³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... .

Colín-Ramírez et al (2010)³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... implemented the first strategy, recommending for parents a more active lifestyle, and, after 12 months, the intervention group reduced the daily number of hours playing videogames. The second strategy, discussing SB in the classroom, was still effective after 18 months-follow-up, but not after 28 months. This result is consistent with the systematic review and meta-analysis of Maniccia et al. (2012)⁴⁰40. Maniccia DM, Davison KK, Marshall SJ, Manganello JA, Dennison BA. A meta-analysis of interventions that target children’s screen time for reduction. Pediatrics. 2011;128(1):e193–e210. https://doi.org/10.1542/peds.2010-2353
https://doi.org/10.1542/peds.2010-2353... of interventions targeting reducing children’s screen time, in which the authors observed larger statistically significant effects during the intervention period than during follow-up⁴⁰40. Maniccia DM, Davison KK, Marshall SJ, Manganello JA, Dennison BA. A meta-analysis of interventions that target children’s screen time for reduction. Pediatrics. 2011;128(1):e193–e210. https://doi.org/10.1542/peds.2010-2353
https://doi.org/10.1542/peds.2010-2353... .

Screen time was the most prevalent type of SB investigated, even among interventions implemented at schools, where children and adolescents spend a great part of their day sitting and a relatively small amount of time using electronic media for recreational purposes.

Schools are an ideal setting for interventions promoting healthier behaviors and reducing time spent in sedentary activities, as they allow interdisciplinary and multisectoral actions and facilitate parents’ involvement, favoring changes in family’s behavior. Schools also enable beneficial environmental modifications, such as building bike racks and walking trail, and providing sports equipment to be use during the children’s breaks²⁵25. Hardman CM, Barros MVG, Lopes AS, Lima RA, Bezerra J, Nahas MV. Efetividade de uma intervenção de base escolar sobre o tempo de tela em estudantes do ensino médio. Rev Bras Cineantropom Desempenho Hum. 2014;16 Supl 1:25-35. https://doi.org/10.5007/1980-0037.2014v16s1p25
https://doi.org/10.5007/1980-0037.2014v1... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... .

Previous reviews²⁰20. Schmidt ME, Haines J, O’Brien A, McDonald J, Price S, Sherry B, et al. Systematic review of effective strategies for reducing screen time among young children. Obesity (Silver Spring). 2012;20(7):1338-54. https://doi.org/10.1038/oby.2011.348
https://doi.org/10.1038/oby.2011.348... ,²¹21. Wu L, Sun S, He Y, Jiang B. The effect of interventions targeting screen time reduction: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4029. https://doi.org/10.1097/MD.0000000000004029
https://doi.org/10.1097/MD.0000000000004... observed that interventions effectively controlled and/or reduced recreational screen time (the most prevalent type of SB within young people)³3. Salmon J, Tremblay MS, Marshall SJ, Hume C. Health risks, correlates, and interventions to reduce sedentary behavior in young people. Am J Prev Med. 2011;41(2):197-206. https://doi.org/10.1016/j.amepre.2011.05.001
https://doi.org/10.1016/j.amepre.2011.05... among children and adolescents even in low-, middle- and upper-middle-income countries¹²12. Ministério da Saúde (BR); Ministério do Planejamento, Orçamento e Gestão, Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015. Rio de Janeiro: IBGE; 2016..

In our review, studies evaluated recreational screen time and other types of SB using a questionnaire. Although questionnaires are the most common tool applied to measure SB, they might not be the most accurate for relying solely on participants’ or their parents’ memories to report activities done over a period of time. Yet, objective measurements express a general SB measure, precluding the identification of the contexts in which this behavior has been adopted. A single study within our syntheses applied an objective measurement and not a questionnaire³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... .

Although at-home recreational screen time is above the recommended¹⁰10. Tremblay MS, LeBlanc AG, Janssen I, Kho ME, Hicks A, Murumets K, et al. Canadian sedentary behaviour guidelines for children and youth. Appl Physiol Nutr Metab. 2011;36(1):59-64. https://doi.org/10.1139/H11-012
https://doi.org/10.1139/H11-012... ,¹¹11. Council on Communication and Media. Children, adolescents, and the media. Pediatrics. 2013;132(5):958-61. https://doi.org/10.1542/peds.2013-2656
https://doi.org/10.1542/peds.2013-2656... , children and adolescents also spend a lot of time in SB in others settings, especially at school, while attending classess or during the breaks.

Effective interventions included the following educational strategies: school board and teachers meeting, to create a supportive environment for health behaviors; parents education sessions³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ; and textbooks for teachers and workbooks for adolescents on PA and SB, discussed over class.³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... The most prevalent strategies applied were distributing guidelines and newsletters on nutrition and PA,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... and arranging instructional meetings²⁷27. Guimarães RF, Silva MP, Martini MCS, Guerra-Júnior G, Gonçalves EM. The effects of an after-school intervention program on physical activity level, sedentary time, and cardiovascular risk factors in adolescents. Motriz. 2017;23 Spec N°2:e101769. https://doi.org/10.1590/s1980-6574201700si0069
https://doi.org/10.1590/s1980-6574201700... .

Our results showed that seven studies in Latin America adopted family involvement²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁸28. Bandeira AS, Silva KS, Sá SAM, Guerra PH, Mota J, Barbosa Filho VC. Effect of a multicomponent intervention on variables related to screen time in adolescents: a cluster-randomized controlled trial. Rev Bras Ativ Fis Saude. 2018;23:1-8. https://doi.org/10.12820/rbafs.12e0005
https://doi.org/10.12820/rbafs.12e0005... , which was effective when combined with educational strategies, information, exercise breaks in the classroom, extra PA sessions and health messages²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,²⁹29. Rauber SB, Castro HO, Marinho A, Vicent JB, Ribeiro HL, Monteiro LZ, et al. Effects of a physical activity and nutritional intervention in overweight and obese children trhough an educational and recreational camp. Nutr Health. 2018;24(3):145-52. https://doi.org/10.1177/0260106018771519
https://doi.org/10.1177/0260106018771519... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... . Biddle et al. (2014)⁴¹41. Biddle SJH, Petrolini I, Pearson N. Interventions designed to reduce sedentary behaviours in young people: a review of reviews. Br J Sports Med. 2014;48(3):182-6. https://doi.org/10.1136/bjsports-2013-093078
https://doi.org/10.1136/bjsports-2013-09... review, on interventions to reduce SB in young people, also identified family involvement as an effective strategy. Although some authors observed a more favorable trend in interventions with children younger than six years, we found only one study within this age group³¹31. Martínez-Andrade GO, Cespedes EM, Rifas-Shiman SL, Romero-Quechol G, González-Unzaga MA, Benítez-Trejo MA, et al. Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City. BMC Pediatr. 2014;14(1):77. https://doi.org/10.1186/1471-2431-14-77
https://doi.org/10.1186/1471-2431-14-77... and its intervention was focused on PA and dietary habits, not affecting SB.

Schmidt et al. (2012)²⁰20. Schmidt ME, Haines J, O’Brien A, McDonald J, Price S, Sherry B, et al. Systematic review of effective strategies for reducing screen time among young children. Obesity (Silver Spring). 2012;20(7):1338-54. https://doi.org/10.1038/oby.2011.348
https://doi.org/10.1038/oby.2011.348... and Wu et al. (2016)²¹21. Wu L, Sun S, He Y, Jiang B. The effect of interventions targeting screen time reduction: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4029. https://doi.org/10.1097/MD.0000000000004029
https://doi.org/10.1097/MD.0000000000004... reported that electronic monitor devices, contingent feedback, clinical counseling, and classroom-based health curriculum were effective in reducing screen time among children and adolescents. In both of these reviews, all but one study, conducted in Mexico, were in high-income countries and, as aforementioned, SB determinants and correlates differ according to country’s culture and resources²²22. Mielke GI, Brown WJ, Nunes BP, Silva ICM, Hallal PC. Socioeconomic correlates of sedentary behavior in adolescents: systematic review and meta-analysis. Sports Med. 2017;47(1):61-75. https://doi.org/10.1007/s40279-016-0555-4
https://doi.org/10.1007/s40279-016-0555-... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... ,⁴²42. Stierlin AS, De Lepeleere S, Cardon G, Dargent-Molina P, Hoffmann B, Murphy MH, et al. A systematic review of determinants of sedentary behaviour in youth: a DEDIPAC-study. Int J Behav Nutr Phys Act. 2015;12:133. https://doi.org/10.1186/s12966-015-0291-4
https://doi.org/10.1186/s12966-015-0291-... ,⁴³43. Guerra PH, Farias Júnior JC, Florindo AA. Sedentary behavior in Brazilian children and adolescents: a systematic review. Rev Saude Publica. 2016;50:9. https://doi.org/101590/S1518-8787.2016050006307
https://doi.org/101590/S1518-8787.201605... . This finding reinforces the need to test whether intervention strategies to reduce SB in children and adolescents in high-income countries are also relevant in low-, middle- and middle-upper income countries.

In Latin America, most of the effective interventions lasted at least six months,²⁶26. Leme ACB, Lubans DR, Guerra PH, Dewar D, Toassa EC, Philippi ST. Preventing obesity among Brazilian adolescent girls: six-month outcomes of the Healthy Habits, Healthy Girls–Brazil school-based randomized controlled trial. Prev Med. 2016;86:77-83. https://doi.org/10.1016/j.ypmed.2016.01.020
https://doi.org/10.1016/j.ypmed.2016.01.... ,³⁰30. Bacardí-Gascon M, Pérez-Morales ME, Jiménez-Cruz A. A six month randomized school intervention and an 18-month follow-up intervention to prevent childhood obesity in Mexican elementary schools. Nutr Hosp. 2012;27(3):755-62. https://doi.org/10.3305/nh.2012.27.3.5756
https://doi.org/10.3305/nh.2012.27.3.575... ,³²32. Colin-Ramírez E, Castillo-Martínez L, Orea-Tejeda A, Vergara-Castañeda A, Keirns-Davis C, Villa-Romero A. Outcomes of a school-based intervention (RESCATE) to improve physical activity patterns in Mexican children aged 8-10 years. Health Educ Res. 2010;25(6):1042-9. https://doi.org/10.1093/her/cyq056
https://doi.org/10.1093/her/cyq056... ,³³33. Andrade S, Verloigne M, Cardon G, Kolsteren P, Ochoa-Avilés A, Verstraeten R, et al. School-based intervention on healthy behaviour among Ecuadorian adolescents: effect of a cluster-randomized controlled trial on screen-time. BMC Public Health. 2015;15:942. https://doi.org/10.1186/s12889-015-2274-4
https://doi.org/10.1186/s12889-015-2274-... similar to studies conducted in high-income countries²¹21. Wu L, Sun S, He Y, Jiang B. The effect of interventions targeting screen time reduction: a systematic review and meta-analysis. Medicine (Baltimore). 2016;95(27):e4029. https://doi.org/10.1097/MD.0000000000004029
https://doi.org/10.1097/MD.0000000000004... and in line with the minimum length recommended to promote behavior change⁴⁴44. Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol. 1994;13(1):39-46. https://doi.org/10.1037//0278-6133.13.1.39
https://doi.org/10.1037//0278-6133.13.1.... .

The main limitation of our review is lack of searches in non-indexed Latin American journals and grey literature, which might have excluded studies that reported no intervention effect. Moreover, our evidence comprises studies from a small number of Latin America countries (n=4).

Our investigation was the first to summarize the effect and characteristics of Latin America interventions to control/reduce SB among children and adolescents. Another strength is the risk of bias assessment. However, as the high risk of bias in dropout and selection rates could play a role in the non-effect of some interventions²³23. Guerra PH, Nobre MRC, Silveira JAC, Taddei JAAC. School-based physical activity and nutritional education interventions on body mass index: a meta-analysis of randomised community trials - Project PANE. Prev Med. 2014;61:81-9. https://doi.org/10.1016/j.ypmed.2014.01.005
https://doi.org/10.1016/j.ypmed.2014.01.... ,²⁹29. Rauber SB, Castro HO, Marinho A, Vicent JB, Ribeiro HL, Monteiro LZ, et al. Effects of a physical activity and nutritional intervention in overweight and obese children trhough an educational and recreational camp. Nutr Health. 2018;24(3):145-52. https://doi.org/10.1177/0260106018771519
https://doi.org/10.1177/0260106018771519... , results should be interpreted with caution.

Our findings indicate gaps and a need for further studies that (i) define SB as a primary objective and implement strategies to reduce it; (ii) target sedentary activities and settings other than at-home screen time and time spent sitting in the classroom; (ii) use objective tools together with questionnaires to measure SB, informing a more reliable SB time and which settings and types of sedentary activity are more common among young people; (iv) conduct interventions in Latin America countries other than Brazil, Mexico, Ecuador, and Colombia.

Most Latin America interventions did not define SB as a primary objective or applied strategies specific to it. Yet, they effectively reduced SB, mainly recreational screen time, among children and adolescents. Effective interventions were conducted at school and often applied educational and informative strategies, as meetings, seminars, workshops, and distribution of guidelines and newsletters.

These results are important for public managers to plan actions to reduce SB among children and adolescents considering contexts and activities other than at-home leisure time, as young people are also sedentary at school and transportation.

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