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GUIDELINE
Year : 2021  |  Volume : 16  |  Issue : 3  |  Page : 225-238
Joint consensus statement of the Saudi Public Health Authority on the recommended amount of physical activity, sedentary behavior, and sleep duration for healthy Saudis: Background, methodology, and discussion


1 The University Sleep Disorders Center, College of Medicine, King Saud University; National Plan for Science and Technology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Lifestyle and Health Research Center, Health Sciences Research Center, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia
3 Department of Exercise Physiology, College of Sport Sciences and Physical Activity, King Saud University, Riyadh, Saudi Arabia
4 Department of Community Health Sciences, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
5 Comprehensive Specialized Clinics for the Security Forces in Jazan, General Administration for Medical Services, Ministry of Interior, Riyadh, Saudi Arabia
6 Department of Physical Education, College of Sport Sciences and Physical Activity, King Saud University, Riyadh, Saudi Arabia
7 Saudi Public Health Authority, Riyadh, Saudi Arabia

Date of Submission20-Jan-2021
Date of Acceptance19-Mar-2021
Date of Web Publication20-Jul-2021

Correspondence Address:
Prof. Ahmed S BaHammam
University Sleep Disorders Center, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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DOI: 10.4103/atm.atm_32_21

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   Abstract 


The Saudi Public Health Authority recently prepared a Consensus Statement regarding how much time a person should spend engaged in physical activity, sedentary behavior, and sleep to promote optimal health across all age groups. This paper describes the background literature, methodology, and modified RAND Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT approach that guided the development process. A Leadership Group and Consensus Panels were formed, and credible existing guidelines were identified. The Panel identified clear criteria to choose the best practice guidelines for the set objectives after evaluation, based on GRADE table evidence, findings table summaries, and draft recommendations. Updating of the selected practice guidelines was performed, and the Consensus Panels separately reviewed the evidence for each behavior and decided to adopt or adapt the selected practice guideline recommendations or create de novo recommendations. Data related to cultural factors that may affect the studied behaviors, such as prayer times, midday napping or “Qailulah,” and the holy month of Ramadan, were also reviewed. Two rounds of voting were conducted to reach a consensus for each behavior.


Keywords: Adults, Grading of Recommendations Assessment, Development and Evaluation-ADOLOPMENT, infants, preschoolers, public health recommendations, toddlers


How to cite this article:
BaHammam AS, Alghannam AF, Aljaloud KS, Aljuraiban GS, AlMarzooqi MA, Dobia AM, Alothman SA, Aljuhani O, Alfawaz RA. Joint consensus statement of the Saudi Public Health Authority on the recommended amount of physical activity, sedentary behavior, and sleep duration for healthy Saudis: Background, methodology, and discussion. Ann Thorac Med 2021;16:225-38

How to cite this URL:
BaHammam AS, Alghannam AF, Aljaloud KS, Aljuraiban GS, AlMarzooqi MA, Dobia AM, Alothman SA, Aljuhani O, Alfawaz RA. Joint consensus statement of the Saudi Public Health Authority on the recommended amount of physical activity, sedentary behavior, and sleep duration for healthy Saudis: Background, methodology, and discussion. Ann Thorac Med [serial online] 2021 [cited 2021 Sep 24];16:225-38. Available from: https://www.thoracicmedicine.org/text.asp?2021/16/3/225/321893




International studies have consistently shown that daytime movement behaviors – involving not only physical activity, but also sedentary behavior and sleep duration – are major health indicators.[1],[2],[3] These behaviors are strongly interrelated; however, several guidelines regarding factors associated with movement focus on each activity separately, which, when taken in isolation, may be insufficient for the purpose of developing and implementing recommendations needed to achieve optimal physical and mental health. A consolidated approach considers overall activity across 24 h and accounts for periods of physical activity, sedentariness, and sleep.

Current evidence supports the need for regular and adequate physical activity and sleep duration as a means to longer and healthier lives and disease prevention.[1],[2],[4] Physical activity may decrease cardiovascular risks, improve lipid profile, control Type 2 diabetes, prevent the incidence of certain types of cancer, increase bone density, improve psychological health, cognitive function, and well-being, and reduce mortality.[3] In addition, regular physical activity may decrease inflammatory responses throughout the body. It has been established that inflammation can increase the risk of heart diseases – it accelerates aging and depression and can also lead to major neurocognitive disorders.[5] Physical activity can also improve brain health and neuroplasticity and enhance cognitive function.[6] Moreover, it may improve learning and cognitive function in children as well.[7]

On the other hand, sedentary behavior is a significant factor associated with several noncommunicable diseases and total mortality.[3],[5] It is estimated that sedentary behavior is globally responsible for 9% of premature mortality, or more than 5.3 million deaths annually.[8] According to the WHO's global statistics, one in four adults is not active enough, and more than 80% of the world's adolescent population is not sufficiently physically active.[3] Several studies have linked sedentary behavior to cardiometabolic biomarkers such as increased waist circumference, triacylglycerol and HbA1c levels, and systolic blood pressure and decreased high-density lipoprotein cholesterol levels; it is also associated with increased risk of metabolic syndrome and diabetes.[9],[10],[11] A meta-analysis has also reported evidence of a significant positive association between sedentary behavior and the risk of type 2 diabetes and all-cause mortality.[12]

Insufficient sleep or irregular sleep patterns have also been linked to increased morbidity and mortality.[13],[14],[15] For instance, sleep deprivation or short sleep duration has been found to be associated with greater risks of developing heart diseases,[16] stroke,[17] type 2 diabetes,[18] hyperlipidemia,[19] high blood pressure,[20] cancer,[21] systemic inflammation,[22] and obesity.[23],[24] Not getting the required amount of sleep can lead to dangerous health outcomes that may affect almost all bodily organs and systems, such as cognitive impairment, poor academic performance, hypertension, and insulin resistance, in addition to other health problems.[25] The body's immune system is negatively affected by inadequate sleep, in addition to an increase in systemic inflammation, inflammatory marker levels, and the occurrence of hormonal disturbances. Evidence suggests that insufficient sleep alters gene expression in the human blood cells and decreases circadian rhythm amplitude in gene expression. Furthermore, shorter sleep duration is associated with increased mortality, increased risk of motor vehicle accidents and industrial accidents, and deteriorating job performance.

According to national population-based data, Saudi Arabia has one of the lowest physical activity rates and the world's highest sedentary behavior rate.[26] In addition, local-level studies have demonstrated that Saudi Arabia has one of the lowest levels of nocturnal sleep duration.[27],[28],[29],[30],[31]

A few countries have developed specific 24-h movement guidelines regarding regular physical activity, screen time, and sleep for subjects in their early years, children and adolescents, adults, and older adults. However, there are no practice guidelines for the regulation of physical activity, sedentary behavior, and sleep over 24 h for all age groups in Saudi Arabia. Furthermore, Saudi Arabia is culturally different from Western countries, and national practice guidelines need to account for cultural factors, such as prayer times, the Ramadan month, and the habit of siesta (midday napping or “Qailulah”), that may affect behavior. This calls for the urgent need to establish specific Saudi 24-h Movement Practice Guidelines. Such guidelines will help healthcare providers prescribe the optimal amount of daily physical activity and sleep to promote a healthier lifestyle. In addition, public policy initiatives addressing worker fatigue and transportation safety are similarly hampered by the absence of evidence-based national practice guidelines that address healthy habitual physical activity and sleep duration. Local health societies and organizations have repeatedly stressed the importance of increasing physical activity, reducing sedentary behavior, and getting adequate sleep for good health; however, their message is undermined by the lack of national guidelines for physical activity, sedentary behavior, and healthy sleep duration. Therefore, health practitioners, public policymakers, and public health activities would benefit from these evidence-based guidelines and recommendations addressing the daily levels of physical activity, sedentary behavior, and sleep needed to support optimal health and functioning.

This paper describes the background literature, methodology, and modified RAND Appropriateness Method (RAM) and Grading of Recommendations Assessment, Development, and Evaluation (GRADE)-ADOLOPMENT approach that guided the development process. The recommendations are published in a concomitant paper in this issue of the Journal.[32]


   Methods Top


Working committees and their roles

In February 2020, the Saudi Public Health Authority constituted a National Committee to develop the 24-h Movement Practice Guidelines for Saudi Arabia by integrating the relevant information on physical activity, sedentary behavior, and sleep duration. The committee comprised seven-panel members from various specialties (physical activity specialists, exercise physiologists, epidemiologists, nutrition and diet experts, sleep medicine specialists, and guideline-development methodologists) and was supported by three subcommittees (Core Panels) for each addressed topic.

The development process for each practice guideline involved two interdependent groups: a Core Panel and an Expert Panel. The Core Panel guided the Expert Panel through the voting process (in accordance with the RAM) and provided formulated recommendations to it. The Expert Panel used the data and evidence provided by the Core Panel to come to a consensus.

The Saudi Public Health Authority was responsible for communications, logistics, and final approval of guideline topics. The National Committee was responsible for supervising each guideline's development, communicating with the guideline panels, conducting the literature searches, updating the systematic review-related information, and chairing the guideline panel meetings.

The guideline core panel members were involved in:

  • Prioritization of questions related to the guideline topics
  • Formulation of recommendations for physical activity, sedentary behavior, and sleep duration for healthy children, adolescents, adults, and older adults during panel meetings and drafting a practice guideline manuscript for peer-reviewed publication. Summaries of the guideline development process were narrated through online presentations
  • Formulation of recommendations regarding unique cultural and religious factors that may affect nighttime sleep duration, such as prayer times, daytime napping, and the Ramadan month.


Research questions defined by the Core Panel committees for physical activity, sedentary behavior, and sleep duration with respect to their duties

  • Question 1: What is the dose (i.e., duration, frequency, intensity, and type) of physical activity, as measured using both objective and subjective methods, needed for optimal health?
  • Question 2: What is the dose (i.e., duration, patterns [frequency, interruptions], and type) of sedentary behavior, as measured using both objective and subjective methods, needed for optimal health?
  • Question 3: What is the nocturnal sleep duration needed for optimal health?


The Grading of Recommendations Assessment, Development, and Evaluation-ADOLOPMENT method

One way of developing guidelines is to use the work of previously established societies. This “GRADE-ADOLOPMENT” methodology detailed by Schünemann et al. in 2017[33] combines the advantages of adoption, adaptation, and de novo development of recommendations based on the GRADE evidence to decision frameworks.

Due to time restraints, the panel agreed to limit the selected practice guidelines to the best available guidelines that addressed the research questions. The screened guidelines were evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument, and the practice guidelines that received the highest quality scores based on this instrument were chosen for the adaptation process. A guideline methodologist Ali M. Dobia (AMD) was also invited to be part of the guideline development team.

Moreover, each of the selected practice guidelines was updated by reviewing published systematic reviews and conducting systematic reviews of randomized controlled trials (RCTs) published after the adopted practice guidelines.

A systematic search of RCTs and non-RCTs and observational studies was performed for cultural factors that may influence nocturnal sleep duration (i.e., prayer times, naps, and the Ramadan month) as well.

[Figure 1] presents the timeline and sequence of steps involved in the development of the Saudi 24-h Movement Guidelines.
Figure 1: Timeline and sequence of steps involved in the development of the Saudi 24-h Movement Guidelines for Physical Activity, Sedentary Behavior, and Sleep Duration

Click here to view


Searching for guidelines and other relevant evidence

Core Panel members performed a systematic search using Medline/PubMed and Scopus to find all pertinent articles and practice guidelines published from January 2015 to April 2020 for presentation to the panel members. The keywords for each topic used in the search strategy were as follows:

  • Physical activity and sedentary behavior: “physical activity;” “physical activity guidelines;” “movement guidelines;” “chronic diseases;” “review;” “systematic review;” “meta-analysis;” “randomized controlled trial;” “cardiovascular disease;” “cancer;” “hypertension;” 'diabetes;” “cognitive function;” “academic performance;” “metabolic syndrome;” “obesity;” “mortality;” “mental health;” “psychiatric health;” “immunity;” “inflammation”
  • Sedentary behavior: “sedentary;” “guidelines;” “;systematic review;” “meta-analysis” “obesity;” “motor development;” “psychological health;” “cognitive development;” “fitness;” “health;” “depression;” “cardiovascular*;” “cancer;” “pain;” 'diabetes;” “cognitive function;” “academic performance;” “metabolic*;” “mortality;” “mental health”
  • Sleep duration: “sleep duration;” “guidelines;” “meta-analysis;” “randomized controlled trial;” “cardiovascular disease;” “cancer;” “hypertension;” “diabetes;” “cognitive function;” “memory;” “academic performance;” “metabolic syndrome;” “obesity;” “pain;” “mortality;” “metal health;” “psychiatric health;” “immunity;” “inflammation;” “job performance.”


Eligibility criteria for the adopted practice guidelines

The Core Panels for each topic decided to include structured practice guidelines that were based on systematic reviews of the related research evidence. The following criteria were used to select the adopted practice guidelines: (1) published in the past 5 years; (2) addressed the research questions (covered all Population, Intervention, Comparator, and Outcome [PICO] elements); (3) followed the GRADE process; and (4) included existing and accessible GRADE tables and summaries of findings.

Information about the evidence-based methods used in the practice guidelines was obtained from the Methods sections and search strategies reported in the guidelines and grading strength of evidence.

The selected practice guidelines

For physical activity, the Core Panels adopted the UK Chief Medical Officers' Physical Activity Guidelines and supplemented them with Canadian and US Practice Guidelines to cover all age groups when needed, as these guidelines met the criteria set by the panel.[34],[35],[36],[37] The panel used eight health indicators – adiposity, motor development, psychosocial health, cognitive development, fitness, bone and skeletal health, cardiometabolic health, and risks/harm.[3],[5],[6] The Saudi physical activity guidelines have been developed based on national evidence from the literature, including systematic review, RCTs, as well as recently available reports from the General Authority of Statistics, and were reviewed by the physical activity Consensus Panel. The selected guidelines and evidence were appraised by three independent reviewers based on the AGREE II instrument. Thereafter, the scores for each guideline were aggregated, and the highest scoring guideline in each age group was selected for guideline adaptation. In addition, the culture of the Saudi population, related to religion and lifestyle, was considered while adapting the selected physical activity recommendations.

For sedentary behavior, the Core Panels adopted the Australian 24-h Movement Guidelines for the Early Years (birth to 5 years), the Australian 24-h Movement Guidelines for Children (5–12 years) and Young People (13–17 years), and the UK Chief Medical Officers' Physical Activity Guidelines,[34],[38],[39] as these guidelines met the criteria set by the Panel. The Panel used the following health indicators: adiposity, motor development, psychosocial health, cognitive development and performance, fitness, bone and skeletal health, cardiometabolic health, cancer, pain, mortality, and risks/harm.

For sleep duration, the draft “Recommended amount of sleep for healthy adult and pediatric populations: A joint consensus statement of the American Academy of Sleep Medicine (AASM) and Sleep Research Society (SRS) and National Sleep Foundations' (NSF) “sleep time duration recommendations” best fits the criteria approved by the Sleep Duration Core Panel.[13],[40],[41] These were appraised based on the evidence in the GRADE tables, summaries of the tables of findings, and draft recommendations from the AASM/SRS and NSF Draft Guidelines.[33]

The Panel used the following health categories and subcategories adopted by the AASM in rounds 1 and 2 voting. These categories were general health, cardiovascular health (cardiovascular disease and hypertension), metabolic health, diabetes, obesity, mental health, mood, psychiatric health, immunologic health, immune function, inflammation, human performance, cognitive performance, driving performance, job performance, cancer (female cancers [breast, ovarian], general cancers, and colorectal cancer), pain, and mortality.[13]

Two guidelines were adopted because the AASM/SRS guidelines did not cover all the targeted age groups. Therefore, to address sleep duration in all age groups (including neonates and older adults over 65 years of age), the NSF guidelines were also used. The incorporation of these two guidelines ensured trustworthiness in the adoption and adaptation process.

The Grading of Recommendations Assessment, Development, and evaluation recommendation system

The following criteria were used to grade the evidence:

  • Category A: RCTs (with narrow confidence intervals)
  • Category B: Low-quality RCTs
  • Category C: Nonrandomized trials and observational studies
  • Category D: The Saudi Public Health Authority Expert Panel consensus judgment. This category was only used when insufficient evidence was available in the literature and the provision of a recommendation was considered important.


Although the level of recommendation confidence is a continuum, the GRADE system describes two levels of evidence: “strong” and “conditional.” When feasible, we indicated the level of evidence.

A “strong” recommendation was defined as a recommendation when the panel was confident that the desirable effects of adherence to the recommendation outweighed the undesirable effects. A “conditional” recommendation was defined as a recommendation when the panel inferred that the desirable effects of adherence to the recommendation probably outweighed the undesirable effects, but the panel was not confident about the trade-offs.

A conditional recommendation was indicated between brackets after the recommendation.

Preparing the draft-adopted guidelines

A qualitative exploratory descriptive study was conducted to integrate the cultural factors and local customs based on the available data. In addition, the chosen guidelines were not the only sources used. Specifically, new updates from published systematic reviews and RCTs published after the publication of the adopted practice guidelines were used to develop a thorough guideline that accounted for new updates and cultural factors [Figure 2]. The search was restricted to studies conducted in human adults and published in English. Systematic reviews of longitudinal studies and RCTs published after the publication of the adopted practice guidelines were performed [A summary of the studies is available in Supplement I].
Figure 2: Integrating the recommendations extracted from the literature review, selected practice guidelines, recommendations from randomized controlled trials and systematic reviews published after the selected practice guidelines, and Expert Panel judgments

Click here to view


Similar work was carried out for all studies that assessed the interaction between sleep and Ramadan, sleep and prayer times, and sleep duration and daytime naps [Supplement II].

The Core Panel members for each topic developed expository drafts of the proposed guidelines in each field (physical activity, sedentary behavior, and sleep duration). Thereafter, the organizing committee clarified all ambiguous and incomprehensible phrases, removed redundant sentences, and ensured the overall coherence of all practice guidelines. The panel also took into consideration the traditions and culture of Saudi Arabia.

Expert Panel selection

The main selection criteria considered for selecting the expert panelists were acknowledged leadership in the panel member's specialty, absence of conflicts of interest, regional diversity (when feasible), and diversity of practice settings (academic vs. clinical practice). The experts were not chosen just because they were easily accessible or friendly.[42] The Expert Panels permitted sufficient diversity while ensuring that all members had a chance to participate.[42] This, of course, depended on the availability of specialists in each of the three addressed specialties (names of the experts are included in the Acknowledgment Section). For the physical activity Expert Panel, the panelists included specialists in exercise science, physical therapy, physical education, and exercise physiology, clinical specialists from the leading institutions in Saudi Arabia, and a research methodology expert. For the sedentary behavior Expert Panel, the panelists included specialists in sedentary behavior, exercise science, physical therapy, physical education, and exercise physiology, clinical specialists from leading institutions in Saudi Arabia, and a research methodology expert. For the sleep duration Expert Panel, the panelists included experts in sleep medicine and related specialties (family medicine, psychiatry, child development, and behavioral sleep medicine), clinical specialists from the leading institutions in Saudi Arabia and the Saudi Sleep Medicine Group, and a research methodology expert.

The modified RAND appropriateness method

Consensus on the formulated recommendation was reached using the RAM, wherein experts used the current scientific evidence in conjunction with expert opinion to reach an agreement.

The RAM utilizes crucial scientific literature, together with two turns of voting (the first of which was anonymous), to establish agreement on the suitability of approval and to avoid any ego effects or dominance that might impact the group decision-making process.

Round 1 voting

In round 1, the Expert Panel members received the recommendations via an online link and were asked to rate each recommendation's appropriateness (on a 1–5 Likert scale). They did not interact to ensure that there was no interference during voting. However, they were allowed to use the synthesized evidence provided by the Core Panel overseeing the consensus process. An Expert Information Sheet was sent to the participants in the Expert Panel for each topic (specialty) by e-mail and WhatsApp to give a brief overview of the project to all selected experts who agreed to participate in both voting rounds.

The Saudi Public Health Authority Ethics Committee approved the RAM study before its first round was initiated (approval number SCDC-IRB-A013-2020). Expert Panel member participation in the two rounds was considered as consent.

Members of each Core Panel reviewed the results of round 1 voting and the available evidence, and the Expert Panel members were provided with feedback to refine their answers. This iterative process was used to guarantee credibility.

Round 2 voting

Round 2 voting aimed to give the Expert Panel members the chance to discuss their ratings face to face over 1 day after considering their knowledge of how all the other experts had rated. Round 2 voting was conducted via a Zoom meeting and was led by an experienced moderator for each discussed topic. The moderator focused on recommendations where there was significant disagreement in the experts' ratings to find out whether there was genuine clinical disagreement about appropriateness or if there was a problem with the rating structure.[42]

Data analysis for rounds 1 and 2

The answers were aggregated, and frequencies and percentages were calculated for the answers using the online questionnaire itself before the data were tabulated with the qualitative responses as feedback for round 2.

Each indication was classified as “appropriate,” “uncertain,” or “inappropriate” for the procedure under review in accordance with the experts' median score and the level of disagreement among the experts. Indications with median scores in the 1–2 range were classified as inappropriate and those in the 4–5 range as appropriate; a score of 3 was classified as uncertain. Each statement that achieved 80% or higher from the summation of scores 4 and 5 on the Likert scale was considered to be in agreement. Consensus was defined as an 80% or higher agreement.

After round 1

For physical activity, one recommendation had <80% agreement in round 1, and the rest scored above 80%.

For sedentary behavior, 13 out of 16 statements achieved 80% or higher agreement. Three statements received a score <80% agreement – statement 2 received 64% agreement; statement 3 received 75% agreement; and statement 9 received 73% agreement.

For sleep duration recommendations, all statements achieved 80% or higher agreement.

After round 2

For physical activity recommendations, all statements achieved more than 80% agreement.

For sedentary behavior, all recommendations achieved more than 80% agreement.

For sleep duration recommendations, all statements achieved 90% or higher agreement.

Voting in the second round led to the establishment of the final Consensus Recommendations. After all panel members approved the phrasing and language of the final statements, they were submitted to the Saudi Public Health Authority Boards of Directors for their endorsement.


   Summary of Literature Top


Summary of the literature published after the publication of the adopted practice guidelines

Research gaps were identified through the updates of the systematic reviews of studies published after the publication of the adopted practice guidelines.

A summary of these systematic reviews is presented in Supplement I. Twenty-six systematic reviews that assessed the impact of sleep duration on health were identified: 15 reviews in adults and 11 in children and adolescents. Thirteen RCTs assessed the effects of sleep duration on health.

The evidence extracted from the recent systematic reviews and RCTs supported the AASM/NSF recommendations; therefore, the Core Panel adopted the AASM/NSF recommendations.

Sixteen systematic reviews that assessed the impact of sedentary behavior on health were identified: Five reviews in adults, nine in children and adolescents, and two that included both children and adults.

Based on the evidence from the recent systematic reviews, the National Committee agreed to initially adopt the Australian 24-h Movement Guidelines for the Early Years (birth to 5 years), the Australian 24-h Movement Guidelines for Children (5–12 years) and Young People (13–17 years), and the UK Chief Medical Officers' Physical Activity Guidelines recommendations without major changes in the physical activity and sedentary behavior recommendations.

A few minor changes to the wording of the guidelines were made by the Saudi Consensus Panel, not to the guideline recommendations as such but more precisely to the wording of the Good Practices statements.

Although a few studies specific to the Saudi population have been published on the relationship between physical activity level and health outcomes, there is a lack of robustness in terms of both the quantity and quality of the studies. Most of the local studies were cross-sectional, and only four studies were RCTs or had a large sample size. The local studies did not address all health outcomes determined in the search methods. Only eight studies used objective measures, such as those related to the use of accelerometers or pedometers. Thus, none of the local studies could be used to modify the recommendations. Thus, a strategic national plan to develop national evidence to investigate the relationship between physical activity levels/sedentary behavior and health outcomes is strongly needed.

Summary of literature related to the interaction between Ramadan fasting, prayer times, and daytime naps on the one side and nocturnal sleep duration on the other

Daytime naps

Summary of evidence

Cross-sectional and longitudinal studies have shown that several factors other than sleep duration can affect the relationship between sleep and health outcomes, such as bedtime and rise time, self-reported sleep quality, daytime napping, and comorbid sleep disorders.[43],[44],[45] Although the current practice guidelines address sleep duration only, other factors that can affect sleep duration in Saudi culture also need to be addressed.

Napping (afternoon/midday sleep or a siesta) is a culturally driven behavior that is a common practice, especially in some Mediterranean cultures, primarily for climatic reasons.[44] In addition, daytime napping in Saudi Arabia also has a religious dimension.[46],[47] Qailulah, the term used in Islamic literature to define a midday nap, is a well-established Islamic habit.[47] One Hadith by the Prophet Mohammed peace be upon him (PBUH) says, “Take a short nap, for Devils do not take naps” (Sahih Aljamie, Alalbani 1647). Another Hadith by the Prophet (PBUH) presents specifics about the proper timing for a nap: “Sleeping early in the day betrays ignorance, in the middle of the day is right, and at the end of the day is stupid” (Fath Al-Bari). Many Saudis take a daytime nap in an attempt to abide by these hadiths of the prophet. A third Hadith by the Prophet (PBUH) also points to the time of the daytime nap in Islamic culture: “We used to offer the Jumua (Friday) prayer with the Prophet and then take the afternoon nap” (Sahih Al-Bukhari SB 5923). Therefore, these inherent cultural factors should be considered when formulating the relevant guidelines.

The AASM consensus recommendation for adults focus on “nightly” sleep without the description of napping.[13]

Napping in adults

Summary of evidence

Studies in Saudi adults have demonstrated that daytime napping is a common practice.[30],[48],[49] A biphasic pattern of objective sleep tendency has been documented in healthy, normal young adults as well as the elderly.[50] Even after obtaining a normal night's sleep, a subject may experience mid-afternoon sleepiness due to circadian sleep–wake regulation mechanisms.[51]

Laboratory-based experimental studies have demonstrated several beneficial effects of napping, including improvement in cognitive function, reduced stress, enhancement of the immune system, and reduced pain.[44] On the other hand, epidemiological studies have reported that long naps are associated with increased cardiometabolic risk, mortality, and cognitive decline.[52],[53],[54],[55] Nevertheless, not all population-based studies agree with the above findings, and some suggest that napping is not associated with an increased risk of mortality, especially in the older population.[56]

Several observational, cross-sectional studies of longevous populations from the Mediterranean region[57] and China[58],[59] indicate that napping may improve survival. Two recent large-scale Chinese epidemiological studies (>18,000 participants in both studies; mean age 63 years)[58],[59] with a follow-up for 3–5 years reported that, compared with shorter naps of ≤30 min and after adjusting for potential confounders, long naps (≥60 min or ≥90 min) were associated with a higher risk of incident coronary heart diseases,[58],[59] hypertension,[60] type-2 diabetes,[61] and metabolic syndrome.[62]

Another study of older individuals aged 75–94 years demonstrated that, when nighttime sleep duration was accounted for, daytime napping had a protective effect in terms of mortality;[63] however, for those with a nighttime sleep duration of more than 9 h, daytime napping was associated with increased mortality risk.[63]

Nap timing


   Summary of evidence Top


In Islamic culture, the daytime nap time is around noontime or after the Dhuhr prayer.[46],[47] A study that assessed the effect of daytime napping on reaction time demonstrated that naps taken after 6 h or 18 h of rise time were more beneficial than those taken after 30 h, 42 h, or 54 h of rise time,[64] suggesting that earlier naps are beneficial, because earlier naps prevent the drop in core body temperature associated with extended wakefulness, which causes sleepiness.[64] In contrast, later naps that coincide with the circadian drop in core body temperature may necessitate a longer nap duration (e.g., >2 h) to reduce sleep pressure.[64],[65] This suggests that earlier naps of shorter duration may be more beneficial than later naps of a longer duration. Moreover, a later nap time may influence nocturnal sleep.

Nap duration


   Summary of evidence Top


Based on the currently available data [summarized in Supplement I], the ideal nap duration for healthy young adults is approximately 10–20 min.[65],[66],[67],[68],[69],[70] Naps longer than 30 min may progress into slow-wave sleep, making awakening more difficult and increasing the risk of sleep inertia, usually defined as a sense of disorientation and transient reduction in cognitive performance after long naps of >30 min, which may impair alertness and performance.[71]

Napping in children

Summary of evidence

Napping is a known physiological phenomenon in children who regularly take daytime naps between 1 and 4 years of age.[72] With increasing age, daytime napping usually ceases in school-going children.[72] A longitudinal US study (sample size, 1930) that followed children from to 1997 to 2002 showed a significant association between nighttime sleep duration and obesity;[73] interestingly, the study showed that napping had no effect on the development of obesity, although it was not a substitute for sufficient nighttime sleep.[73]

However, in Saudi Arabia, studies have shown that napping continues in children in elementary school; a study in elementary schoolchildren reported that 41% of them were taking a daytime nap more than three times per week.[31],[74] Napping was found to be highly prevalent in Saudi adolescents as well, with approximately 60% of participants taking daytime naps more than three times per week.[75] Another study that assessed sleep patterns among Saudi adolescents reported that 59% of the study group participants had an occasional daytime nap, and 30% reported daily napping.[76] Napping in Saudi children could be explained by going to bed late and getting up early for school, and hence not getting enough nocturnal sleep, which is compensated by daytime napping.[74] A systematic review also demonstrated that napping after the first 2 years of life correlated with reduced night sleep and hence a redistribution in 24 h sleep timing.[77]

Thus far, there is no agreement on the timing of cessation of daytime napping in children. Lack of this information makes it difficult to formulate a clear opinion about the role of napping in the development of children in different age groups and the role of daytime napping in supplementing 24-h sleep in children.[77]

A recent systematic review of napping patterns in children aged 0–12 years revealed two time points in the transition to napping cessation. In children <24 months of age, napping is common, and the cessation rate is <2.5%.[77] After this age, an evident acceleration in the cessation rate was noted, combined with an extraordinary variation in prevalence across studies and global regions.[77] Finally, after 5 years of age (equivalent to school-going age), the majority of children stopped daytime napping.[77]

However, the currently available data have major limitations, as nearly all longitudinal studies on napping have been reported from Western societies, with limited studies from our region. Therefore, the present understanding of the practice of napping among children is limited to certain geographical locations and cultures and may not necessarily be applicable to our culture. More local studies on the health effects of napping in schoolchildren are needed.

Prayer times and sleep

Summary of evidence

The sleep pattern of Saudis is significantly influenced by prayer times. Muslims are required to perform five daily obligatory prayers (As-Sala¯t) at certain times of the day. The Saudi culture is a religious culture where a good proportion of Saudis adhere to the exact prayer times. For those who strictly follow these prayer times, sleep time and pattern and light exposure are affected by these prayer times as well.[47]

Prayer times were formerly timed according to the movement of the sun. Because of the tilting of the earth, its rotation around the sun, and the various latitudes of the earth's locations, the times for the prayers are not fixed and are influenced by the season and the location.[47] Prayer times are referred to in one verse of the Qur'an as follows: “Perform As-Sala¯t (prayer) from mid-day till the darkness of the night (i.e., the Dhuhr, Asr, Maghrib, and Isha prayers), and recite the Qur'an in the early dawn (i.e., the morning Fajr prayer)” (17.78).

A field study of adult Omanis that objectively assessed sleep duration and pattern reported that 11% of the studied population wake up for Fajr prayer and then go back to sleep after prayer.[78] In addition, the same group reported the results of a field study that assessed the effect of sleep pattern in adults on inflammation and oxidative stress as reflected by the levels of the antioxidant glutathione (GSH), malondialdehyde (MDA), and C-reactive protein (CRP) in the plasma.[79] The levels of GSH, MDA, and CRP in biphasic dawn-sleepers were comparable to those in subjects with a monophasic sleep pattern; the levels were worse in subjects with a polyphasic sleep pattern, who also had more systemic inflammation.[79]

During summer, nights become shorter as days dawn earlier; hence, the Fajr (dawn) prayer comes at an earlier time, especially as Saudi Arabia does not apply daylight saving time.[46] Therefore, some of those who wake up for Fajr prayer in summer may sleep after prayer until they have to work; in other words, they split their sleep.[80] A study that assessed nocturnal sleep architecture and objective daytime sleepiness in subjects who split their sleep due to the Fajr prayer revealed no differences in sleep architecture or daytime sleepiness in the consolidated and split-sleep schedules when the total sleep duration was maintained.[80]

Laboratory studies indicate that having a constrained sleep period at night followed by a daytime nap has comparable recovery value to the same amount of consolidated one block-sleep taken at night.[69],[81] However, most of these were short-term studies. Space simulation studies also suggest that splitting sleep into two phases does not disturb cognitive function, sleepiness, or inflammatory responses to sleep deprivation.[82],[83] However, these studies are conducted under special conditions, making it difficult to extrapolate their results to the general population.

A recent study assessed hippocampal function in four groups of young adults by evaluating short-term topographical memory using the Four Mountains Test. Group 1 had 5 h of nocturnal sleep (n = 30), group 2 had 6.5 h of nocturnal sleep (n = 29), group 3 had 6.5 h of sleep split into 5 h of nocturnal time in bed and 1.5 h daytime nap (n = 29), while the control group 9 h of nocturnal sleep (n = 30).[84] Compared to the control group, Groups 1 and 2 had significantly impaired performance, while the performance of participants on the split sleep schedule (5.0 ± 1.5 h) did not significantly differ from that of controls.[84] Although the split-sleep protocol cannot be considered a replacement for adequate consolidated nocturnal sleep, this demonstrates the benefits of a long daytime nap (split sleep) in subjects who do not get enough nocturnal sleep.

A field study with junior doctors reported that adopting a split sleep protocol with napping during night shifts led to a similar amount of total sleep per 24 h as obtained by day shift doctors.[85] Nevertheless, based on the above observations, the evidence cannot be considered strong enough to draw any strong conclusions, and more studies are needed to assess the long-term effects on health outcomes.

Ramadan and sleep

Summary of evidence

Diurnal intermittent fasting during the holy month of Ramadan is the fourth pillar of Islam. This practice is anticipated to foster performers to wake-up early (at predawn) for an important meal that has a religious dimension. Ramadan is a Hijri month that follows the lunar system, and hence, the month occurs in a different season every 9 years, which in turn affects the duration of daytime fasting and possibly influences nocturnal sleep duration.[86],[87] During Ramadan, there is a sudden shift of mealtime to the dark phase of the day. Increasing evidence shows that mealtimes interact closely with the circadian rhythm.[88] Eating during the dark phase of the day causes desynchronization between the peripheral circadian clock and the central biological clock in the suprachiasmatic nucleus.[89] The resulting misalignment increases the risk of developing cardiometabolic disorders.[90] A recent systematic review and meta-analysis of 10 observational and experimental studies that assessed the effect of meal timing on obesity and metabolic alterations in humans reported a negative impact of late meal timing on weight and metabolism.[91] Eating and staying awake for the whole night and sleeping in the daytime does not equate with getting enough nocturnal sleep.[92] Studies on shift workers who work and eat at night and sleep in the daytime have demonstrated that a considerable percentage of them develop “shift work disorder,” a circadian rhythm sleep disorder characterized by excessive sleepiness, insomnia, or both.[93]

A few studies in Saudi Arabia consistently showed a significant and sudden delay in bedtime and rise time during Ramadan.[30],[94],[95],[96] Interestingly, the delay in bedtime during Ramadan was also documented in non-Muslim residents of Saudi Arabia, suggesting that this delay is related to the lifestyle changes that occur during Ramadan.[30] This shift delay in the sleep/wake pattern is partially ascribed to the delay in the start of work times during the month of Ramadan in Saudi Arabia. A Saudi study that objectively assessed sleep patterns during Ramadan reported a delay in bedtime and wake times and a reduction in nocturnal sleep duration during the holy month, from 5.9 h at baseline to 4.9 h at the end of the 1st week of Ramadan and 4.8 h at the end of the 2nd week of Ramadan.[96] Another recent study demonstrated an objective reduction in nocturnal sleep duration in Saudis during Ramadan.[97] A recent meta-analysis of 24 studies demonstrated a 1 h reduction in total sleep time, with the reduction being most significant in adolescents.[98]

A study that assessed the alterations in the circadian rhythm of proximal skin temperature as a marker of core body temperature in a sample of young Saudis in an otherwise free-living unconstrained environment during Ramadan reported a delay in the acrophase of the proximal skin temperature, signifying a shift-delay in the circadian clock.[99] This finding was supplemented by two Saudi studies that demonstrated a flattening of the melatonin rhythm, suggesting that the Ramadan month could be associated with a disruption of the circadian rhythm.[95],[100] Excessive eating at night and exposure to bright light, in addition to the delay in work and school times, have been proposed to cause this delay in bedtime and rise time and the reduction in nocturnal sleep.[101]

A summary of studies is shown in Supplement II.


   Discussion Top


This paper describes the methods used to develop the Saudi 24-h Movement Practice Guidelines for all age groups with regard to physical activity, sedentary behavior, and sleep duration. These combined guidelines reflect the complementary and integrated interactions between these three behavioral aspects and shift our thinking away from individual guidelines for each behavior. This approach has been used in new guidelines in several developed countries and has been well received by stakeholders.

These guidelines will help Saudis achieve a balance of movement behaviors and encourage a shift from unhealthy behaviors (e.g., excessive screen time) to healthier behaviors (e.g., adequate age-appropriate physical activity and sleep duration), resulting in improved overall health, wellbeing, and quality of life, regardless of age. This will also help Saudis understand what a healthier day looks such as overall by shifting their focus from incorporating physical activity only into their waking hours to an understanding of what a healthy 24-h period consists of. The guidelines will also assist health professionals and policymakers as they work to support Saudis of all ages in attaining optimal health.

The current guidelines made use of recently published practice guidelines while also accounting for newly published data and adjusting for cultural factors when needed and when the relevant data were available. The methods used for developing these practice guidelines are well-established, comprehensive, and appropriate methods that are transparent and meticulous. The composition of the Core Panel members, which included specialized academics and a methodologist who guided all aspects of the development process, is a major strength of the current practice guidelines. The methodologist ensured that the Core Panels followed the GRADE system and directed the ADOLOPMENT approach. Another strength of the approach used was the diversity of the Expert Panels, which included academics, practitioners, and stakeholders related to the practice guidelines, such as general practitioners, psychiatrists, a specialist in child developmental behavior, and specialists in behavioral sleep medicine.

The current practice guidelines involved adopting previously published practice guidelines that used the GRADE approach; this method is known as the GRADE-ADOLOPMENT approach.[33],[102] Based on this approach, and after reviewing the recently published evidence, the Saudi practice guidelines Expert Panels did not find sufficient changes that required altering the directions or strength of the recommendations of the adopted practice guidelines. The advantage of this approach is that it reduces time and cost; therefore, the GRADE-ADOLOPMENT approach is especially recommended when a reliable set of guidelines and related materials, such as PICOs that implement transparent processes, are available to avoid duplicates.[39]

Nevertheless, this development process is not without its challenges, as the Core Panels had to systematically review recent evidence published after the publications of the selected practice guidelines. In addition, Saudi Arabia is culturally distinct from Western societies, particularly when it comes to sleep duration, and several unique factors may affect sleep habits and hence nocturnal sleep duration. The Sleep Duration Core Panel identified the following factors that may affect sleep duration: Prayer time, including dawn (Fajr) prayer, the Ramadan month, and the cultural habit of taking a daytime nap.

The Core Panels discussed whether to include cross-sectional and observational studies in the updated systematic reviews; it was decided to include only recent systematic reviews and RCTs published after the publication of the adopted practice guidelines for the development of the Saudi recommendations, because even if several studies had been found, the level of evidence was not expected to have been enough to change the overall recommendation. However, for local and cultural factors that may influence behaviors, cross-sectional and observational studies were included due to a lack of high-quality and robust RCTs.

The use of online assessment for both round 1 and round 2 voting and telecommunication software availability made it easy to conduct both rounds of voting in a relatively short time.

An Arabic version of the recommendations was developed and approved by the Saudi Public Health Authority and will be promoted, which will allow the assessment of community ownership and the impact on the community.

Updating the guidelines

The National Organizing Committee recommends that these practice guidelines be reviewed and updated at least every 5 years or when significant new evidence emerges.

Strengths of the Saudi practice guidelines

The strengths of these practice guidelines include the review of evidence published after the publication of the adopted practice guidelines and cultural and religious factors being accounted for when needed. In addition, recommendations related to sleep duration during Ramadan and the interaction between nocturnal sleep and prayer times are useful for all Muslims and can serve more than 1.5 billion Muslims worldwide.

Acknowledgments

The organizing committee would like to thank all the experts who participated in voting in rounds 1 and 2 and approved the final draft of the recommendations [Supplement III].

Financial support and sponsorship

The development of this document was financially supported by the Saudi Public Health Authority (2020).

Conflicts of interest

There are no conflicts of interest.


   Supplement I Top

















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   Supplement II Top













   References Top


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   Supplement III Top


The organizing committee would like to thank all the experts who participated in voting in rounds 1 and 2 and approved the final draft of the recommendations.

Sleep Duration Committee

Prof. Siraj Wali

Pulmonary and Sleep Medicine, King Abdulaziz University, Jeddah

Prof. Muslim Mohammed Alsaadi

Pediatric Sleep Medicine, College of Medicine, King Saud University, Riyadh

Prof. Hamdan Al-Jahdali

Pulmonary and Sleep Disorders, King Abdelaziz Medical Center, Riyadh

Prof. Adel Alharbi

Pediatrician, Pulmonary and Sleep Medicine , Prince Sultan Military Medical City, Riyadh

Dr. Mouhamd Ghyath Jamil

Pulmonary, Critical Care and Sleep Medicine, King Faisal Hospital & Research Center, Riyadh

Dr. Wadha Helal Alotaibi

Pediatric Pulmonary and Sleep Medicine, King Fahad Medical City, Riyadh

Dr. Aljohara Almeneessier

Family Medicine, King Saud University, Riyadh

Dr. Sultan Alshahrani

Psychiatrist and Sleep Medicine, King Abdullah bin Abdulaziz University Hospital/Princess Norah University, Riyadh

Dr. Abdullah Alshamrani

Pediatric Sleep Medicine, Prince Sultan Military Medical City, Riyadh

Dr. Muhannad Hawari

Pulmonary and Sleep Medicine, King Faisal Hospital & Research Center, Riyadh

Dr. Abdullah Khayat

Pediatric Pulmonary and Sleep Medicine, Taif University, Taif

Dr. Ahmed Almutairi

Adult Pulmonary and Sleep Medicine, King Abdulaziz Medical City, Riyadh

Dr. Mohammed Albalawi

Pediatric Pulmonary and Sleep Medicine, King Faisal Specialist Hospital & Research Center, Riyadh

Dr. Ranya Alshumrani

Pediatric Pulmonary and Sleep Medicine, King Abdulaziz University Hospital, Jeddah

Dr. Riyad Omar Allehebi

Pulmonary and Sleep Medicine, King Fahad Medical City, Riyadh

Dr. Fawaz Alharbi

Sleep Medicine, Prince Sultan Military Medical City, Riyadh

Dr. Sultan Ali Qanash

Pulmonary and Sleep Medicine, King Abdulaziz Medical City, Jeddah

Dr. Fayez Almutairi

Pulmonary and Sleep Medicine, King Abdelaziz National Guard Hospital, Alhasa

Dr. Ahmad Mansoor Aldobyany

Pulmonary and Sleep Medicine, King Abdullah Medical City, Makkah

Dr. Yousef Alqurashi

Respiratory and Sleep Medicine, Imam Abdulrahman bin Faisal University/King Fahad University Hospital, Dammam

Dr. Meteb Hamid Alenazi

Psychiatry and Sleep Medicine, King Saud University, Riyadh

Dr. Saad Alshareef

Pulmonary and Sleep Medicine, Al-Imam University, Riyadh

Dr. Shaden Qasrawi

Pulmonary and Sleep Medicine, Kingdom Hospital, Riyadh

Dr. Noor Adnan Almodihesh

Child and Adolescence Psychiatry, King Saud University & Medical City, Riyadh

Dr. Salih Aleissi

Sleep Medicine, King Saud University and Medical City, Riyadh

Dr. Mana Mubarak Alshahrani

Family Medicine and Sleep Medicine, King Faisal Medical City, Abha

Dr. Afnan Adel Shukr

Pulmonary and Sleep Medicine, King Abdullah Medical Complex, Jeddah

Dr. Mashni Alsaeed

Sleep Technology and Behavioral Sleep Medicine, King Faisal Specialist Hospital, Jeddah

Mr. Mohammed Alhasson

Pulmonary and Sleep Medicine, King Fahad Specialist Hospital, Qassim

Dr. Ali Abdulmana Awadh

Family Medicine, University Sleep Disorders Center, Riyadh

Dr. Areej Ayedh Alharthi

Neurology, King Khalid University Hospital, Riyadh,

Physical Activity and Sedentary Behavior Committee

Prof. Khalid Saleh Almuzaini

Exercise Physiology, King Saud University, Riyadh

Dr. Shaea Ayed Alkahtani

Exercise Physiology & Energy Metabolism, King Saud University, Riyadh

Dr. Mohammad Ali Alahmadi

Exercise Physiology, Taibah University, Madinah

Dr. Abdulazeem Alotaibi

Exercise Physiology, Qassim University, Qassim

Dr. Faisal Awad Barwais

Exercise Physiology, Umm Al-Qura University, Makkah

Dr. Anwar Abdulaziz Alnuaim

Physical Activity & Public health, King Faisal University, Alhasa

Dr. Mohammed Shuaib Alibrahim

Movement Science, King Faisal University, Riyadh

Dr. Huda Ahmad Alaamer

Nutrition & Food Science, Princess Nourah bint Abdulrahman University, Riyadh

Dr. Baraa Sami Quronfulah

Health Promotion, Umm Al-Qura University, Makkah

Dr. Aqeel Mohammed Alenazi

Physiotherapy & Rehabilitation, Prince Sattam bin Abdulaziz University, Wadi Ad-dawasir



 
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    Abstract
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