Meeting 24-h movement guidelines and associations with health related quality of life of Australian adolescents

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Original research

Meeting 24-h movement guidelines and associations with health related quality of life of Australian adolescents Asaduzzaman Khan a,∗ , Eun-Young Lee b , Mark S. Tremblay c a b c

School of Health and Rehabilitation Sciences, The University of Queensland, Australia School of Kinesiology and Health Studies, Queen’s University, Kingston, ON K7L2N9, Canada Healthy Active Living and Obesity (HALO) Research Group, CHEO Research Institute, Ottawa, ON K1H 8L1, Canada

a r t i c l e

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Article history: Received 15 June 2020 Received in revised form 8 October 2020 Accepted 28 October 2020 Available online xxx Keywords: Movement behaviours Physical activity Screen time Sleep HRQoL Adolescents

a b s t r a c t Objective: This study determined the prevalence of adolescents meeting the individual and combinations of the Australian 24-Hour Movement Guidelines, and their associations with the health related quality of life (HRQoL). Methods: The participants were 3096 adolescents (mean age: 12.4 years; 49% female) from wave 7 of the birth-cohort of the Longitudinal Study of Australian Children. The outcome was parent-reported HRQoL. Meeting the 24-Hour Movement Guidelines was defined as: ≥60 min/day of moderate to vigorous physical activity (MVPA), ≤2 hour/day of recreational screen time, and 9-11 hour/night of sleep. Generalised estimating equations were used to examine the associations between meeting vs. not meeting recommendations and HRQoL outcomes. Results: The prevalence of adolescents meeting all three recommendations was 2.4%, with 23% meeting two, and 57% meeting one recommendation. Meeting all three recommendations was associated with higher overall HRQoL score (␤ = 4.96, 95% CI: 2.54–7.38) as well as physical (␤ = 5.22, 95% CI: 2.61–7.83) and psychosocial (␤ = 4.76, 95% CI: 1.77–7.75) scores. Meeting combinations of screen time with MVPA or sleep recommendations were associated with higher scores for all HRQoL outcomes, while meeting MVPA and sleep recommendations was associated with overall HRQoL score. Compared to meeting no recommendation, meeting more recommendations was significantly and incrementally associated with higher scores for all HRQoL outcomes (ptrend <0.001). Conclusions: Overall, meeting more recommendations within the 24-Hour Movement Guidelines was associated with better HRQoL outcomes. However, only a small percentage of adolescents met all the recommendations, which underscores the need for promoting and supporting adherence to these behaviours. © 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

1. Introduction Sleep, sedentary behaviour, and physical activity (PA) are timedependent behaviours that fall on a movement intensity continuum across the entire day, and are referred to as movement behaviours 1 . Health benefits of each of these movement behaviours are well documented; however, they have traditionally been studied individually, and in isolation of each other, ignoring the interactions between them. Given that these behaviours are mutually exclusive but together make-up the whole 24 -h day, there is growing interest in understanding how these behaviours interact and collectively relate to the health and wellbeing of children and adolescents

∗ Corresponding author. E-mail address: [email protected] (A. Khan).

1.

Recognising the importance of these behaviours for health, it has been recommended that children and adolescents (aged 5-17 years) accumulate at least 60 min per day of moderate-to vigorousphysical activity (MVPA), limit recreational screen-time to no more than two hours per day, and acquire uninterrupted sleep of 911 hours for 5-13 year-olds and 8-10 hours for 14-17 year-olds per night to optimise health and wellbeing 1,2 . Accumulating evidence suggests that certain combinations of these movement behaviours within a 24 -h period may have important health implications for children and adolescents 3–6 . A number of studies showed that meeting more recommendations of movement behaviours was associated with better health outcomes in a gradient pattern 3,6,7 . Clearly it is important to understand the balance between the engagements in these behaviours, and examine the health implications of these integrated, rather than segregated, behaviours, which

https://doi.org/10.1016/j.jsams.2020.10.017 1440-2440/© 2020 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: Khan A, et al,Meeting 24-h movement guidelines and associations with health related quality of life of Australian adolescents, J Sci Med Sport, https://doi.org/10.1016/j.jsams.2020.10.017

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can inform strategies aiming at optimising health and wellbeing of children and adolescents. Australia has recently released new guidelines for children and young people: 24-Hour Movement Guidelines for Children and Young People (5-17 years) - An Integration of Physical Activity, Sedentary Behaviour, and Sleep 2 ; however, exploration of the movement behaviours and their relationships with health outcomes is limited. A number of Australian studies have looked at pre-school children’s adherence to 24-Hour Movement Guidelines and their associations with various health outcomes 8–12 . However, these studies are based on non-representative samples of Australian children aged < 5 years. A few multi-country studies, based on The International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) project, have examined the 24 -h movement behaviours and their relationships with adiposity, dietary patterns, and quality of life of children aged 11-13 years from 12 countries, including Australia 6,13,14 ; however, these studies were based on non-representative samples and lacked country level estimates of the associations. Available evidence suggests that unhealthy behaviours are common among Australian children and adolescents with sub-optimal adherence to health behavior recommendations 15 . The most recent Australian Report Card on Physical Activity for Children and Youth graded “D-” for both physical activity (20-26% meeting the MVPA recommendation) and sedentary behaviour (20-26% meeting the screen time recommendation) for Australian children and youth 16 . In addition, normative Australian data showed that one in four children aged 11-12 years experienced inadequate sleep, while about half experienced poor sleep quality based on the current sleep recommendation 17 . Although a few studies have recently examined the movement behaviours and their relationships with psychosocial wellbeing of pre-school children in Australia 8,10,11 , only one study, as a part of a multi-country research with non-representative samples, has looked at movement behaviours and their relationship with health related quality of life (HRQoL) of Australian school-aged children 14 . HRQoL is an important multi-dimensional construct of children’s physical, mental, emotional, and social functioning, and can be considered as an indicator of overall health 18 . Thus, examining the associations of movement behaviours with HRQoL will add to the limited evidence base on how these behaviours related to physical and psychosocial health of school-aged children, and can provide additional evidence of benefits, if any, of meeting any combinations of the movement behaviours. The purpose of this study was therefore to examine (i) the prevalence of adolescents meeting the individual and combinations of the Australian 24-Hour Movement Guidelines, and (ii) associations between meeting the guideline(s) and HRQoL, including its physical and psychosocial components, in a representative sample of Australian adolescents.

then randomly selected to take part in the LSAC. Data were collected from multiple respondents including parents of the study child, the study child, carers/teachers (depending on the child’s age), and interviewers. In earlier waves of the study, the primary respondent was the child’s parent; however, as children grow older, they have progressively become the primary respondents of the study. A variety of data collection methods were used in the study, including: face-to-face interviews, self-complete questionnaires, direct anthropometric measures (e.g., height, weight, body-fat), time use diaries, and computer-assisted telephone interviews (CATI). The interviews and questionnaires included validated scales that were age-appropriate 19 . Each postcode of the study participants was linked by the data custodian to the “Statistical Area 2” (SA2) area identifier, developed by the Australian Bureau of Statistics. Survey weights for each wave were calculated taking into account the selection probability of each child, and were adjusted for non-response, loss to follow-up and benchmarked to population numbers in major categories of the population of children born in 2004 20 . This research is based on data from wave 7 of the B-cohort of the LSAC, collected in 2016 from children aged 12-13 years. Although screen time and sleep were captured in multiple waves of the LSAC, wave 7 was the first wave in which the participating children completed their compliance with the recommended 60 min of MVPA per day, and hence offered the first opportunity to examine the three movement behaviours simultaneously. Of the 3381 children who participated in wave 7, 284 were dropped from the analysis due to non-response on at least one of the movement behaviours. One additional participant was dropped due to a missing SA2 identifier, making the final analytical sample of 3096 participants. For surveillance of the overall guidelines, three movement behaviour recommendations should be assessed 2 . The following three criteria must be met for minimal inclusion as meeting the guidelines: (1) accumulating at least 60 min of MVPA per day; (2) no more than 2 hours of recreational screen time per day; and (3) uninterrupted sleep of 9-11 hours for those aged 5-13 years and 810 hour for those aged 14-17 years per night. Participants who met all three recommendations were categorised as meeting the overall movement guidelines. The recommendations indicate that each of these three criteria should be met when averaging daily time spent in each activity across all 7 days of the week. Physical activity was assessed with one item: “About how many days each week do you do at least 60 minutes of moderate or vigorous physical activity? (This is all the time you spent in activities that increased your heart rate and made you breathe hard)”. The participating children completed this item with the number of days they did ≥ 60 min of MVPA. An answer of 7 days was used as the criteria for meeting the guideline. Parent-reported data were used to capture children’s recreational screen time using four items: (a) About how many hours on a typical weekend day does the study child watch TV programmes or movies at home? (b) About how many hours on a typical weekday does the study child watch TV programmes or movies at home? (c) About how many hours on a typical weekend day does study child play electronic games? and (d) About how many hours on a typical weekday does study child play electronic games? Recreational screen time for an average day was computed by using: [5 x weekday screen time + 2 x weekend day screen time]/7. Study children were asked to indicate their typical time of sleep onset and typical wake-up time during school days and non-school days: (a) “About what time do you fall asleep on a usual school night?”, (b) “About what time do you wake up in the morning on a usual school day?”, (c) “About what time do you fall asleep on the nights when you do not have school the next day?”; and (d) “About what time do you wake up in the morning on the days when you do not have school?”. Responses to each question were collected on a continuous scale to assess duration of sleep on a typ-

2. Methods This study used data from the birth (B) cohort of the Longitudinal Study of Australian Children (LSAC), a nationally representative longitudinal study with children born between March 2003 and February 2004. Using a cross-sequential design and the Medicare Australia enrolment database as its sampling frame, the LSAC has been collecting data every two years on child, parental, family, community and school characteristics that influence children’s development as they grow-up. A two-stage cluster sampling design was used in the LSAC with stratification by state and then by major metropolitan centre versus others. First, approximately 10% of all Australian postcodes were randomly selected. Second, a number of children proportional to population size for each postcode were randomly selected. Children were directly identified from the date of birth field in the Medicare Enrolment Database and 2

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ical night, using [5 x school-day sleep duration + 2 x non-school-day sleep duration]/7. The outcome of the analysis was HRQoL, measured by using parent-reported version of the Pediatric Quality of Life Inventory Version 4.0 (PedsQL), a multidimensional scale that measures HRQoL in population aged 2–18 years. The PedsQL is a 23-item scale with four subscales: Physical Functioning (8 items), Social Functioning (5 items), Emotional Functioning (5 items) and School/Day care Functioning (5 items)18 . A five-point Likert scale was utilised for each item, and item scores were summed to generate total HRQoL, physical (sum of Physical Functioning items), and psychosocial health (sum of Social, Emotional and School/Day care functioning items) summary scores. Each summary score was then reverse transformed to a 0-100 scale linearly with a higher score corresponding to a better HRQoL. The PedsQL demonstrates high reliability and validity, and the parent-proxy version exhibits strong concordance with the self-report18 . Covariates included age (in months), sex (male/female), language spoken at home (non-English/English) and area of residence (metropolitan vs non-metropolitan). Height (cm) and weight (kg) of study children were measured using a portable laser stadiometer (Invicta Plastics, Leicester, UK) and body fat scales. Height and weight were used to calculate body mass index (BMI), which was used as a continuous variable in the analyses. Family socioeconomic position (SEP) summarized the social and economic capital available to families and comprised of combined annual family income, both parents’ employment status and education 21 . Neighborhood socioeconomic status was assessed using the Socioeconomic Indexes for Areas (SEIFA) index of relative socioeconomic advantage and disadvantage 22 . Continuous descriptive variables were summarised using weighted means and standard deviations (SD), and categorical variables were summarised by weighted percentages. In addition, weighted proportions of meeting individual and combinations of recommendations (i.e., MVPA only, recreational screen time only, sleep only, MVPA + screen time, MVPA + sleep, and screen time + sleep) and their general combinations (i.e., all three, two out of three, one out of three, and none) of the Australian 24Hour Movement Guidelines for children and youth were calculated. Statistical weighting was used in generating the prevalence estimates. A series of generalized estimating equations (GEE) with an exchangeable correlation was used to examine the associations of meeting specific recommendations and their combinations with HRQoL outcomes, including its physical and psychosocial components 23 . GEE was used to take into account the nested structure of the data (i.e., children nested within SA2) in order to model spatial clustering. A robust standard error estimator was used to reduce the influence of outliers. A set of covariates, initially considered for adjustment, included: sex, BMI, language spoken at home, area of residence, SEP and SEIFA. As SEIFA was considerably associated with the SEP and area of residence, we did not consider SEIFA for any further analysis to avoid collinearity. For any specific combination of movement behaviours, not meeting the recommendation was the reference group, and for the general combination of movement behaviours, not meeting any of the three recommendations was the reference group. Since the associations between movement behaviours and HRQoL outcomes may vary by sex, different combinations of movement behaviours with sex interaction terms (e.g., MVPA*sex, screen-time + sleep*sex) were created and tested for potential moderation effects on HRQoL outcomes. Positive regression coefficients indicate better HRQoL, and negative regression coefficients suggest poorer HRQoL relative to the reference group. Lastly, we conducted a linear trend test for the general combinations of movement behaviours and HRQoL outcomes. Data were analysed using Stata SE 14.0.

Characteristics

All sample

Age, years [M (SD)] Age range, years Female [%]

12.37 (0.28) 12-13 48.7

Area of residence [%] Metropolitan Non-Metropolitan

61.5 38.4

Language spoken at home [%] English Not-English

90.6 9.4

Maternal education [%] Postgraduate degree Graduate diploma or certificate Bachelor degree Advanced diploma or diploma Certificate Other No response

8.5 8.4 16.6 12.5 34.6 1.8 17.6

Movement behaviours [M (SD)] Average MVPA, min/day Average screen time, hr/day Average sleep, hr/night

28.1 (17.1) 3.2 (1.9) 9.5 (0.8)

HRQoL outcomes [M (SD)] PedsQL total Physical functioning total Psychosocial functioning total

80.5 (13.9) 83.4 (16.0) 78.2 (15.3)

Fig. 1. Venn diagram showing the proportions (%) of adolescents meeting the Australian 24-Hour Movement Guideline recommendations and no recommendation, LSAC, Cohort B, Wave 7, 2016 (n = 3096).

3. Results A comparison between those who were included in the current analysis (n = 3096) and those excluded (n = 285) did not show any significant difference with respect to sociodemographic variables including sex, language spoken at home, area of residence, and SEP. Descriptive characteristics of the sample are presented in Table 1. The study participants were aged 12-13 years and 48.7% were female. Participating adolescents spent an average of 190 minutes (∼3.2 hours) per day on screens for recreational pursuits; 28 minutes for MVPA per day, and 9.5 hours of sleep per night. Proportions of adolescents meeting specific and general combinations of recommendations are presented in Fig. 1. Of the sample, 18.0% did not meet any of the recommendations. Proportions of 3

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adolescents meeting any one or two recommendations were 56.8% and 22.7%, respectively, while only 2.4% met all three recommendations. Of the sample that met only one recommendation, meeting the sleep recommendation only was the most prevalent (49.7%). Of the sample that met only two recommendations, meeting the sleep and screen time recommendation was the most prevalent (17.8%). As sex did not moderate the associations between different combinations of movement behaviours and HRQoL outcomes, the estimates are presented in the total sample without any stratification by sex. Associations between meeting the specific and general combinations of movement behaviours and HRQoL outcomes are presented in Table 2. The GEE modelling, adjusted for sex, language spoken at home, area of residence, BMI and SEP, showed that meeting at least the sleep or screen time recommendation was significantly associated with overall HRQoL score (␤ = 2.70, 95% CI: 1.46 – 3.93, and ␤ = 1.60, 95% CI: 0.46 – 2.75, respectively). Similar positive associations were also observed for both the physical health and psychosocial health summary scores. However, meeting at least MVPA was not significantly associated with any of the HRQoL outcomes. Meeting the combinations of ‘screen time and sleep’ recommendations or ‘screen time and MVPA’ recommendations was significantly associated with all HRQoL outcomes. For example, average physical health summary score was significantly higher for adolescents who met both screen time and MVPA recommendations (␤ = 4.01, 95% CI: 1.45 – 6.58). Likewise, average psychosocial health summary score was significantly higher for adolescents who met both screen time and sleep recommendations (␤ = 2.51, 95% CI: 1.14 – 3.87). The evidence was marginal for the association between meeting the MVPA and sleep recommendations and overall HRQoL score; however, meeting the two recommendations was not significantly associated with physical or psychosocial summary score. The modelling also showed that meeting all the recommendations was significantly associated with each of the HRQoL outcomes. For example, meeting MVPA, screen time and sleep recommendations was significantly and positively associated with the overall HRQoL score (␤ = 4.96, 95% CI: 2.54 – 7.38). When the general combination of movement behaviours was considered, meeting more recommendations, compared to meeting no recommendation, was significantly and incrementally associated higher scores for all HRQoL outcomes (ptrend <0.001). Meeting all three recommendations was significantly associated with higher HRQoL score (␤ = 7.39, 95% CI: 4.65 – 10.13), meeting any two was significantly associated with higher HRQoL total score (␤ = 3.49, 95% CI: 1.75 – 5.23), while meeting any one was significantly associated with higher HRQoL score (␤ = 2.58, 95% CI: 0.99 – 4.17). Similar dose-response trends were also observed for the physical health and psychosocial health scores (Table 2).

cents meeting combinations of screen time with MVPA or sleep recommendations reported higher summary scores for all HRQoL outcomes compared to those who did not. Meeting the sleep recommendation appeared to be more strongly associated with HRQoL outcomes than meeting the screen time or MVPA recommendation. As the 24 -h movement behaviour paradigm has been gaining momentum globally since Canada spearheaded the development of the 24-Hour Movement Guidelines in 2016 1 , accumulating evidence suggests protective associations between meeting MVPA, screen time, and sleep recommendations and mental health indicators in different population groups 7,14,24 , but with limited evidence in Australian school-aged children. To our knowledge, there is only one study that has examined the relationships between meeting movement behaviour recommendations and HRQoL in non-representative samples of children aged 9-11 years from 12 countries, including Australia 14 .This multi-country study used a non-representative sample of 447 children selected from an Australian capital city and did not present country level results for meeting the movement behaviour recommendations. Nonetheless, the overall findings of our study align with the results based on the full sample from 12 countries14 , that children meeting the screen time + sleep duration recommendation, and meeting all three recommendations had better HRQoL outcomes than children not meeting these guidelines. Our findings also suggest that HRQoL outcomes are generally better when more recommendations are met within the Australian 24-Hour Movement Guidelines in a dose-response manner, which is in line with previous research 3,6,7 . However, PedsQL subjectively measures one’s perception of their own health and related dimensions of life quality, which may be considered as an inferior measure of children’s health status. Replicating our results using more robust methods (e.g., longitudinal, objective measures) in future studies can inform prevention efforts (i.e., early detection of populations at risk) that will improve children’s HRQoL. When meeting an individual recommendation was considered, meeting the MVPA recommendation at least was not associated with any components of HRQoL. This null association found in our study is somewhat counterintuitive, given the well-documented benefits of MVPA on varying aspects on health in this population group 24 . This may be because of the low prevalence of MVPA (9%) and the variance that existed in the HRQoL data as indicated in their SDs. Perhaps among those who met the MVPA recommendation at least, the variations in HRQoL might have been too large with such a small proportion of individuals included in this group to detect statistically significant associations. It is also possible that MVPA may be less important than screen time or sleep when it comes to HRQoL or the MVPA recommendation threshold may not be sensitive enough to detect differences in HRQoL for this age group. Similar explanation can be made for the null associations between meeting the MVPA and sleep recommendations and physical/psychosocial health summary scores shown in our study. Indeed, recent work on adolescents has shown strong and positive associations between meeting the screen time or sleep recommendation and cognitive function 25 , impulsivity 26 or suicidal ideation and attempts 27 . While the association between physical activity and HRQoL in adolescents may differ by settings (indoor vs. outdoors) where physical activity has occurred 28 , the ‘optimal dose’ of physical activity for mental health outcomes remains uncertain 29 . The consistent and linear associations between meeting the general combinations of recommendations and HRQoL shown in our study adds to the literature and contributes to building a stronger case for taking a holistic and integrated approach to health promotion efforts. Though some discrepancies were observed across the associations between meeting individual or a combination of two recommendations and HRQoL outcomes, our results assert that

4. Discussion Taking an integrated 24 -h movement behaviour paradigm approach, this study is the first to examine whether meeting individual and combinations of recommendations within the new Australian 24-Hour Movement Guidelines was associated with HRQoL, using a nationally representative sample of Australian adolescents aged 12-13 years. In this sample, only 2.4% of the adolescents met all the recommendations, while the majority (80%) met any one or two of the three recommendations. Compared to meeting no recommendation, meeting more recommendations within the Australian 24-Hour Movement Guidelines was associated with better HRQoL outcomes, including physical and psychosocial health, as indicated by the significant ptrends values. Specifically, meeting all three individual recommendations was significantly associated with better HRQoL outcomes. Adoles4

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Table 2 Associations between meeting the MVPA, screen time, and sleep recommendations and combinations of these recommendations with health related quality of life outcomes among Australia adolescents (n = 3096), LSAC, 2016. Recommendations Specific combinations

%

Total PedsQl score ␤ (95% CI)*

Physical health total score ␤ (95% CI)*

Psychosocial health total score ␤ (95% CI)*

MVPA + screen time + sleep Not met Met

97.6 2.4

1.00 (Reference) 4.96 (2.54 – 7.38)

1.00 (Reference) 5.22 (2.61 – 7.83)

1.00 (Reference) 4.76 (1.77 – 7.75)

MVPA + screen time Not met Met

97.0 3.0

1.00 (Reference) 3.50 (1.11 – 5.89)

1.00 (Reference) 4.01 (1.45 – 6.58)

1.00 (Reference) 3.11 (0.21 – 6.02)

MVPA + sleep Not met Met

93.3 6.7

1.00 (Reference) 1.99 (0.09 – 3.89)

1.00 (Reference) 2.10 (-0.17 – 4.37)

1.00 (Reference) 1.94 (-0.14 – 4.01)

Screen time + sleep Not met Met

79.8 20.2

1.00 (Reference) 2.32 (1.14 – 3.50)

1.00 (Reference) 2.11 (0.79 – 3.44)

1.00 (Reference) 2.51 (1.14 – 3.87)

At least MVPA Not met Met

97.6 9.3

1.00 (Reference) 1.09 (-0.55 – 2.73)

1.00 (Reference) 1.68 (-0.29 – 3.66)

1.00 (Reference) 0.66 (-1.16 – 2.48)

1.00 (Reference) 1.60 (0.46 – 2.75)

1.00 (Reference) 1.77 (0.50 – 3.03)

1.00 (Reference) 1.49 (0.16 – 2.81)

25.8 74.2

1.00 (Reference) 2.70 (1.46 – 3.93)

1.00 (Reference) 2.05 (0.63 – 3.47)

1.00 (Reference) 3.24 (1.87 – 4.61)

18.1 56.8 22.7 2.4

1.00 (Reference) 2.58 (0.99 – 4.17) 3.49 (1.75 – 5.23) 7.39 (4.65 – 10.13) ptrend <0.001

1.00 (Reference) 2.47 (0.66 – 4.28) 3.24 (1.25 – 5.22) 7.51 (4.52 – 10.50) ptrend <0.001

1.00 (Reference) 2.71 (0.98 – 4.45) 3.75 (1.83 – 5.66) 7.35 (4.04 – 10.66) ptrend <0.001

At least screen time Not met Met At least sleep Not met Met General combinations None One out of three Two out of three Three p-trend

74.0 26.0

*adjusted for age, sex, language spoken at home, area of residence, BMI and socio-economic position (SEP).

meeting all three recommendations is better than meeting two, meeting two is better than meeting one, and meeting one is better than meeting no recommendation for favourable HRQoL outcomes. Another noteworthy finding is that meeting the screen time recommendation alone or with other recommendations (e.g., with sleep or MVPA recommendation) were favourably associated with HRQoL. Earlier cross-sectional and longitudinal studies conducted on Australian adolescents unequivocally suggested an inverse association between screen time and HRQoL, regardless of sex, age, ethnicity, or weight status 14,28,30 . Thus, meeting the screen time recommendation may play an important role in wellbeing of Australian adolescents. In our study, screen time included both playing videogames and watching television. Given that electronic devices for screen time are constantly evolving with technological advancement, future research is suggested to incorporate a broad range of screen time behaviours such as smartphone use or the usage of social media platforms that are popular among teens (e.g., Instagram, Snapchat). A particular strength of this paper is the use of a nationally representative large sample of adolescents with standardized measures. We used three HRQoL indicators (PedsQL total, Physical and Psychosocial summary scores) in the analysis, and consistent associations of movement behaviours across the three HRQoL indicators increases confidence in our findings. The clustering of data was taken into account using GEE modelling. The analysis was adjusted for multiple potential confounders, including BMI and family socioeconomic position. However, this study has a number of limitations to acknowledge. The present study is based on a cross-sectional sample of adolescents with a narrow age range (12–13 years), which precludes generalisation of the study findings to other childhood ages. The HRQoL data used in this analysis were obtained from parental report and as such, they offer a single-point-of view, and

may not represent the same construct to health status perceived by the children. Screen time was assessed using parent-reported two items: watching TV and playing electronic games, and did not include time spent on social media, which is likely to underestimate the overall screen time use. The sleep duration was assessed using time of sleep onset and wake-up time, which may not represent uninterrupted sleep. Finally, the cross-sectional design of this study precludes making any causal inferences about the relationships. In conclusion, about a quarter (23%) of the analytical sample met any two recommendations of the Australian 24-Hour Movement Guidelines; however, only 2.4% met all the three recommendations. Meeting the movement behaviour recommendations was cross-sectionally associated with better HRQoL of adolescents with meeting more recommendations displaying better HRQoL outcomes including physical and psychosocial health. Although the association was not evident for physical activity alone, the combined effects of meeting physical activity and screen time recommendations demonstrated significant associations with the HRQoL outcomes. Strategies are needed to promote and support adherence to the guidelines, particularly the screen time and sleep recommendations given their potential importance as shown in our study. More research, especially longitudinal studies, are needed to understand the complexity of these movement behaviours, particularly by types (e.g., use smartphone/social media) and settings (e.g., indoors vs outdoors for physical activity), and their interactions with various health outcomes in adolescents. Authors’ contribution AK conceptualized and designed the study, and carried out the analysis. AK and YL drafted the manuscript. MST added important

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intellectual content. All authors critically reviewed the manuscript and approved the final manuscript as submitted.

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Ethics approval The LSAC was approved by the Australian Institute of Family Studies Ethics Committee (AIFS15-01). Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Acknowledgments This paper uses unit record data from Growing Up in Australia, the Longitudinal Study of Australian Children, which was conducted in partnership between the Department of Social Services (DSS), the Australian Institute of Family Studies (AIFS) and the Australian Bureau of Statistics (ABS). The authors thank the LSAC study participants, staff and students for their contributions. References 1. Tremblay MS, Carson V, Chaput JP et al. Canadian 24-Hour Movement Guidelines for Children and Youth: An Integration of Physical Activity, Sedentary Behaviour, and Sleep. Appl Physiol Nutr Metab 2016; 41(6 Suppl 3):S311–27. 2. Department of Health. Australian 24-Hour Movement Guidelines for Children and Young People (5-17 years) – An Integration of Physical Activity, Sedentary Behaviour and Sleep, Canberra, Department of Health, Australian Government, 2019. 3. Carson V, Tremblay MS, Chaput JP et al. Associations between sleep duration, sedentary time, physical activity, and health indicators among Canadian children and youth using compositional analyses. Appl Physiol Nutr Metab 2016; 41(6 Suppl 3):S294–S302. 4. Chaput JP, Carson V, Gray CE et al. Importance of all movement behaviors in a 24 hour period for overall health. Int J Environ Res Public Health 2014; 11(12):12575–12581. 5. Saunders TJ, Gray CE, Poitras VJ et al. Combinations of physical activity, sedentary behaviour and sleep: relationships with health indicators in school-aged children and youth. Appl Physiol Nutr Metab 2016; 41(6 Suppl 3):S283–93. 6. Roman-Vinas B, Chaput JP, Katzmarzyk PT et al. Proportion of children meeting recommendations for 24-hour movement guidelines and associations with adiposity in a 12-country study. Int J Behav Nutr Phys Act 2016; 13(1):123. 7. Lee E, Spence J, Tremblay M et al. Meeting 24-Hour Movement Guidelines for Children and Youth and associations with psychological well-being among South Korean adolescents. Ment Health Phys Act 2018; 14:66–73. 8. Cliff DP, McNeill J, Vella SA et al. Adherence to 24-Hour Movement Guidelines for the Early Years and associations with social-cognitive development among Australian preschool children. BMC Public Health 2017; 17(Suppl 5):857. 9. Hesketh KD, Downing KL, Campbell K et al. Proportion of infants meeting the Australian 24-hour Movement Guidelines for the Early Years: data from the Melbourne InFANT Program. BMC Public Health 2017; 17(Suppl 5):856. 10. Hinkley T, Timperio A, Watson A et al. Prospective associations with physiological, psychosocial and educational outcomes of meeting Australian 24-Hour Movement Guidelines for the Early Years. Int J Behav Nutr Phys Act 2020; 17(1):36.

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