Physical activity and sedentary behaviour in the Middle East and North Africa: An overview of systematic reviews and meta-analysis

To support the global strategy to reduce risk factors for obesity, we synthesized the evidence on physical activity (PA) and sedentary behaviour in the Middle East and North Africa (MENA) region. Our systematic overview included seven systematic reviews reporting 229 primary studies. The meta-analysis included 125 prevalence measures from 20 MENA countries. After 2000, 50.8% of adults (ranging from 13.2% in Sudan to 94.9% in Jordan) and 25.6% of youth (ranging from 8.3% in Egypt to 51.0% in Lebanon) were sufficiently active. Limited data on PA behaviours is available for MENA countries, with the exception of Gulf Cooperation Council countries. The meta-regression identified gender and geographical coverage among youth, and the PA measurement as predictors of PA prevalence for both adults and youth. Our analysis suggests a significant PA prevalence increase among adults over the last two decades. The inconsistency in sedentary behaviour measurement is related to the absence of standardized guidelines for its quantification and interpretation. The global epidemic of insufficient PA is prevalent in MENA. Lower PA participation among youth and specifically females should be addressed by focused lifestyle interventions. The recognition of sedentary behaviour as a public health issue in the region remains unclear. Additional data on PA behaviours is needed from low- and middle-income countries in the region.


Rationale
3 Describe the rationale for the review in the context of what is already known. 3 Objectives 4 Provide an explicit statement of questions being addressed with reference to participants, interventions, comparisons, outcomes, and study design (PICOS).

METHODS
Protocol and registration 5 Indicate if a review protocol exists, if and where it can be accessed (e.g., Web address), and, if available, provide registration information including registration number. 4 Eligibility criteria 6 Specify study characteristics (e.g., PICOS, length of follow-up) and report characteristics (e.g., years considered, language, publication status) used as criteria for eligibility, giving rationale.

5
Information sources 7 Describe all information sources (e.g., databases with dates of coverage, contact with study authors to identify additional studies) in the search and date last searched. 4 Search 8 Present full electronic search strategy for at least one database, including any limits used, such that it could be repeated. 4 Study selection 9 State the process for selecting studies (i.e., screening, eligibility, included in systematic review, and, if applicable, included in the meta-analysis).

5
Data collection process 10 Describe method of data extraction from reports (e.g., piloted forms, independently, in duplicate) and any processes for obtaining and confirming data from investigators.

5
Data items 11 List and define all variables for which data were sought (e.g., PICOS, funding sources) and any assumptions and simplifications made.

5-7
Risk of bias in individual studies 12 Describe methods used for assessing risk of bias of individual studies (including specification of whether this was done at the study or outcome level), and how this information is to be used in any data synthesis.
9 Table S7 Summary measures 13 State the principal summary measures (e.g., risk ratio, difference in means). 6-8 Synthesis of results 14 Describe the methods of handling data and combining results of studies, if done, including measures of consistency (e.g., I 2 ) for each meta-analysis.

6-8
10-13 Tables S8-11 Risk of bias within studies 19 Present data on risk of bias of each study and, if available, any outcome level assessment (see item 12). 10 Tables S8-11 Results of individual studies 20 For all outcomes considered (benefits or harms), present, for each study: (a) simple summary data for each intervention group (b) effect estimates and confidence intervals, ideally with a forest plot. Tables S8-11 Synthesis of results 21 Present results of each meta-analysis done, including confidence intervals and measures of consistency. 10-14 Tables 2-3 Risk of bias across studies 22 Present results of any assessment of risk of bias across studies (see Item 15). Table 4 Additional analysis 23 Give results of additional analyses, if done (e.g., sensitivity or subgroup analyses, meta-regression [see Item 16]). Tables 2-3

Figure 2 DISCUSSION
Summary of evidence 24 Summarize the main findings including the strength of evidence for each main outcome; consider their relevance to key groups (e.g., healthcare providers, users, and policy makers). Tables 6-7 Limitations 25 Discuss limitations at study and outcome level (e.g., risk of bias), and at review-level (e.g., incomplete retrieval of identified research, reporting bias).

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Conclusions 26 Provide a general interpretation of the results in the context of other evidence, and implications for future research. 19 FUNDING

Funding
27 Describe sources of funding for the systematic review and other support (e.g., supply of data); role of funders for the systematic review.  Specify the study design with terms such as ''overview of (systematic) reviews,'' ''umbrella review,'' ''(systematic) review of systematic reviews,'' or ''(systematic) meta-review'' in the title of the OoSRs.

Protocol and registration 5a
Indicate if a protocol exists or not. 4 5b If registered, provide the name of the registry (such as a valid Web address, PROSPERO). 4 6. Eligibility criteria and outcomes of interest 6a Specify inclusion and exclusion criteria for study design, participants, interventions, and comparators in detail.

4-5 6b
List (and define whenever it is necessary) the outcomes for which data were recorded, ideally include prioritization of main and additional outcomes.

4-5 6c
Include adverse events as (primary or secondary) outcome of interest. Define them and grade their severity (such as mild, moderate, severe, fatal; severity could also be described in the appendix), if appropriate.

4-5 6d b
Specify report characteristics (such as language restrictions, publication status, and years considered) used as criteria for eligibility for the OoSRs (see also item 7).

4-5 7. Information sources 7a
Search at least two electronic databases. 4 7b Search supplementary sources (e.g., hand searching, reference lists, related reviews and guidelines, protocol registries, conference abstracts, and other gray literature).

7c
Report the date of last search and/or dates of coverage for each database. 4 8. Search strategy c 8a Specify full electronic search strategy (algorithm) for at least one database including any limits used (e.g., language and date restrictions-see also subitems 6d and 7c) such that it could be repeated.
Published in the protocol 8b Present any additional search process (e.g., algorithm or filter for adverse events, searches in pertinent websites) specifically to identify adverse events that have been investigated.
Published in the protocol 9. Data management and selection process 9a d Describe the software that was used to manage records and data throughout the OoSRs.

4-5 9b
Define what is an SR and provide the process for selecting SRs and its relevant details (screening the title and abstract or full text by at least two reviewers, selection by multiple independent investigators and resolving disagreements by consensus).

4-5 9c
Report any attempt to handle overlapping (include one review among multiple potential candidates by choosing for example the most updated SR, the most methodologically rigorous SR or the SR with larger number of primary studies).
4-5 10. Additional search for primary studies 10 Report additional search to identify eligible primary studies (e.g., searching in more databases or update the search) and its relevant details.

Data collection process 11a
Describe the method of data extraction from included SRs (e.g., data collection form, extraction in duplicate and independently, resolving disagreements by consensus).

4-5 11b
Report any processes for obtaining, confirming, or updating data from investigators (e.g., contact with authors of included reviews, obtain data from primary studies of included reviews).

4-5
12. Data items 12 List (and define whenever is necessary) the variables for which data were recorded (e.g., PICOS items, number of included studies and participants, dose, length of follow up, results, funding sources) and any data assumptions and simplifications made.
4-5 13. Assessment of methodological quality and quality of evidence 13a State the evaluation of reporting or/and methodological quality (e.g., using PRISMA or PRISMA-harms, AMSTAR or R-AMSTAR) of the included reviews.
9 Table S7 13b e State the evaluation of quality for individual studies that are included in the SRs (inform whether tools such as Jadad or RoB of Cochrane were used by the included reviews) and for the additional primary studies.
9 Table S7 13c State the evaluation of quality of evidence (e.g., using GRADE approach). Table 1 13d Describe the methods (e.g., piloted forms, independently, in duplicate) used for the quality assessment.
9 Table S7  Table 1 14. Meta-bias(es) 14 Specify any planned assessment of meta-bias(es) (such as publication bias or selective reporting across studies, ROBIS tool). Table 1 15. Data synthesis 15a Specify clearly the method (narrative, meta-analysis, or network meta-analysis) of handling or synthesizing data and their details (e.g., state the principal summary measures that were extracted or calculated, how heterogeneity was assessed, what statistical approaches were used if a quantitative synthesis has been conducted) 7 16. Review and primary study selection 16a Provide the details of review selection (e.g., numbers of reviews screened, retrieved, and included and excluded in the overview) and the number of the additional eligible primary studies that were included, ideally with a flow diagram of the overview process.

10-14
16b Present a flow diagram that gives separately the number of studies focused on harms outcomes.

10-14
16c c List the studies (full citation) that were excluded after reading the full text and provide reasons.
Tables S8-S11 17. Review and primary study characteristics 17a c Describe characteristics of each included SR in tables (such as title or author, search date, PICOS, design and number of studies included, number and age range of participants, dose/frequency, follow up period [treatment duration], review limitations, results or conclusion) and of each additional primary study.

10-14
Tables S8-S11 17b For each included SR report language and publication status restrictions that have been used.

10-12
Tables S3-S4 18. Overlapping 18 Present or/and discuss about overlapping of studies within SRs (at least one of the following): • Present measures of overlap (such as CCA).
• Provide citation matrix. c • Give the number of index publications or/and discuss about overlapping. f Tables S5-S6 19. Present assessment of methodological quality and quality of evidence 19 Present results in text or/and tables c of any quality assessment (see also subitems 13a-c): • Reporting or/and methodological quality of the included SRs. • Inform for the quality of the individual studies that were included in the SRs (report results for sequence generation, allocation concealment, blinding, withdrawals, bias etc.) and for the additional included primary studies. • Quality of evidence.
Tables S8-S11 20. Present meta-bias(es) 20 Present results of any assessment of meta-bias(es) (such as publication bias or selective reporting across studies, ROBIS assessment). Table 1 21. Synthesis of results 21a Summarize and present the main findings of the overview for benefits and harms. If a quantitative synthesis has been conducted, present each summary measure with a confidence interval, prediction interval, or a credible interval and measures of heterogeneity or inconsistency. Tables S8-S11  Tables 2-3 21b

10-14
Give results of any additional analyses, if done (such as sensitivity, subgroup analyses, or meta-regression). Tables 4  Table S12  21c Report results for adverse events separately for each intervention.
N/A Discussion 22. Summary of evidence 22 Provide a concise summary of the main findings with the strengths and shortcomings of evidence for each main outcome. Tables 5-7 23. Limitations 23a Discuss limitations of either the overview or included studies (or both) (e.g., different eligibility criteria, limitations of searching reviews, language restrictions, publication and selection bias).

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23b Report possible limitations of the included reviews related to harms (issues of missing data and information, definitions of harms, rare adverse effects). 18   Global youth and adult general populations "In most studies of represented countries, less than 50% of the population was active." "Males were more active than females in adult and youth populations." "Countries with the highest prevalence of PA in adults are: Switzerland, Sweden and Denmark and those with the lowest were Thailand, Saudi Arabia, Brazil and Iran." "Countries with the highest prevalence of PA in youth are: Australia, China and Ireland and those with the lowest were Belgium, France and Tonga." "The highest prevalence of physical inactivity was among Saudi Arabian women and the ones with the lowest prevalence were men from the United States." "The prevalence of meeting PA recommendations was reported more frequently than prevalence of physical inactivity or 'no leisuretime physical activity'. " "The prominent used surveys are BRFSS, IPAQ, and Active Australia." "Discrepancy in the methods of data collection and classification of 'sufficient physical activity' across studies. " "The use of different surveys, all reporting time in PA, may not be comparable when it comes to reporting the prevalence of the sample meeting the minimum levels of PA." "The IPAQ overestimate the prevalence of PA compared with BRFSS." "Different studies used different age ranges, causing difficulties when comparing activity levels across studies among both youth and adults." "Difficulty and variability to capture transportation, occupation and active living behaviors such as chores and gardening (important for accumulating health-enhancing physical activity) from instrument to instrument." "The use of the same instrument across populations will not capture the variability in the type of activities between populations and could not cover all aspects of physical activities. As a consequence, differences in PA levels across populations may be masked." "The compilation of existing international data available on the prevalence of meeting public health PA recommendations in adults and youth will serve as a resource to epidemiologists and interventionists alike as it provides a benchmark for improvement and intercountry comparisons, as well as a basis for further examinations." "Three multinational examinations of PA behavior that examine at least 23 countries each, which allows for some more direct comparisons across countries." "Need to discuss on the most appropriate and feasible methods to use in the measurement of PA in epidemiologic studies have not been recently instituted, as they have been ongoing for more than 20 years." "No health-based criteria for steps per day have been developed in adults or youth. It is not known that the accumulation of >13 0000 steps/ day for boys is sufficient to result in health benefits." "Surveillance studies need to strive for an international standardization and recommendation-based metric to allow for greater comparisons between countries and regions and to determine the prevalence of meeting recommendations that are based on improved health such as 30 min moderate PA on 5 days per week or 20 min of vigorous PA on 3 days per week." "Need for more PA data globally, there is a pressing need to understand changes in PA levels in several regions, in particular those countries undergoing economic and social transition." "Greater collaboration among researchers in the standardization of surveillance methods to ensure that quality physical activity and inactivity surveillance is being conducted on a global level." "Designing studies that are comprehensive in the measurement of activity and sedentary behaviors Global need to increase PA.
including transportation, occupation, recreation and other utilitarian tasks." "Models of 'best practice' in the surveillance of PA should be identified and utilized in a collaborative fashion across countries." Mabry, 2010 4 PA Sedentary behaviour (if reported in the included study on physical activity) GCC Adult general population "Low prevalence of participation in levels of PA sufficient for health benefits among men and women in the GCC." "The best available evidence indicates that the prevalence of sufficient PA participation ranged from 39.0% to 42.1% for men and 26.3% to 28.4% for women in the GCC." "The levels of PA in the GCC are lower than those found in national studies conducted in 51 developing countries, which also utilized the IPAQ instrument 11 ." "The prevalence rates for non-occupational PA in the GCC States are lower than those found in developed countries." "Four studies have used the GPAQ or IPAQ instruments classified PA on duration only (150 min per week) and not in combination with frequency (at least five sessions a week), an important part of the recommended amount of "Due to the variations in methodological quality, it is difficult to compare prevalence rates and draw conclusions on the differences in prevalence of sufficient PA between countries of the GCC." "While pedometers and accelerometers can provide objective data on 'movement', they do not identify the particular PA 'behaviors' that can be captured using self-report instruments; also, because of cost and study logistics, these instruments (while they are beginning to be used in some developed countries) at this stage tend to be used for evaluating outcomes of smallscale intervention trials, more so than for population surveillance." "Good-quality population data on PA in the region is scarce." "English language restriction." "No gray literature and Arabiclanguage publications search." "Only the national population was included in the sample when the GCC population is predominantly non-nationals." "The results of three studies in this review utilized the GPAQ, which is a WHO instrument, and would have details on PA behaviour in three domains (occupation, transport and leisure), providing detailed evidence to inform related policy and program development." "The IPAQ and GPAQ selfreport instruments are beginning to deliver internationally comparative data, which recent peerreviewed publications suggest is of reasonable quality. There is some recent evidence on their reliability and repeatability, and they can provide a costeffective method for population monitoring of PA levels." "Further research on the determinants of physical inactivity in the region is required, in order to have a better understanding of what might be done to increase PA participation." "Need to examine potential seasonal variations in PA. This is of potential interest, given the particular climates of GCC countries." "Future studies in the GCC neighbors, carrying out surveys in different seasons, would help to identify potential climatic determinants of PA participation." "The need for countries to obtain accurate population-level information on prevalence and trends in PA participation, by using internationally recognized standard instruments." "More research on sedentary behaviour, in addition to developing a better understanding of PA in this region." "Accurate information on the prevalence of PA in the GCC region is also necessary in order to establish the nature of the links between physical inactivity and obesityevidence that is needed in order to advocate for implementation of the most-relevant preventive initiatives." GPAQ should be incorporated into the surveillance system for obesity and related chronic disease risk factors in all six GCC countries.
Health promotion strategies should aim to increase PA among both men and women as a priority public health issue.
The use of a standard, valid and reliable measure for PA is crucial, not only for population surveillance but for program development, evaluation and inter-country comparison.
Standardized study protocols to allow crosscountry comparisons.
PA needed for health benefits." "The GCC studies measured total PA while the Australian and the USA studies report on nonoccupational PA, thus making comparisons difficult." "The studies in this review identified two primary correlates of PA -gender and age." "Based on the two highest quality studies in this review, the proportion of physically active men was 13-14% points higher than women." "The observed gender differences in PA participation are highly likely contributing to the higher prevalence of obesity in women compared with men in the GCC States." 'Correlation with age is less clear." "The variation in the methodological quality of the studies: • Non-population-based sampling, "Skilled workers and professionals were more inactive than unskilled workers in the region. Similarly, higher education was a significant factor." "Females were more inactive in the South Asian region when compared to males, a finding which is seen in most other regions and even in developed countries. Gender is an important factor to determining PA levels of a population." "Cultural expectations may restrict the participation of women in certain forms of PA in some religious and ethnic groups in the region. Several studies reported higher physical inactivity among South Asian women." "The traditional role of South Asian women in taking care of household work and supporting extended family members may limit the time available for them to engage in PA, in particularly leisure time physical activities." "Most of studies were limited to regional populations." "As South Asian countries have considerably diverse ethnic groups, the regional findings may not be generalized to whole country or for the entire South Asian region." "No uniformity on PA assessment tools." "Several studies have used IPAQ, differences in the formats used limit comparability." "A marked heterogeneity on the definition of physical inactivity/sedentary life style and physical activity levels and in the used tools. Hence, comparisons between studies were undertaken with caution." "Only limited number of articles reported data on the subdomains of physical activity (work, transport, and leisure)." "The comprehensive and easily replicable search strategy applied to three major medical databases." "Systematic selection of the studies through the application of well-defined inclusion/exclusion criteria. The GPAQ is known to be reliable for surveys in developing countries, adaptable to incorporate cultural differences." "The GPAQ used in the WHO STEPwise surveys and in the included studies give uniformity to the gathered data and allow meaningful comparisons." "It is important for future researchers to adhere to a uniform way to evaluate PA in order to derive intraand inter-regional comparable data and observe secular trends in PA."  Notes: From the total number of 7 studies 11-17 with physical inactivity data (reported alone or with PA data), only 2 studies 11,17 , with physical inactivity data not overlapping with an included PA data, were included. A total of eight data points on physical inactivity, from these 2 studies of Guthold, 2008 andKhuwaja, 2010, in three different MENA countries were added to PA activity data and used for the meta-analyses among ADULTS.
No converted data from physical inactivity to PA among YOUTH was included. The 2 publications have reported nil and mild/poor PA levels (considered as physical inactivity) among youth was Wasfi, 2007 andMehairi, 2013 14,15 . These later reported also acceptable/moderate and high/good physical activity levels among youth that were already included in the PA     Notes: All non-reported data was searched and extracted from the original study. Any additional information found relevant in the original study was added to the reported data for the purpose of completeness.
If not reported, the prevalence of the outcome among the total study population (males and/or females) was calculated using row and/or calculated data available in the original study. The calculated prevalence measure was reported and marked using two stars (**).
If not reported, the total sample size for each gender strata was calculated based on the percentage of males or females in the sample.
If not reported, the number for cases in each gender strata was calculated based on the reported prevalence and the total sample size in the strata.
If not reported, the total number for cases in the entire sample was calculated by the addition of the number of cases in each reported stratum. If any discordance between the reported data in the SR and data available in the original study, this later was retained.  Notes: All non-reported data was searched and extracted from the original study. Any additional information found relevant in the original study was added to the reported data for the purpose of completeness. If not reported, the prevalence of the outcome among the total study population (males and/or females) was calculated using row and/or calculated data available in the original study. The calculated prevalence measure was reported and marked using two stars (**). If not reported, the total sample size for each gender strata was calculated based on the percentage of males or females in the sample. If not reported, the number for cases in each gender strata was calculated based on the reported prevalence and the total sample size in the strata. If not reported, the total number for cases in the entire sample was calculated by the addition of the number of cases in each reported stratum. If any discordance between the reported data in the SR and data available in the original study, this later was retained.  Notes: All non-reported data was searched and extracted from the original study. Any additional information found relevant in the original study was added to the reported data for the purpose of completeness.
If not reported, the prevalence of the outcome among the total study population (males and/or females) was calculated using row or calculated data available in the original study. The calculated prevalence measure was reported and marked using two stars (**).
If not reported, the total sample size for each gender strata was calculated based on the percentage of males or females in the sample.
If not reported, the number for cases in each gender strata was calculated based on the reported prevalence and the total sample size in the strata.
If not reported, the total number for cases in the entire sample was calculated by the addition of the number of cases in each reported stratum.
For not reported mean time measures on the total study population, the overall males and females weighted mean time was calculated using mean time and the proportion of males and females in the sample, respectively. If any discordance between the reported data in the SR and data available in the original study, this later was retained.
Extra studies are studies included in a SR and reporting one or more PA related outcome on MENA countries that were not reported in the SR (outcome or country not included in the SR). Extra data from these studies was extracted and used for the qualitative and quantitative synthesis. Converted data from physical inactivity to PA was used only for the quantitative synthesis and was not reported in the above tables.