Clustering of diet, physical activity and sedentary behaviour and related physical and mental health outcomes: a systematic review

(2023) 23:1572 Alosaimi et al. BMC Public Health https://doi.org/10.1186/s12889-023-16372-6 BMC Public Health Open Access RESEARCH Clustering of diet, physical activity and sedentary behaviour and related physical and mental health outcomes: a systematic review Noura Alosaimi1*, Lauren B. Sherar1,2, Paula Griffiths1 and Natalie Pearson1,2 Abstract Background Physical activity (PA), sedentary behaviour (SB) and diet play an important role in the physical and mental health of young people. Understanding how these behaviours cluster, and the impact of clusters on health is important for the development of public health interventions. This review examines the prevalence of clusters of PA, sedentary time, and dietary behaviours, and how clusters relate to physical and mental health indicators among children, adolescents and young adults. Methods Electronic (PubMed, Web of Science and Scopus) and manual searches were conducted for articles that were (i) observational studies including children, adolescents and/or young adults aged 5–24 years, (ii) examined the ’patterning’, ‘clustering’, or ‘co-existence’ of each of PA, dietary behaviour and SB, and (iii) published in English up to and including July 2022. In addition to information on clustering, data on physical and mental health outcomes were extracted where reported. Included studies were assessed using the Cochrane risk of bias for observational studies. A narrative synthesis was conducted due to high heterogeneity. This review was registered with PROSPERO (CRD42021230976). Results Forty-nine cross-sectional studies and four prospective cohort studies from eighteen countries reporting data from 778,415 individual participants were included. A broad range of clusters (n = 172) were found (healthy, unhealthy, and mixed). Mixed clusters were common (n = 98), and clusters of high diet quality, low PA and high SB were more prevalent in girls, while mixed clusters of high PA, high SB and low diet quality were more prevalent in boys. Unhealthy clusters comprising low moderate to vigorous PA, low consumption of fruits and vegetables, and high screen time were prevalent, particularly in those from lower socioeconomic status families. Compared to those with healthy behavioural clusters, those with unhealthy and mixed clusters had a higher adiposity, higher risk of cardiovascular disease, poorer mental health scores, and lower cardiorespiratory fitness. Conclusions PA, SB and diet cluster in healthy, unhealthy and mixed patterns in young people that differ across sociodemographic characteristics. Unhealthy clusters are associated with poorer health outcomes. Intervention strategies targeting un-clustering multiple unhealthy behaviours should be developed and evaluated for their impact on health outcomes. *Correspondence: Noura Alosaimi Full list of author information is available at the end of the article © The Author(s) 2023. 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. Alosaimi et al. BMC Public Health (2023) 23:1572 Page 2 of 44 Keywords Clustering, Physical activity, Sedentary behaviours, Diet, Obesity, Depression, Young people Background Overweight and obesity, and their associated comorbidities, are increasing globally [1]. In the UK, the prevalence of obesity in adults has tripled over the last 20 years and continues to rise albeit at slower rates [2]. A similar pattern is seen in children (aged 10–11 years) in the UK, with obesity levels increasing from 21.0% in 2019–20 to 25.5% in 2020–21 [3]. Living with overweight or obesity is associated with long term health conditions including cardiovascular disease, diabetes, depression and premature mortality [4]. Furthermore, obesity is challenging to manage, and intervention strategies targeted at younger age groups should be a priority [5]. Modifiable health behaviours, including physical inactivity, sedentary behaviours (SB), and unhealthy dietary habits, have all been linked independently to increased risk of obesity in children, adolescents, and young adults [6–8]. Physical activity (PA), SBs, and dietary habits are developed early in life and have been shown to track through childhood [9–15] into adulthood [16]. Evidence suggests that poor lifestyle behaviours are likely to co-occur or ‘cluster’ within groups of individuals [14, 15, 17, 18], and that clustering of unhealthy behaviours increases significantly with age [19]. A recent study found that the prevalence of clustering of unhealthy behaviours increased from 29.0% in children aged 2–5 years to 73.9% among older adolescents aged 16–19 years [19]. Moreover, the most common health behaviour combinations at both time points were high screen time and unhealthy diet (the prevalence increased from 14.4% at ages 2–5 years to 45.3% for ages 16–19 years) [19]. It has been found that the clustering of unhealthy behaviours has synergistic effects on health outcomes, meaning that a combination of health behaviours is more harmful to health than the sum of the effects of each individual health behaviour; this, in turn, will increase the risk of chronic illnesses and premature mortality [20]. For example, clustering of multiple unhealthy behaviours (i.e., SB, lack of PA, and poor dietary habits) has been shown to be associated with poor mental and physical health outcomes such as increased likelihood of developing depression [21–23], anxiety, psychological distress, and weight gain [24]. Furthermore, Nelson et al. found that 51% of boys and 43% of girls had three or more behavioural risk factors that were associated with obesity, including low PA, high screen time, low consumption of fruits and vegetables (FV), and high consumption of soft drinks and snacks [25]. Conversely, clustering of beneficial health-related behaviours (being physically active, a non-smoker, moderate drinker and consuming five or more servings of FV a day) has been shown to be associated with improved mental health, improved self-reported physical (...truncated)