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1451BullFC,etal.Br J Sports Med 2020;54:14511462.doi:10.1136/bjsports-2020-102955World Health Organization 2020 guidelines on physical activity and sedentarybehaviourFiona C Bull ,1,2 Salih S Al-Ansari,3 Stuart Biddle,4 Katja Borodulin,5,6 Matthew P Buman ,7 Greet Cardon,8 Catherine Carty,9,10 Jean-Philippe Chaput ,11 Sebastien Chastin ,12 Roger Chou,13 Paddy C Dempsey,14,15 Loretta DiPietro,16 Ulf Ekelund ,17,18 Joseph Firth,19,20 Christine M Friedenreich,21 Leandro Garcia,22 Muthoni Gichu,23 Russell Jago ,24 Peter T Katzmarzyk,25 Estelle Lambert ,26 Michael Leitzmann,27 Karen Milton ,28 Francisco B Ortega,29 Chathuranga Ranasinghe,30 Emmanuel Stamatakis ,31 Anne Tiedemann,32 Richard P Troiano ,33 Hidde P van der Ploeg,34,35 Vicky Wari,36 Juana F Willumsen1 GuidelinesTo cite:BullFC,Al-AnsariSS,BiddleS,etal.Br J Sports Med 2020;54:14511462.For numbered affiliations see end of article.Correspondence toProfessor Fiona C Bull,Physical Activity Unit,Department of Health Promotion,World Health Organization,Geneva,GE,Switzerland;bullf who.intAccepted 7 September 2020 Author(s)(or their employer(s)2020.Re-use permitted under CC BY.Published by BMJ.ABSTRACTObjectives To describe new WHO 2020 guidelines on physical activity and sedentary behaviour.Methods The guidelines were developed in accordance with WHO protocols.An expert Guideline Development Group reviewed evidence to assess associations between physical activity and sedentary behaviour for an agreed set of health outcomes and population groups.The assessment used and systematically updated recent relevant systematic reviews;new primary reviews addressed additional health outcomes or subpopulations.Results The new guidelines address children,adolescents,adults,older adults and include new specific recommendations for pregnant and postpartum women and people living with chronic conditions or disability.All adults should undertake 150300 min of moderate-intensity,or 75150 min of vigorous-intensity physical activity,or some equivalent combination of moderate-intensity and vigorous-intensity aerobic physical activity,per week.Among children and adolescents,an average of 60 min/day of moderate-to-vigorous intensity aerobic physical activity across the week provides health benefits.The guidelines recommend regular muscle-strengthening activity for all age groups.Additionally,reducing sedentary behaviours is recommended across all age groups and abilities,although evidence was insufficient to quantify a sedentary behaviour threshold.Conclusion These 2020 WHO guidelines update previous WHO recommendations released in 2010.They reaffirm messages that some physical activity is better than none,that more physical activity is better for optimal health outcomes and provide a new recommendation on reducing sedentary behaviours.These guidelines highlight the importance of regularly undertaking both aerobic and muscle strengthening activities and for the first time,there are specific recommendations for specific populations including for pregnant and postpartum women and people living with chronic conditions or disability.These guidelines should be used to inform national health policies aligned with the WHO Global Action Plan on Physical Activity 20182030 and to strengthen surveillance systems that track progress towards national and global targets.INTRODUCTIONIn 2018,the World Health Assembly(WHA)approved a new Global Action Plan on Physical Activity(GAPPA)201820301 and adopted a new voluntary global target to reduce global levels of physical inactivity in adults and adolescents by 15%by 2030.As part of the WHA Resolution(WHA71.6),Member States requested that WHO update the 2010 Global Recommendations on Physical Activity for Health.2Global and national guidelines on physical activity are a central component of a comprehen-sive and coherent governance and policy frame-work for public health action.WHO recommends all countries establish national guidelines and set physical activity targets.To help support popula-tions to achieve the targets and maintain healthy levels of physical activity,all countries are advised to develop and implement appropriate national and subnational policies and programmes to enable people of all ages and abilities to be physically active and improve health.Given that the most recent global estimates show that one in four(27.5%)adults3 and more than three-quarters(81%)of adolescents4 do not meet the recommendations for aerobic exercise,as outlined in the 2010 Global Recommendations on Physical Activity for Health,2 there is an urgent need to increase priority and investment directed towards services to promote physical activity both within health and other key sectors.These data also reveal no overall improvement in global levels of participation over the last two decades and substan-tial gender differences.3 4 Furthermore,national data consistently show inequalities in participation by age,gender,disability,pregnancy,socioeconomic status and geography,1 amplifying the need to inten-sify investment in physical activity.This paper reports on the development of new WHO guidelines on physical activity and sedentary behaviour.5 These guidelines provide evidence-based public health recommendations concerning the amount(frequency,intensity,duration)and types of physical activity that offer significant health on November 26,2020 by guest.Protected by copyright.http:/ J Sports Med:first published as 10.1136/bjsports-2020-102955 on 25 November 2020.Downloaded from 1452BullFC,etal.Br J Sports Med 2020;54:14511462.doi:10.1136/bjsports-2020-102955Guidelinesbenefits and mitigate health risks(for definitions see table 1).These guidelines have been developed for children,adolescents,adults,older adults and,for the first time,include specific recom-mendations on physical activity for pregnant and postpartum women and people living with chronic conditions or disability.In addition,for the first time,these WHO guidelines address the health impact of sedentary behaviour.The new WHO guidelines update previous WHO recommendations on physical activity for health released in 20102 with the most recent advances in the evidence base for these behaviours and associated selected health consequences.These new guidelines,together with the Guidelines on Physical Activity,Sedentary Behaviour and Sleep for Children Under 5 Years of Age,6 provide evidence-updated recommendations for physical activity and sedentary behaviour across the life course.The primary audiences and users of these guidelines are policy makers in ministries of health,education,sport,transport,envi-ronment,social or family welfare and related sectors,working in high-income as well as low-income and middle-income coun-tries(LMICs),who formulate country-specific guidelines and who develop national or subnational plans and programmes to increase physical activity and reduce sedentary behaviours across the life course.Additional key users of these guidelines include researchers and those working in health services providing advice and guidance(such as community health workers,primary,secondary or tertiary nurses or doctors),allied health Table 1 Glossary of termsTermDefinitionAerobic physical activityActivity in which the bodys large muscles move in a rhythmic manner for a sustained period of time.Aerobic activityalso called endurance activityimproves cardiorespiratory fitness.Examples include walking,running,swimming and bicycling.Balance trainingStatic and dynamic exercises that are designed to improve an individuals ability to withstand challenges from postural sway or destabilising stimuli caused by self-motion,the environment or other objects.Bone-strengthening activityPhysical activity primarily designed to increase the strength of specific sites in bones that make up the skeletal system.Bone-strengthening activities produce an impact or tension force on the bones that promotes bone growth and strength.Examples include any type of jumps,running and lifting weights.DisabilityFrom the International Classification of Functioning,Disability and Health,an umbrella term for impairments,activity limitations and participation restrictions,denoting the negative aspects of the interaction between an individual(with a health condition)and that individuals contextual factors(environmental and personal factors).Domains of physical activityPhysical activities can be undertaken in various domains,including one of more of the following:leisure,occupation,education,home and/or transport.Household domain physical activityPhysical activity undertaken in the home for domestic duties(such as cleaning,caring for children,gardening,etc).Leisure-domain physical activityPhysical activity performed by an individual that is not required as an essential activity of daily living and is performed at the discretion of the individual.Examples include sports participation,exercise conditioning or training and recreational activities such as going for a walk,dancing and gardening.Light-intensity physical activity(LPA)On an absolute scale,light intensity refers to physical activity that is performed between 1.5 and 3 METs.On a scale relative to an individuals personal capacity,light-intensity physical activity is usually a 24 on a rating scale of perceived exertion scale of 010.Examples include slow walking,bathing or other incidental activities that do not result in a substantial increase in heart rate or breathing rate.Metabolic equivalent of task(MET)The metabolic equivalent of task,or simply metabolic equivalent,is a physiological measure expressing the intensity of physical activities.One MET is the energy equivalent expended by an individual while seated at rest,usually expressed as mLO2/kg/min.Moderate-intensity physical activity(MPA)On an absolute scale,moderate-intensity refers to the physical activity that is performed between 3 and 3 METs(ie,3 times the intensity of rest).On a scale relative to an individuals personal capacity,MPA is usually a 5 or above on a scale of 010.Multicomponent physical activityMulticomponent physical activity are activities that can be done at home or in a structured group or class setting and combine all types of exercise(aerobic,muscle strengthening and balance training)into a session,and this has been shown to be effective.An example of a multicomponent physical activity programme could include walking(aerobic activity),lifting weights(muscle strengthening)and could incorporate balance training.Examples of balance training can include walking backwards or sideways or standing on one foot while doing an upper body muscle-strengthening activity,such as bicep curls.Dancing also combines aerobic and balance components.Occupation domain physical activitySee work domain physical activity.Physical activity(PA)Any bodily movement produced by skeletal muscles that requires energy expenditure.Physical inactivityAn insufficient physical activity level to meet present physical activity recommendations.Recreational screen timeTime spent watching screens(television(TV),computer,mobile devices)for purposes other than those related to school or work.Sedentary screen timeTime spent watching screen-based entertainment while sedentary,either sitting,reclining or lying.Does not include active screen-based games where physical activity or movement is required.Sedentary behaviourAny waking behaviour characterised by an energy expenditure of 1.5 METs or lower while sitting,reclining or lying.Most desk-based office work,driving a car and watching television are examples of sedentary behaviours;these can also apply to those unable to stand,such as wheelchair users.The guidelines operationalise the definition of sedentary behaviour to include self-reported low movement sitting(leisure time,occupational and total),TV viewing or screen time and low levels of movement measured by devices that assess movement or posture.Transport domain physical activityPhysical activity performed for the purpose of getting to and from places,and refers to walking,cycling and wheeling(ie,the use of non-motorised means of locomotion with wheels,such as scooters,roller-blades,manual wheelchair,etc).In some contexts,operation of a boat for transport could also be considered transport-related physical activity.Vigorous-intensity physical activity(VPA)On an absolute scale,vigorous intensity refers to physical activity that is performed at 6.0 or more METs.On a scale relative to an individuals personal capacity,VPA is usually a 7 or 8 on a rating scale of perceived exertion scale of 010.Work domain physical activityPhysical activity undertaken during paid or voluntary work.on November 26,2020 by guest.Protected by copyright.http:/ J Sports Med:first published as 10.1136/bjsports-2020-102955 on 25 November 2020.Downloaded from 1453BullFC,etal.Br J Sports Med 2020;54:14511462.doi:10.1136/bjsports-2020-102955Guidelinesand exercise professionals and non-governmental organisations.Communication of these guidelines to members of the public is essential and requires tailoring of the core messages to appro-priate and accessible language and formats relevant to cultural contexts in order to be effective.METHODS AND PROCESS FOR DEVELOPING THE WHO GUIDELINESThe guidelines were developed in accordance with the processes set out in the WHO Handbook for Guidelines Development7 and commenced in 2019.A Guideline Development Group(GDG)was established comprising relevant experts from required disciplines as well as policy makers and end users of the recommendations,with regional and gender balance.Details of the members of the GDG are available.5At the first meeting in July 2019,the GDG reviewed and finalised the scope of the guidelines and agreed on the set of population,intervention or exposure,comparator and outcome(PI/ECO)questions and critical and important outcomes to be assessed(table 2).The GDG did not include sleep as a behaviour within the scope of these guidelines but did recognise sleep as an important health outcome when considering the impact of physical activity.Between August and February 2020,the WHO secretariat coordinated the commissioning of literature searches and systematic evidence reviews and the GDG subworking groups met virtually to review,summarise and draft preliminary recommendations.Updating searches and new evidence reviewsThe WHO guidelines on physical activity and sedentary behaviour were developed by using,and systematically updating,the evidence collated for the development of other recent national physical activity guidelines that met the following three criteria:(1)the evidence reviews had been conducted according to standard and rigorous systematic processes that were well documented;(2)the assessment of the certainty of the evidence used the Grading of Recommendations Assessment,Develop-ment and Evaluation(GRADE)method or an equivalent meth-odology that was clearly described and documented and(3)the evidence reviews addressed the popula
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