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Background: Sedentary behaviour is when someone is awake, in a sitting, lying or reclining posture and is an independent risk factor for multiple causes of morbidity and mortality. A dose-response relationship has been demonstrated, whereby increasing sedentary time corresponds with increasing mortality rate. This study aimed to identify current levels of sedentary behaviour among General Practitioners (GPs), by examining and synthesising how sedentary behaviour has been measured in the primary care literature. Methods: A systematic review was conducted to identify studies relating to levels of sedentary behaviour among GPs. Searches were performed using Medline®, Embase®, PscycINFO, Web of Science and the Cochrane Library, from inception of databases until January 2020, with a subsequent search of grey literature. Articles were assessed for quality and bias, with extraction of relevant data. Results: The search criteria returned 1707 studies. Thirty four full texts were reviewed and 2 studies included in the final review. Both were cross-sectional surveys using self-reported estimation of sedentary time within the International Physical Activity Questionnaire (IPAQ). Keohane et al. examined GP trainees and GP trainers in Ireland. 60% reported spending in excess of 7 h sitting each day, 24% between 4 and 7 h, and 16% less than or equal to 4 h. Suija et al. examined female GPs in Estonia. The mean reported daily sitting time was 6 h and 36 min, with 56% sitting for over 6 h per day. Both studies were of satisfactory methodological quality but had a high risk of bias. Conclusion: There is a paucity of research examining current levels of sedentary behaviour among GPs. Objective data is needed to determine GPs’ current levels of sedentary behaviour, particularly in light of the increase in remote consulting as a result of the COVID-19 pandemic. Keywords: General practice, Primary care, Sedentary behaviour, Systematic review, Physical activity Background the rate of energy expended at rest . For example, 1.0 Sedentary behaviour is when someone is awake, in a sit- METs is the rate of energy expenditure while sitting at ting, lying or reclining posture, in a state of low energy rest . A 2.0 METs activity, such as ironing, expends expenditure, typically expending less than 1.5 metabolic twice the energy used by the body when sitting at equivalent of tasks (METs) [1, 2]. METs allow compari- rest . Physical activity is any movement of the body sons to be made between the energy expended during produced by skeletal muscles that requires energy ex- different states . METs are calculated as a ratio of the penditure . Physical activity can therefore be rate of energy expended during an activity compared to viewed as a spectrum, ranging from sedentary behav- iour to light, moderate and vigorous physical activity * Correspondence: email@example.com (Fig. 1.). Physical inactivity is a separate entity, instead Centre for Medical Education, School of Medicine, Dentistry and Biomedical defined as when an individual has insufficient levels Sciences, Queen’s University Belfast, Belfast, UK 2 of physical activity, i.e. less than current physical ac- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK tivity recommendations [2, 5]. © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Mayne et al. BMC Family Practice (2021) 22:6 Page 2 of 8 Fig. 1 Spectrum of physical activity The effect of sedentary behaviour on health has been specific, individualised and personally relevant. Numer- an area of interest among researchers since the pioneer- ous studies have demonstrated that GPs who are more ing work of the epidemiologist, Jeremy Morris, in the physically active are more likely to recommend physical 1940s and 1950s. Morris and colleagues demonstrated activity to their patients [21–30]. Patients are also more that sedentary bus drivers had higher rates of mortality likely to make healthy lifestyle changes recommended by due to coronary heart disease than bus conductors, their their doctor if they believe their doctor follows the more active colleagues [6, 7]. Since then, there has health advice themselves [31–34]. It could therefore be been an ever-increasing weight of evidence to demon- argued that reducing sedentary behaviour and increasing strate the negative health effects of sedentary behav- physical activity among GPs could lead to health benefits iour . It is now acknowledged that sedentary for both GPs themselves, at an individual level, and their behaviour is associated with multiple adverse health patients, at a population level. Within the context of outcomes, including mental health issues, obesity, day-to-day General Practice, this would primarily involve type 2 diabetes, multiple forms of cardiovascular dis- interrupting or replacing prolonged periods of sitting ease and dementia, as well as breast, colorectal, endo- with physical activity. One example is the use of active metrial and ovarian cancer [8–12]. As a result of workstations, such as standing desks, combined with these adverse health outcomes, sedentary behaviour is short breaks for physical activity, such as “exercise associated with increased all-cause mortality, even snacks”. Sitting while using a computer or telephone is a when allowing for confounding variables [12–15]. form of sedentary behaviour (≤1.5 METs), whereas These findings demonstrate a dose-response relation- standing while using a computer or telephone is a form ship, whereby increasing sedentary time corresponds of light physical activity (1.8 METs) . Reducing sed- with increasing mortality rate [12–15]. Sedentary be- entary behaviour among GPs, by replacing sedentary be- haviour has significant economic costs. Sedentary be- haviour with physical activity, could therefore play a haviour was estimated to cost the United Kingdom vital role, as part of a multifaceted approach alongside (UK) National Health Service (NHS) £0.7 billion in public health initiatives and changes to the built envir- 2016–2017 . A total of 69,276 deaths could po- onment, in ensuring a culture shift away from an in- tentially have been avoided in the UK if sedentary be- creasingly sedentary society, towards an increasingly haviour was eliminated . In light of these findings, physically active society. 2019 UK physical activity guidelines state that The aim of this systematic review is to identify the through all stages of life, individuals should minimise current levels of sedentary behaviour among GPs. The their sedentary behaviour, and break up periods of review examines and synthesises how sedentary behav- sedentary behaviour where possible . iour has been measured in the primary care literature. Previous studies have examined levels of sedentary be- haviour among other professions [17, 18], however Gen- Methods eral Practice is a different working environment, with This systematic review was conducted according to Pre- different challenges and opportunities from other profes- ferred Reporting Items for Systematic Reviews and sions, even within the field of healthcare. Primary care Meta-Analyses (PRISMA) guidance. The focus of this re- has been described as “the cornerstone” of the NHS, view was the identification of peer-reviewed, published providing over 300 million patient consultations per year articles which reported sedentary behaviour among GPs [19, 20]. This enables General Practitioners (GPs) to play (including family doctors and primary care doctors and/ an important role in both primary and secondary pre- or physicians). Searches were performed using Medline®, vention, by providing evidence-based lifestyle guidance Embase®, PscycINFO and Web of Science databases, to patients. GPs can reinforce important public health with assistance from a medical librarian (last search per- messages among their patients, making them more formed on 29th January 2020). Given the low number of Mayne et al. BMC Family Practice (2021) 22:6 Page 3 of 8 eligible studies identified, a subsequent search of the quality assessment scale adapted for cross sectional stud- Cochrane Library database, as well grey literature within ies, both included studies were of satisfactory methodo- thesis, dissertation and clinic trial databases (OpenGrey, logical quality (Table 1). The main reasons for study EThOS, DART-Europe, OATD, International Clinical exclusion were studies not taking place in the General Trials Registry Platform) was performed, with hand- Practice setting, studies examining patients, not GPs searching of reference lists of screened studies. Terms themselves, and studies not examining sedentary behav- relating to General Practice and sedentary behaviour iour. Although 5 studies initially appeared to relate to were combined using keywords, title, or abstract, with levels of sedentary behaviour among GPs, 3 of these were appropriate alternative spellings and truncation symbols. excluded as they used an incorrect, imprecise or outdated Due to the small number of available studies identified, definition of sedentary behaviour [22, 23, 40]. Brotons a narrative synthesis was undertaken of the included et al. , Cornuz et al.  and Jonsdottir et al. did studies. not clearly state how they defined GPs as being sedentary. It appears that they were instead referring to GPs who did Study selection not exercise regularly, who would currently be defined as Detailed searches were performed within Medline®, being physically inactive (ie. not meeting physical activity Embase®, PscycINFO, Web of Science and Cochrane Li- recommendations). A description of the studies included brary databases, as well grey literature within thesis, dis- in the final review is displayed in Table 2. sertation and clinic trial databases (OpenGrey, EThOS, The first study included was a cross-sectional survey of DART-Europe, OATD, International Clinical Trials all GP trainees and GP trainers in the Republic of Ireland Registry Platform), supplemented by hand-searching of by Keohane et al. . In total there were 219 eligible re- reference lists of screened studies. Two authors inde- spondents . The primary aim of the study was to ex- pendently screened titles and abstracts of publications plore levels of physical activity among Irish GPs and GP retrieved from the completed searches, once duplicates trainees, with an additional aim of investigating their per- were removed. A third author was available to resolve ceived barriers to exercise . The study used the self- any conflicts in study inclusion. Articles were discarded administered International Physical Activity Questionnaire if they did not meet the inclusion criteria, with a record (IPAQ) to assess levels of physical activity [41–43]. Within kept of the number discarded at each stage and reason the short form of the IPAQ, although it is primarily a tool for exclusion. Although no language restrictions were used for self-estimation of physical activity, there is a made, all included papers were written in English. Ex- question relating to sedentary behaviour . Participants tracted data included populations and settings, sample are asked about the time they spend sitting on a weekday sizes and response rates, methodological issues, eligibil- while at work, at home, while doing course work and dur- ity criteria, study design, and definitions and measures. ing leisure time, which may include time spent sitting at a The terms ‘general practitioner’, ‘GP’, ‘family physician’, desk, visiting friends, reading or sitting or lying down to and ‘family practitioner’ were all considered to relate to watch television . In the study by Keohane et al., 60% the same discipline. For the purposes of this study, the reported spending in excess of 7 h sitting each day, 24% term used is ‘general practitioner’ or ‘GP’. between 4 and 7 h, and 16% less than or equal to 4 h . There was no significant difference in sitting time between Data synthesis and quality assessment male and female respondents (p=0.61) . There was, Data were synthesised in terms of reported hours of sed- however, a statistically significant difference in sitting time entary behaviour among study participants. Objective reported by trainees working in hospital compared to criteria were used to assess quality and risk of bias those working in GP Practices (p<0.05) and between within recruitment, sample population, reliability and qualified GPs and GP trainees (p<0.05) . There was validity of outcome measures according to the no specific detail of the mean levels of sitting time within Newcastle-Ottawa quality assessment scale adapted for each of these groups . It is likely that trainees working cross sectional studies, as previously described by Her- in the hospital setting were overall less sedentary than zog et al.  and Luchini et al.  (additional file 1). those working in the GP Practice setting, and therefore GP trainees were overall less sedentary than qualified GPs, Results however, in the absence of sufficient data we cannot say One thousand seven hundred and seven studies were this with certainty . identified after duplicates were removed. After screening The second study included was a cross-sectional sur- titles and abstracts, 1673 were excluded. Out of 34 full text vey of female GPs in Estonia . There were 198 re- articles which were reviewed, only 2 measured sedentary sponses included in the analysis . The aim of this behaviour among GPs, both of which were included in the study was to explore physical activity among Estonian final review (Fig. 2). Applying the Newcastle-Ottawa GPs, as well as their physical activity counselling Mayne et al. BMC Family Practice (2021) 22:6 Page 4 of 8 Fig. 2 Flow diagram for identification, screening, eligibility, and inclusion of papers for review practices . Only female GPs were included, as 95% of Discussion GPs in Estonia were female at the time of the study . Overview The self-administered International Physical Activity This is the first systematic review of the levels of seden- Questionnaire (IPAQ) short form was translated into Es- tary behaviour among GPs. One thousand seven hun- tonian and used to assess self-reported levels of physical dred and seven studies were identified from our search activity, as well as sitting time [42–44]. The mean criteria, with 2 studies included in the final review. In- amount of daily sitting time was 6 h and 36 min, with cluded studies were cross-sectional, with self-reporting 56% sitting for over 6 h per day . Levels of physical of sedentary behaviour in hours and minutes. Both stud- activity were compared between those who reported sit- ies were of satisfactory methodological quality, however ting less than 6 h per day and those who reported sitting both had risk of bias and lack of objectivity. They both more than 6 h per day . Although those who re- focused primarily on levels of physical activity among ported sitting less than 6 h per day appeared to be GPs, using the International Physical Activity Question- slightly more physically active, this was not statistically naire (IPAQ). In the IPAQ, just one question concerns significant (p=0.207) . sedentary behaviour, where participants are asked to Mayne et al. BMC Family Practice (2021) 22:6 Page 5 of 8 � � � � Table 1 Quality assessment of the included studies based on the Newcastle-Ottawa quality assessment scale adapted for cross sectional studies Study Design Selection (max. 5*) Comparability (max. 2*) Outcome (max. 3*) Total score Representativeness of the sample Sample Nonrespondents Ascertainment of Based on design and Assessment of Statistical (max. size exposure analysis outcome test 10*) Keohane et al. Cross- * * ** * * 6*  sectional Suija et al.  Cross- * * ** * * 6* sectional Scoring Very Good Studies: 9–10 stars Good Studies: 7–8 stars Satisfactory Studies: 5–6 stars Unsatisfactory Studies: 0 to 4 stars Mayne et al. BMC Family Practice (2021) 22:6 Page 6 of 8 Table 2 Description of Included Studies Author Country Number of Study Criteria for inclusion Assessment method Objectivity Quality participants design Keohane Ireland 219 Cross- GP Trainers and GP Self-reported Non- Satisfactory et al. sectional Trainees questionnaire objective Suija et al. Estonia 198 Cross- Female GPs Self-reported Non- Satisfactory sectional questionnaire objective estimate how much time they spent sitting on a week Although there has been an increasing volume of re- day . Both studies may have been affected by selec- search examining sedentary behaviour in other settings, tion bias, whereby survey participants may have been this study has identified a lack of research in the field of less sedentary and more physically active than those who General Practice. Most studies in the General Practice did not respond. The study by Suija et al. questioned setting appear to focus on either physical activity or sed- only female GPs, so findings may not be valid among entary behaviour of patients, not among GPs themselves. male GPs, however there were no significant differences between males and females in the study by Keohane Conclusion et al. . As responses were self-estimated, as oppose In light of the established associations between sedentary to objectively measured findings, participants may also behaviour, adverse health outcomes and mortality, GPs have either overestimated or underestimated their true should consider their own levels of sedentary behaviour, levels of physical activity and sedentary behaviour. Both as well as that of their patients. GPs can potentially be studies used validated questionnaires for the self- key protagonists in reducing sedentary behaviour among assessment of physical activity and sedentary behaviour. the general population by virtue of their position in the There is some debate regarding the validity of self- healthcare system, where they have significant levels of estimated, compared to objectively measured, findings of patient contact and opportunities for health promotion. sedentary behaviour and physical activity [38, 39, 42, 43, At present, there is a paucity of research examining 45–49]. It is widely acknowledged that objective data current levels of sedentary behaviour among GPs. This (such as that obtained using accelerometers or pedome- systematic review identified just 2 papers assessing levels ters) has higher validity than self-estimation of sedentary of sedentary behaviour among GPs, both of which used behaviour and physical activity, with self-estimation self-reported estimations [41, 44]. Given that GPs who shown to typically underestimate sedentary behaviour by are more physically active are more likely to recommend approximately 1.74 h per day [45, 46, 50]. With the re- physical activity to their patients, and patients are more cent increase in remote consulting among GPs as a re- likely to make healthy lifestyle changes if they believe sult of the COVID-19 pandemic, GPs have less face-to- their doctor follows the health advice themselves, by re- face interaction with patients, with the majority of con- ducing their sedentary behaviour and increasing their sultations now happening via telephone and video . physical activity, GPs could play an important role in the This opens up both challenges and opportunities for development of a less sedentary and more physically ac- GPs regarding their levels of sedentary behaviour [52, tive society [31–34]. There is therefore a clear need for 53]. It does, however, mean that GPs now have more in more reliable and objective data to determine the common with workers in other medical and non-medical current levels of sedentary behaviour among GPs, par- environments, such as office and call centre workers, ticularly in light of the increase in remote consulting as where interventions targeted at reducing levels of seden- a result of the COVID-19 pandemic. tary behaviour have had varying levels of success [54–58]. Strengths and limitations Additional Files Strengths of this systematic review were the use of a clearly defined search and study selection strategy, with Additional file 1. Critical appraisal tool for cross-sectional studies. Modi- double reviewing of all stages. Using a wide search strat- fied from the Newcastle-Ottawa Quality Assessment Scale for Cohort egy, with no exclusion based on language, supplemented Studies. by hand-searching of reference lists, allowed authors to identify as many eligible studies as possible. Despite this, just 2 eligible studies were identified, both in English. A Abbreviations COVID-19: Coronavirus disease 2019; GP: General Practitioner; limitation of this review is the lack of studies available in IPAQ: International Physical Activity Questionnaire; METs: Metabolic the area of sedentary behaviour among GPs. Sedentary Equivalent of Tasks; NHS: National Health Service; PRISMA: Preferred behaviour is a novel and emerging area of research. Reporting Items for Systematic Reviews and Meta-Analyses Mayne et al. BMC Family Practice (2021) 22:6 Page 7 of 8 Acknowledgements 13. Chau JY, Grunseit AC, Chey T, Stamatakis E, Brown WJ, Matthews CE, et al. We gratefully acknowledge the assistance of Richard Fallis, Subject Librarian Daily sitting time and all-cause mortality: a meta-analysis. PLoS One. 2013; for Medicine, Dentistry and Biomedical Sciences, Queen’s University Medical 8(11):e80000. Library, in providing guidance with the literature search for the systematic 14. 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