Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: an integration of physical activity, sedentary behaviour, and sleep.

The Canadian Society for Exercise Physiology assembled a Consensus Panel representing national organizations, content experts, methodologists, stakeholders, and end-users and followed an established guideline development procedure to create the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: An Integration of Physical Activity, Sedentary Behaviour, and Sleep. These guidelines underscore the importance of movement behaviours across the whole 24-h day. The development process followed the strategy outlined in the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. A large body of evidence was used to inform the guidelines including 2 de novo systematic reviews and 4 overviews of reviews examining the relationships among movement behaviours (physical activity, sedentary behaviour, sleep, and all behaviours together) and several health outcomes. Draft guideline recommendations were discussed at a 4-day in-person Consensus Panel meeting. Feedback from stakeholders was obtained by survey (n = 877) and the draft guidelines were revised accordingly. The final guidelines provide evidence-based recommendations for a healthy day (24-h), comprising a combination of sleep, sedentary behaviours, and light-intensity and moderate-to-vigorous-intensity physical activity. Dissemination and implementation efforts with corresponding evaluation plans are in place to help ensure that guideline awareness and use are optimized. Novelty First ever 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older with consideration of a balanced approach to physical activity, sedentary behaviour, and sleep Finalizes the suite of 24-Hour Movement Guidelines for Canadians across the lifespan.


Introduction
There is unequivocal evidence that sleep (Yin et al. 2017), sedentary behaviour (Biswas et al. 2015), and moderate-to-vigorousintensity physical activity (MVPA; 2018 Physical Activity Guidelines Advisory Committee 2018) are associated with morbidity and mortality in adults independent of age and biological sex. More recently, light-intensity physical activity (LPA) consistent with activities of daily living has also been shown to have a positive effect on health outcomes in a dose-dependent manner Ekelund et al. 2019). Because a change in the amount of time spent in any one of these movement-related behaviours that comprise a 24-h day will change the amount of time spent in another, emerging research has considered how they may interact to influence health outcomes. Indeed, studies that have investigated the combined effect of 24-h movement behaviours on health have clearly shown that the whole 24-h time-use is associated with health outcomes across the lifespan (McGregor et al. 2018(McGregor et al. , 2019 and have underscored the importance of movement behaviours across the whole day (24-h period).
Canada has an established track record in the development of 24-h movement guidelines having previously released guidelines for Children and Youth (aged 5 to 17 years) in 2016 (Tremblay et al. 2016) and for the Early Years (aged 0-4 years) in 2017 (Tremblay et al. 2017b). Following Canada's lead, several jurisdictions including Australia (Okely et al. 2017), New Zealand (Ministry of Health 2017), South Africa (Draper et al. 2020), and the World Health Organization (2019) have since released 24-h movement guidelines for the early years and/or children and youth, embracing the concept that the mixture of movement behaviours across the whole day is important when health enhancement is the desired objective (Tremblay 2020).
The objective of this report is to describe the process that was used to develop the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and for Adults 65 years or older, thereby completing the family of 24-Hour Movement Guidelines for Canadians, and becoming a world first. In contrast to the focus on a single movement behaviour that typifies physical activity guidelines for adults worldwide, the purpose of the evidence-informed 24-Hour Movement Guidelines presented here is to recognize the importance of integrating all movement behaviours and thus, provide more movement options for Canadians and more prevention and treatment options for practitioners.
of the Leadership Committee, the Content Working Group, which included the content and methodology experts, was formed to provide additional opportunities to concentrate on the myriad of details required to generate the systematic reviews for each behaviour. In June 2018, the Leadership Committee formed the broader guideline development Consensus Panel (CP), composed of experts from all relevant disciplines, stakeholders and end us-ers, international collaborators, and members of the target population (Table 1).
The CP first met in October 2018 for 3 days in Ottawa, Ontario, Canada. The objectives of this initial meeting were to provide an overview of the guideline development process, responsibilities, and timelines; introduce the methodology consultants and explain their responsibilities; and learn from international  delegates about their guideline processes and the potential of leveraging relevant work to reduce research waste. In addition, for each behaviour (sleep, sedentary, physical activity, and the integration of all of these behaviours), the respective content expert proposed a set of research questions for group discussion. A total of 7 research questions, 2 each for sleep, sedentary behaviour, physical activity, and 1 for the composition of movement behaviours were determined by consensus. For all research questions, the CP reached agreement on the target population, intervention/exposure, and comparator. The CP also identified and prioritized the "critical" (i.e., essential for decision-making) and "important" outcomes for each research question, and reached consensus regarding the final set of outcomes (summarized in Table 2).

Knowledge translation (KT): dissemination and implementation
Initial discussions regarding the importance of KT, dissemination, and implementation at the first CP meeting resulted in the decision to establish a KT process that would operate in parallel with the guideline development process. Details of the KT process and the constituency of those involved are described in detail elsewhere (Tomasone et al. 2020a). In brief, an integrated KT (Canadian Institutes of Health Research (CIHR) 2016) process was undertaken to collaboratively engage relevant organizations, stakeholders, researchers, and end-users in a KT Advisory Committee to guide all stages of guideline KT efforts. Following the formation of a governance structure and terms of reference for the KT Advisory Committee, the group established the focus of the KT efforts, engaged in formative research to inform dissemination and implementation efforts (including a systematic scoping review examining dissemination and implementation strategies used for national movement guidelines; Tomasone et al. 2020b), established and enacted a guideline dissemination and implementation plan, and structured an evaluation to assess the impact of the KT efforts on Canadians' awareness and knowledge of the guidelines, as well as intentions and behaviours commensurate with the guidelines. Key timelines and events in the KT process are summarized in Fig. 1.

Leveraging evidence from the US 2018 Physical Activity Guidelines Scientific Report
At the first CP meeting the members were informed of the recently released 2018 Physical Activity Guidelines Advisory Committee Scientific Report in the United States (herein called the "US Scientific Report") wherein the findings from 38 rigorously performed systematic reviews were presented describing the associations between physical activity, sedentary behaviour, and numerous health outcomes Physical Activity Guidelines Advisory Committee 2018Torres et al. 2018). A Chairperson of the Scientific Advisory Committee (Dr. Kenneth E. Powell) accepted an invitation to be a member of the CP and to provide a summary of the methods followed and the results observed at this meeting. Dr. Powell conveyed that the literature review team used a methodology informed by best practice for systematic reviews developed by several federal agencies to review, evaluate, and synthesize published, peer-reviewed physical activity research. The protocol-driven methodology was designed to maximize transparency, minimize bias, and ensure the systematic reviews were relevant, timely, and of high quality. Quality control processes were implemented throughout the systematic review process to ensure transparency, integrity, reproducibility, and research excellence in design, implementation, and synthesis of the systematic reviews (Torres et al. 2018).
Following discussion, the CP agreed that the US Scientific Report provided an accurate and comprehensive synthesis of existing evidence regarding the relationships between most aspects of physical activity and health outcomes. Consequently, there was unanimous agreement to leverage the US Scientific Report as the foundational evidence informing the MVPA component of the Canadian guidelines. Based on this decision, the CP also agreed to conduct additional systematic reviews to address gaps in the US Scientific Report. Gaps identified included systematic reviews to consider relationships between LPA, standing, resistance exercise, balance exercise, acute exercise, and exercise frequency of   Sleep duration (Chaput et al. 2020a) Sleep timing and consistency (Chaput et al. 2020b) Integrated  Type of review Population

Inclusion:
Community-dwelling adults aged 18 y and older, including apparently healthy adults. Eligible studies could include adults with a chronic condition (e.g., heart disease, diabetes, and cancer), adults with obesity, metabolic syndrome, or those who had ≥1 fall(s) in the past year among their participant pool Exclusion: Populations comprising pregnant women, residents in long-term care, patients in acute care or a hospital setting, people who were unable to move under their own power, and specialized populations (i.e., elite athletes, disease-specific conditions (e.g., heart disease, diabetes, or cancer, etc., at baseline)) † MVPA and health outcomes. Given the resources available to perform additional systematic reviews, the CP suggested that the Leadership Committee convene at a later date and select 2 of the 6 components of physical activity behaviour for which systematic reviews would be performed. Following discussion, the Leadership Committee decided to conduct additional systematic reviews for resistance training and balance and functional training. The Committee acknowledged the growing body of evidence confirming the health benefits of LPA and standing, but decided against performing a systematic review as it was unlikely to yield the evidence required to identify specific durations of either behaviour that would inform the development of the 24-Hour Movement Guidelines. Consistent with the CP decision to leverage the US Scientific Report to inform the physical activity component of the guidelines, there was unanimous agreement to use the Report as the foundational evidence that identified strong dose-response relationships between sedentary behaviour and incident cardiovascular disease, as well as all-cause and cardiovascular disease mortality, although they found limited evidence of a dose-response gradient between sedentary behaviour and type 2 diabetes, weight status, incident cancer, and cancer-related mortality. The CP also agreed to conduct 2 additional systematic reviews to address gaps in the US Scientific Report related to other critical and important health outcomes (see below).

Systematic reviews
Following discussion related to the leveraging of the US Scientific Report, the CP determined that 6 systematic reviews were required to further inform the development of the 24-h Movement Guidelines. Given that there was a large body of evidence already synthesized in existing systematic reviews for 4 of the research questions (resistance training, balance and functional training, mode and patterns of sedentary behaviour, and sleep duration), overviews of reviews were conducted for these questions and de novo systematic reviews of primary studies were conducted for the remaining 2 research questions (sleep timing and consistency, integrated movement behaviours). A brief overview of all systematic reviews is given in Table 2.
The de novo systematic reviews were conducted using accepted methods (Cook et al. 1997;Higgins and Green 2011). The overviews of reviews were performed as described in a separate report in this special supplement ). In each de novo systematic review, the quality of evidence was rated (from "high" to "very low") by outcome, study design, and age group (where possible), using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework (Guyatt et al. 2008). In brief, quality ratings begin at "high" for evidence from randomized controlled trials and "low" for evidence from all other study designs. From there, quality ratings are decreased if the contributing studies were poorly designed or executed (serious risk of bias), had inconsistent (unexplained heterogeneity) or imprecise (wide confidence intervals) results, or had evidence of publication bias. Quality ratings are increased if other criteria are met, such as a large magnitude of effect or evidence of a dose-response gradient. For the overview of reviews, the quality of the evidence was extracted and reported as evaluated by the systematic review authors, and the quality of the systematic reviews themselves was assessed using the A MeaSurement Tool to Assess systematic Reviews II (AMSTAR II) criteria (Shea et al. 2017). All reviews were prospectively registered in PROSPERO (https://www.crd.york.ac. uk/prospero) and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement for reporting systematic reviews and meta-analyses (Liberati et al. 2009). Below, we briefly describe the topic of each of the systematic reviews. The target population, intervention/exposure, comparator(s), critical and important outcomes, and registration ID for each review are given in Table 2. According to the ProFaNE taxonomy, resistance training is defined as "contracting the muscles against a resistance to "overload' and bring about a training effect in the muscular system. The resistance is an external force, which can be one's own body placed in an unusual relationship to gravity (e.g. prone back extension) or an external resistance (e.g. free weight)" (Lamb et al. 2011). § Gait, balance and functional training or 3D exercise (e.g., Tai Chi or dance) defined according to the ProFaNE taxonomy: "Gait training involves specific correction of walking technique (e.g., posture, stride length and cadence) and changes of pace, level and direction. Balance training involves the efficient transfer of bodyweight from one part of the body to another or challenges specific aspects of the balance system (e.g. vestibular systems). Balance retraining activities range from re-education of basic functional movement patterns to a wide variety of dynamic activities that target more sophisticated aspects of balance. Functional training uses functional activities as the training stimulus and is based on the theoretical concept of task specificity."

Resistance training
An overview of systematic reviews was performed to determine the benefits and harms of resistance training on health outcomes in adults . The overview also explored whether there was evidence that age, exposure dose, or type of resistance training influenced the effects on health outcomes. According to the Prevention of Fall Network Europe (ProFaNE) taxonomy, resistance training was defined as "contracting the muscles against a resistance to 'overload' and bring about a training effect in the muscular system".

Balance and functional training
An overview of systematic reviews was performed to examine the effect of gait, balance, and functional training on health outcomes in adults (McLaughlin et al. 2020). The overview also explored whether there was evidence that age, exposure dose, or type of balance and functional training influenced the relationships with health outcomes. Balance and functional training and 3-dimensional exercise (e.g., Tai Chi, dance, or exergames) were considered in this category, and were defined in accordance with the ProFaNE taxonomy definitions.

Sleep
Two systematic reviews were performed. The first, an overview of systematic reviews, examined the associations between sleep duration and health outcomes in adults (Chaput et al. 2020a). The second sleep systematic review of primary studies examined the associations between sleep timing (e.g., bedtime/wake-up time, midpoint of sleep), sleep consistency/regularity (e.g., intraindividual variability in sleep duration, social jetlag (misalignment of biological and social time), catch-up sleep), and health outcomes in adults (Chaput et al. 2020b).

Sedentary behaviour
A single overview of reviews was performed to answer 2 research questions that considered the impact of patterns of sedentary behaviour on health outcomes in adults ). The first question considered the relationship between types of sedentary behaviour and health outcomes. The second considered the relationships between patterns of sedentary behaviour and health outcomes.

Integration of all movement behaviours
A single systematic review was conducted to determine if the composition of time spent in sleep, sedentary behaviour, LPA, and MVPA is associated with health in adults ). This review considered whether the composition of movement behaviours across the full 24-h day was associated with health outcomes and the extent to which reallocating time across movement behaviours was associated with changes in health outcomes.

Drafting of guideline recommendations
A second meeting of the CP was held in Montebello, Quebec, Canada, in November of 2019. The objectives of this 4-day meeting were to review findings from the systematic reviews and overviews of reviews, develop individual movement behaviour guideline recommendations, and create 24-h movement guideline recommendations for both adults aged 18 to 64 and adults 65 years and older along with the respective preambles. In drafting the guideline recommendations, the CP considered the evidence for the possible benefits and harms of various intensity levels of physical activity, sedentary behaviours, and sleep; stakeholder and end-user preferences and values related to these movement behaviours; and considerations related to feasibility, accessibility, resource use, and equity (Alonso-Coello et al. 2016b). For each guideline recommendation, considerable time was taken to present the breadth and quality of the evidence, and to provide time for a full discussion among Panel members to ensure that the wording of each recommendation was thoughtfully considered and consistent with the evidence. Following completion of a first draft, to provide further opportunity for all Panel members to provide their thoughts and perspectives, the draft guidelines were revisited the next day to ensure that all members had sufficient time to reflect on prior discussions and if required, engage in further discussion to achieve consensus. The draft guideline recommendations that were created at the second CP meeting were then translated into French. Following translation, the guidelines in both languages were sent to the CP members by email for review and comment. All CP members endorsed the draft guidelines.

Stakeholder consultations
An online survey (see Appendix A for the complete survey in English and French) was developed to solicit stakeholder assessment and feedback on (i) the content and wording of the draft guidelines, and (ii) criteria of importance to the AGREE II and GRADE Evidence to Decision (ETD) Framework (i.e., priority, acceptability, feasibility, resource use, cost-benefit ratio, and equity). Stakeholders were any individuals involved with physical activity, sedentary, and/or sleep behaviour in a professional capacity (e.g., policymaker, healthcare provider, public health practitioner, researcher, educator, recreation/sport practitioner). Following approval from Queen's University's Research Ethics Board , the survey was created online using Qualtrics software and was open from January 23 to February 10, 2020. The survey was disseminated through the various networks of the CP and KT Advisory Committee members (Table 1) and followed a snowball sampling methodology to optimize survey reach. Data were imported into SPSS (version 26 for Mac; IBM Corp., Armonk, N.Y., USA) and Excel (Microsoft Corp., Seattle, Wash., USA) for analysis of closed-and open-ended responses, respectively. Descriptive statistics were calculated to summarize stakeholder demographics and closed-ended feedback. Open-ended questions that addressed AGREE II and GRADE ETD Framework criteria were coded using inductive content analysis to identify key suggestions and/or concerns about the guidelines (Faught et al. 2020). Initial codes were generated from the survey responses by 2 research staff members. Overarching categories were formed from grouping codes, and codes were then reviewed and refined by collapsing, separating, or deleting. Key suggestions/concerns were grouped in hierarchal categories and defined using contentcharacteristic words. Comments in English and French were analyzed in parallel and combined in the analyses. Frequency counts of each suggestion and/or concern was quantified through summing the total number of responses for each key code.

Revisions to guidelines based on stakeholder feedback
On March 5, 2020, the Leadership Committee and selected members of the KT Advisory Committee met in Ottawa, Ontario, Canada, either in person or by video conference to collectively review the survey results. The stakeholder feedback for all closed and open questions was carefully considered and the draft guidelines were vised accordingly (see Revisions to guidelines based on stakeholder feedback, below).

Surveillance of the guidelines
The release of Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older requires a shift from the surveillance and monitoring of individual movement behaviours in isolation to the integrated surveillance of all movement behaviours. A Surveillance Subcommittee, which comprised a subset of the CP with movement behaviour surveillance expertise (Table 1), along with additional members from federal government agencies responsible for health surveillance, was assembled to develop specific surveillance recommendations. The Surveillance Subcommittee communicated via email and teleconferences to develop preliminary recommendations for the monitoring and surveillance of the new guidelines. This approach was similar to that followed for the surveillance recommendations created for the 24-Hour Movement Guidelines for Children and Youth (Tremblay et al. 2016) and of the Early Years (Tremblay et al. 2017b).

External review
Four independent reviewers were contracted to assess the entire guideline development process using the AGREE II tool (Brouwers et al. 2016). The available materials presented in this special issue of Applied Physiology, Nutrition, and Metabolism were provided to the independent assessors.

Results
The guideline development process adhered to the framework outlined by Tremblay and Haskell (2012). Throughout the process, methodologists on the CP and Leadership Committee familiar with AGREE II (Brouwers et al. 2010) and GRADE (Guyatt et al. 2008) provided advice and worked closely with the Project Coordinator to ensure we maintained detailed records of all meetings, discussions, and decisions to help inform the guideline recommendations and the Evidence to Decision Framework (Alonso-Coello et al. 2016b, 2016a. The Leadership Committee and Content Working Group met in person or by teleconference approximately 35 times and many more times by email over the course of the guideline development process. CP meetings were held in Ottawa, Ontario, Canada, in October 2018 and in Montebello, Quebec, Canada, in November 2019. During the entire guideline development process the CP received numerous updates detailing key Leadership Committee decisions with opportunity for feedback and clarification.

Resistance training
An overview of reviews was performed to examine the effects of resistance training (RT) on health outcomes (compared with no RT or different types or doses of RT) in adults . Eleven systematic reviews were included, which contained data from 364 primary studies from 28 countries involving 382 627 unique participants . Overall, the quality of the evidence was very low. Compared with no RT, RT was associated with a 21% lower risk of all-cause mortality (lowquality evidence; Saeidifard et al. 2019). Regarding the physical function outcome, compared with no RT, RT improved muscle strength in adults and muscle strength and physical functioning in adults over the age of 65 years (moderate-quality evidence; Muñoz-Martínez et al. 2017;Lai et al. 2018). There was no effect of RT on health-related quality of life (very low-quality evidence; El-Kotob et al. 2020). RT was associated with a 23% reduction in incident fatal coronary heart disease and nonfatal myocardial infarction in men (low-quality evidence; Saeidifard et al. 2019). Effects of RT on cognitive function were inconsistent (very lowquality evidence; Raymond et al. 2013). There were no identified reviews examining the effects of RT on the target population for several important health outcomes (incident diabetes, depression, cancer, brain health, bone health, or falls). Adverse events (both serious and nonserious) were not consistently monitored or reported, but in 22 trials where they were reported, the majority were nonserious, and serious adverse events were infrequent (very low-quality evidence; Liu and Latham 2010). The benefits of RT likely outweigh the harms (very low-quality evidence). There was insufficient evidence to support a specific mode, intensity, or duration of RT. While many of the systematic reviews examined were inclusive of adults over 65 years of age, for the majority of outcomes there were insufficient data to determine if age modified the effect of RT on health outcomes .

Balance and functional training
An overview of reviews was performed to determine the healthrelated effects of balance and functional training, as well as 3-dimensional physical activities (e.g., Tai Chi, dance, or exergames), on health outcomes in adults (McLaughlin et al. 2020). We did not identify any systematic reviews that examined the effects of balance and functional training on our critical or important outcomes in healthy adults aged 18 to 64 years. In adults 65 years or older, we identified 5 systematic reviews that examined balance and functional training, encompassing data from 77 studies and 15 890 participants in 23 countries. In adults over 65 years of age, balance and functional training reduced the rate of falls or the number of people who fell (high-certainty evidence; synonymous with "high-quality evidence"). There was evidence that balance and functional training may reduce fall-related fractures (low-quality evidence; Sherrington et al. 2019), improve physical function (low-quality evidence), and increase physical activity levels (moderate-quality evidence). Conversely, evidence suggested that balance and functional training may have no effect on healthrelated quality of life (low-quality evidence). We did not find studies that examined whether age was an effect modifier or that directly compared different types of balance and functional training. Adverse events were not consistently reported; when they were reported they were infrequent, the majority were not serious, and they were of a musculoskeletal nature or transient (moderate-quality evidence).

Sedentary behaviour
We conducted an overview of reviews of the relationship between types and patterns of sedentary behaviour with health outcomes. This overview included 18 systematic reviews and contained data from 245 studies with more than 510 000 unique participants from 32 countries . Sedentary behaviour was unfavourably associated with cognitive function, depression, function, and disability, physical activity levels, and some domains of quality of life in adults. There was evidence that reducing or breaking up sedentary behaviour may benefit body composition and markers of cardiometabolic risk. Total sedentary behaviour and TV viewing were most consistently associated with unfavourable health outcomes, while there was evidence that computer and Internet use may lead to benefits in cognitive function for older adults. The overall quality of evidence was very low. There was little evidence that sedentary behaviour is associated with musculoskeletal pain, accidents or injuries, fatigue, sleep, or work productivity.

Sleep
For the sleep duration overview of reviews, 11 systematic reviews were included and contained data from 260 studies and 4 437 101 unique participants from 30 countries (Chaput et al. 2020a). Sleep duration was assessed subjectively in 96% of studies and 78% of studies in the reviews were prospective cohort studies. A U-shaped association was observed between sleep duration and health outcomes. The dose-response curves showed that a sleep duration of around 7-8 h per day was most favourably associated with the health outcomes that were examined, with no apparent modification of the association by age in the few relevant studies. The overall quality of evidence was moderate quality for sleep duration for the critical health outcomes examined.
For the sleep timing and consistency de novo systematic review, a total of 41 articles, including 92 340 unique participants from 14 countries, met the inclusion criteria (Chaput et al. 2020b). Sleep was assessed objectively in 37% of studies and subjectively in 63% of studies. Later sleep timing and greater sleep variability were generally associated with more adverse health outcomes, with no apparent modification of the association by age. However, because most studies reported linear associations, it was not possible to identify thresholds for "late sleep timing" or "large sleep variability". In addition, social jetlag (misalignment of biological and social time) was associated with more adverse health outcomes, while weekend catch-up sleep was associated with better health outcomes. Thus, the available evidence indicated that earlier sleep timing and regularity in sleep patterns with consistent bedtimes and wake-up times were favourably associated with health. The overall quality of evidence was rated very low.

Composition of movement behaviours
For the systematic review of original studies that used a compositional data analysis approach to examine the association between the 24-h movement behaviour composition and health outcomes, a total of 8 studies (7 cross-sectional, 1 prospective cohort) of >12 000 unique participants were included . The 8 studies that were identified examined 4 critical outcomes (all-cause mortality, adiposity, cardiometabolic biomarkers, mental health). The results were summarized using narrative syntheses structured around each of these health outcomes. Findings indicated that the 24-h movement behaviour composition was associated with all-cause mortality, adiposity, and cardiometabolic biomarkers. The overall pattern of findings when considering all associations for all health outcomes suggested that health would improve if time was reallocated into MVPA and that health would worsen if time was taken out of MVPA, irrespective of what other movement behaviour MVPA was reallocated out of or into. Health would also improve if time were taken out of sedentary behaviour and reallocated into sleep or LPA. The quality of evidence was very low for all health outcomes. These findings support the notion that the intensity of movement across the entire 24-h day matters and that recommendations for sleep, sedentary, and physical activity can be combined into a single public health guideline.

Stakeholder survey
The draft guidelines developed and approved by consensus at the November 2019 CP meeting were utilized for the online stakeholder survey. The draft guidelines are included as part of the stakeholder survey, which is available in Appendix A.

Demographics
During the two and a half weeks that the online stakeholder survey was open, 877 stakeholders landed on the front page of the survey. The number or responses varied by question with 648 to 839 responses for close-ended questions. There were participants from all Canadian provinces and territories except Nunavut; the greatest proportion were living in Ontario (37.4%), Alberta (15%), British Columbia (12.1%), Québec (6.6%), and Manitoba (5.2%). In addition, 13.3% of stakeholders who responded resided outside of Canada. Stakeholders were encouraged to select any relevant sector(s) with which they associated. The sectors stakeholders most associated with were healthcare (368), public health (294), sport (287), education (287), research (263), and recreation (248). The majority of stakeholders opted to complete the survey in English (94.4%), while 5.6% completed the survey in French.

Content and format of the guidelines
For all sections of the guidelines (i.e., titles, preambles, guidelines) for adults aged 18-64 and 65 years or older, the proportion of stakeholders who strongly agreed or somewhat agreed that the sections were clearly stated ranged from 90.6% to 95%. The proportion who strongly agreed or somewhat agreed with how these sections were stated ranged from 87.6% to 92.1%. A more complete summary of the stakeholder survey results is provided in Table 3. Among the feedback received via the open-ended questions, the most frequently occurring suggestions or concerns were in relation to the high literacy level of the guidelines (if intended for members of the public), guideline terminology (e.g., title too long, "movement" not applicable to sedentary behaviour and sleep), the target audience was unclear (i.e., healthcare practitioners vs. members of the public), and the Guidelines should only be iden-tified by the age intervals (i.e., remove the qualifier "older" for the 65 years or older group guideline).
There was high agreement ("strongly agree" or "somewhat agree") among stakeholders that the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older are a priority (87.5%). There was also high agreement that using the guidelines would be feasible (83.6%), acceptable (68.3%), useful (73.1%), cost-effective (65.6%), and equitable for all adult Canadians (irrespective of gender, race, ethnicity, or socioeconomic status; 85.4%). Additionally, most (69.9%) indicated that the benefits of using the guidelines are likely to outweigh the costs. Open-ended response options were available for stakeholders who chose to elaborate on their responses to closed-ended items. A majority of stakeholders who provided feedback to these items provided favourable or neutral feedback, with the most common requests for examples or additional KT tools. Notably, 140 of 651 (21.5%) stakeholders expanded on their responses to the equity item. Sixty-eight (10.4%) indicated that they felt that the guidelines do not respect the varying socioeconomic statuses of all adult Canadians.

Revisions to guidelines based on stakeholder feedback
Stakeholder feedback did result in some relatively minor, yet important revisions to the draft guidelines. To avoid the inference of ageism, the qualifier "older" for the 65 years or older age group was removed from the title of the guidelines and throughout the guideline document. Three additional changes were made to the content of both guideline preambles: (i) In response to stakeholder concern that the literacy level may be too high for the general population, both preambles were revised to properly identify the target users of guideline documents: "This document is intended for policy makers, health professionals, and researchers and it may be useful to interested members of the public." It is relevant to note that separate public-facing documents using accessible language will be created to disseminate the guidelines to the general public. (ii) To address concerns that the guidelines may not respect the variability in socioeconomic status among Canadian adults, a statement was added as follows: "Following these Guidelines may be challenging at times; progressing towards any of the Guideline targets will result in some health benefits." (iii) A reference to CSEP's "24-Hour Movement Guidelines: Glossary of Terms" was added as part of the list of tools in the final sentence of the preambles. The glossary serves as a useful tool for defining many of the terms (e.g., sedentary, recreational screen time) that stakeholders indicated may have an unclear meaning in the recommendations.
A single revision was made that clarified the content of the guidelines. Stakeholder feedback suggested that "prolonged sitting" should be quantified within the sedentary behaviour recommendation. In response the word "prolonged" was revised to "long periods of sitting" to improve comprehension while staying true to the underlying science of the recommendation .
The revised guidelines were subsequently circulated to the CP for comment and final revisions and unanimous consensus was achieved. Revisions were then translated to revise and finalize the French version. The final guidelines and preamble in both English and French are provided in Figs. 2-3.

GRADE evidence to decision framework: summary
The specific guideline recommendations for the Canadian 24-Hour Movement Guidelines for Adults aged 18 to 64 years and Adults aged 65 years or older are provided here with corresponding statements indicating the overall quality of the evidence that informed the recommendations, and a summary of the key findings for each behaviour that were used to formulate the recommendations and determine the strength of the recommendations. As described earlier, the quality of evidence statements was derived following the objective criteria outlined within the GRADE framework. More information on the factors used to evaluate the quality of evidence is available elsewhere (Guyatt et al. 2008).

Development of recommendations and determination of strength of recommendations
In accordance with the GRADE framework (Alonso-Coello et al. 2016b), the CP considered the proposed wording of the recommendations and the rating of their strength (strong or conditional/ weak), based on the balance of benefits to harms, the quality of evidence, sensitivity to values and preferences of stakeholders and end-users, the potential impact on biological sex, social and health equity, as well as acceptability, feasibility, and resource implications. This collection of information was used to inform the direction (i.e., for or against) and the strength (i.e., strong or conditional/weak) of the recommendations.

MVPA
To arrive at the MVPA recommendation, the CP leveraged evidence from the recently published US Scientific Report (2018  Physical Activity Guidelines Advisory Committee 2018). Within that report the authors concluded that "Strong evidence demonstrates that a strong inverse dose-response relation exists between amount of moderate-to-vigorous physical activity and cardiovascular disease mortality"; and that "Strong evidence demonstrates that the dose-response relationships between moderate-to-vigorous physical activity and all-cause mortality do not vary by age, sex, race, or weight status." For both observations, the US Scientific Report assigned a "strong" grade. Further, the summary findings from 38 systematic reviews led to the conclusion that the majority of risk reduction in all-cause mortality, cardiovascular disease mortality, and incidence of car-  Scientific Report was completed to determine whether performing MVPA in bouts of ≥10 min was required for health benefit. To the contrary, the findings from cross-sectional and prospective cohort studies suggested that physical activity accumulated in bouts that are ≤10 min in duration are also associated with benefits across a variety of health outcomes, including all-cause mortality (Jakicic et al. 2019). The authors noted, however, that the complete absence of findings from randomized controlled trials prevented causal inference and thus, represented a gap in knowledge that should be addressed in future studies. Based on these observations the CP agreed to remove the requirement that MVPA be performed in bouts of ≥10 min from the MVPA recommendation.

LPA
The LPA recommendation was not derived on the basis of a de novo systematic review conducted by our group to determine whether LPA (e.g., walking at a slow or leisurely pace (ϳ3 km/h or less, equivalent to 1.5-<3.0 METs) was associated with health outcomes. However, the findings from 2 recently completed systematic reviews that considered the associations between LPA and all-cause mortality were presented to the CP Ekelund et al. 2019). Ekelund and colleagues (2019) examined the dose-response associations between device-measured LPA (accelerometry) and all-cause mortality in 36 383 adult men and women (73%) with a mean age of 63 years with a mean follow-up of 5.8 years. The novel finding was that device-measured LPA was associated with a substantially reduced risk of death in a doseresponse manner (Ekelund et al. 2019). This finding was consistent with the meta-analysis of Chastin and colleagues (2019) who reported that a doubling of the time spent in LPA was associated with a 29% reduction in mortality.
The CP also noted that standing was an important component of LPA, and that evidence from a study of 16 586 Canadian adults aged 18 to 90 years suggested that time spent standing is inversely related to all-cause mortality (Katzmarzyk et al. 2009). In that study, across successively higher categories of daily standing, the multivariable-adjusted hazard ratios were 1.00, 0.79, 0.79, 0.73,  The CP considered that the findings from the systematic reviews were strong as they were based on device-measures (Ekelund et al. 2019), were current (both published in 2019), and were comprehensive as both included a large number of studies. It was also acknowledged that the health benefits identified in these reviews were consistent with the integration of movement behaviours analysis, demonstrating that health would improve if time during the day was reallocated from sedentary behaviour into LPA . The CP recognized that the benefits of engaging in LPA far outweighed any potential harm; that encouraging participation in routine activities of daily living at home, work, or commuting would not be onerous; and that engaging in LPA is feasible for most if not all adults regardless of age. This is consistent with the Stakeholder Survey results, which indicated that using the guidelines would be feasible (83.6%), acceptable (68.3%), negligible cost (65.6%), and equitable (85.4%). Irrespective of biological sex, race, ethnicity, or socioeconomic status. Considering this evidence in the context of a 24-h day, which includes recommendations regarding sleep, sedentary behaviour, and MVPA, the CP agreed that several hours of LPA, which would comprise the remainder of the day, should be a strong recommendation.

Resistance exercise
The overview of reviews provided evidence that the benefits of RT (i.e., lower risk of mortality or myocardial infarction, improved blood pressure (indirect measure of incident CVD, included to assess effect of dose or age), muscle strength, and physical functioning) are likely to outweigh the potential harms (very lowquality evidence overall; El-Kotob et al. 2020). The potential benefits for mortality and, in particular the moderate quality evidence for improvements in physical functioning, provide support to recommend RT (Guyatt et al. 2013). Feedback from stakeholders revealed that 87.6% of the respondents aged 18-64 years and aged 65 years or older strongly agreed or somewhat agreed with how the recommendations were stated, and 65.6% of stakeholders agreed that the costs to implement the physical activity guidelines would be low or negligible (only 2.7% disagreed). There was debate concerning whether the recommendations should be strong or conditional. While the evidence pertaining to harms was rated as very low quality, there was evidence from 22 trials of 898 participants suggesting that serious adverse events were infrequent. Moreover, other national and international physical activity guidelines strongly recommend muscle strengthening activities using major muscle groups be performed at least twice a week because of the potential benefit relative to harms, providing further support for broad acceptability (World Health Organization 2015; Piercy et al. 2018). On the basis of these observations, the CP agreed that muscle strengthening activities using major muscle groups should be strongly recommended.
The previous Canadian Physical Activity Guidelines recommended adding "muscle and bone strengthening activities using major muscle groups, at least two days per week" (Tremblay et al. 2011). The CP considered whether changes to these recommendations were warranted, including changes to the recommended mode, frequency, or intensity of RT. Overall, there was evidence that a variety of RT programs (e.g., different intensities, durations, and types) were favourably associated with health outcomes. There was no statistically significant dose-response effect of RT frequency on risk of all-cause mortality (low-quality evidence; Saeidifard et al. 2019); indeed performing 1-2 sessions of RT was associated with lower all-cause mortality, and the effects of more than 2 sessions of RT per week were not statistically significantly different than 1-2 sessions. When comparing effects on muscle strength, the effect of frequency was inconsistent when it came to muscles of the upper and lower body, and estimates were imprecise (very low-quality evidence; Ralston et al. 2018). Thus, there was insufficient evidence to support a change in the current recommended frequency of muscle strengthening of major muscle groups at least twice per week (Tremblay et al. 2011). The CP discussed whether the intensity, degree of effort, or mode of RT should be made explicit in the recommendations, to avoid confusion as to what constitutes RT. However, a variety of intensities and modes of RT were associated with benefits, and there was no conclusive evidence on the superiority of 1 intensity or mode. Therefore, the CP decided that the intensity or mode would not be specified in the recommendations, but that knowledge dissemination or translation around recommended types of RT should reflect how existing evidence defined RT.
The CP considered whether RT should be included as part of the recommendation for MVPA. However, compositional analyses used to inform the recommendation of 150 min of MVPA did not include RT . Some CP members felt that it would be important to encourage both MVPA and RT to avoid encouraging only RT or only aerobic physical activity. Thus, the consensus was that we should keep RT as separate from the MVPA recommendation, consistent with previous guidelines. Finally, prior guidelines recommended "muscle and bone strengthening" (Tremblay et al. 2011), and we discussed whether "bone strengthening" should be included as part of the RT recommendation. Bone strengthening includes both RT and impact exercise, but the latter could also include types of MVPA, thus it may be confusing to include bone strengthening with the RT recommendation only. Therefore, the CP decided to remove bone strengthening, and instead mention the importance of impact exercise and RT for bone in the preamble and messaging. There were insufficient data to determine whether the effects were different in adults aged 18-64 years compared with adults aged 65 years or older, but there was evidence of the benefits of RT in adults between the ages of 18-64 years and over 65 years of age (Inder et al. 2016;Lai et al. 2018;Ashton et al. 2020), supporting the decision to retain the recommendations (Tremblay et al. 2011) for strengthening activities in both age groups.

Balance and functional training
In the overview of reviews, no systematic reviews that examined the effects of balance and functional training on the critical or important outcomes in adults aged 18 to 64 years were identified (McLaughlin et al. 2020). Given the evidence in favour of balance and functional training for adults 65 years and older, the CP considered whether it would be advisable to recommend balance and functional training for adults aged 18-64 years in anticipation of needs later in life (i.e., before balance becomes impaired). The CP concluded that there was insufficient evidence to support a recommendation for balance and functional training for adults aged 18 to 64 years, which is consistent with the previous Canadian Physical Activity Guidelines for Adults (18-64 years; Tremblay et al. 2011).
For adults aged 65 years and older, there was evidence that the benefits of balance and functional training outweighed potential harms. The overall quality of the evidence was rated as very low. Although the review by Sherrington et al (2019) rated the evidence pertaining to adverse events as very low quality, adverse event data from the intervention groups of 15 balance and functional training trials comprising 4167 participants suggested that the potential for harm did not outweigh the evidence pertaining to fall prevention. There were no studies that provided clear evidence of the most effective or minimum dose (frequency, intensity or duration; McLaughlin et al. 2020). Specifying a frequency may be less important than encouraging older adults to engage in daily activities that routinely challenge balance (Clemson et al. 2012). Although there was evidence regarding the effectiveness of different types of activities that challenge balance (e.g., balance and functional training, Tai Chi, yoga, or games with virtual reality or visual feedback), there was no evidence directly comparing these activities.
The previous Canadian Physical Activity Guidelines recommended "physical activities to enhance balance and prevent falls" for adults aged 65 years or older (Tremblay et al. 2011). To reflect the types of physical activities for which there was evidence (i.e., tailored exercise or physical activities that provide a sufficient challenge to balance), this terminology was changed to "physical activities that challenge balance" in the current guidelines. The phrase "and prevent falls" was deleted because there was evidence for other outcomes in addition to "falls" (i.e., physical functioning, fall-related fractures, physical activity levels). In addition, the previous guidelines (Tremblay et al. 2011) recommended balance activities only for "those with poor mobility". The evidence indicated that the effect of balance and functional training on rate of falls or risk of having 1 or more falls was not different in individuals with higher versus lower fall risk at baseline (Sherrington et al. 2019). Therefore, in the current guidelines, the evidence supported a recommendation of activities that challenge balance for all adults aged 65 years and older.

Sedentary behaviour
The CP leveraged evidence from the recently published US Scientific Report (2018 Physical Activity Guidelines Advisory Committee 2018) to prevent research waste and help determine the SED recommendation. Within that report the authors concluded that "Strong evidence demonstrates a significant relationship between greater time spent in sedentary behaviour and [1] higher all-cause mortality rates and [2] higher mortality rates from cardiovascular disease"; and that "Strong evidence demonstrates the existence of a direct, curvilinear dose-response relationship between sedentary behaviour and all-cause mortality, with an increasing slope at higher amounts of sedentary behaviour." The authors also concluded that "Strong evidence demonstrates the existence of a direct, positive dose-response relationship between sedentary behaviour and mortality from cardiovascular disease." For all observations, the Physical Activity Guidelines Advisory Committee assigned a "strong" grade. The authors of the US Scientific Report also concluded that limited evidence was available to suggest that the relationships between sedentary behaviour and these outcomes did not vary by age, sex, race/ethnicity, or weight status.
Our sedentary behaviour overview of reviews is consistent with the US Scientific Report and suggests that adults who limit their sedentary behaviour have more favourable levels of several critical and important health outcomes in adults and older adults . Most studies did not examine whether these results varied as a function of age, sex, race/ethnicity, socioeconomic status, weight status, or chronic disease status. The overall quality of evidence was low or very low for the critical health outcomes and low for important health outcomes. Taken together, the findings of our overview of reviews and the US Scientific Report support the recommendation to limit sedentary behaviour.
The findings from the overview of reviews and the US Scientific Report did not identify specific threshold values for daily sedentary behaviour or recreational screen time. However, following much discussion, the CP concluded that specific recommendations were unlikely to cause harm and had the potential for considerable benefit for end users (Chaput et al. 2020c;Neumann and Schünemann 2020). Our sedentary behaviour recommendations were informed by recent meta-analyses (Grøntved and Hu 2011;Chau et al. 2013;Sun et al. 2015;Ekelund et al. 2016Ekelund et al. , 2019Ku et al. 2018Ku et al. , 2019Patterson et al. 2018). These studies suggested that the risk of all-cause mortality increased more rapidly above threshold values ranging from 7 to 9.5 h/day for daily sedentary behaviour (Chau et al. 2013;Ku et al. 2018Ku et al. , 2019Patterson et al. 2018;Ekelund et al. 2019), with lower thresholds generally observed for selfreported sedentary behaviour and higher thresholds for devicemeasured sedentary time (Ku et al. 2018). With respect to screenbased sedentary behaviours, the risk of all-cause mortality was reported to increase above a threshold of 3 (Grøntved and Hu 2011;Ekelund et al. 2016), 3.5 (Patterson et al. 2018), and 4 h/day (Sun et al. 2015) of daily TV viewing, although Ekelund et al. (2016) noted a threshold of 5 h/day for those in the most physically active quartile.
It was considered impractical to provide a range of thresholds (i.e., no more than 7-9.5 h/day for total sedentary behaviour, or 3-4 h/day for recreational screen time). Eight hours/day was the approximate mid-point of the inflection points identified for daily sedentary behaviour and was therefore recommended as the threshold (target) for this behaviour. The reported inflection points for recreational screen time were more tightly clustered between 3 and 4 h/day; a threshold of 3 h/day was therefore suggested as most appropriate. The CP had prolonged and thoughtful discussion regarding these recommendations, which are based on the above evidence as well as the informed opinion of panel experts, and the observation that the benefits associated with adherence to the recommendations outweighed any possible negative consequence. In addition, more than 88.5% of stakeholders agreed with the wording of these recommendations, with few concerns (<11% of respondents) regarding the decision to include a threshold for daily sedentary behaviour or recreational screen time. The CP also recognized that these recommendations would likely stimulate further investigation and research on the health impact of sedentary behaviour across the adult lifespan.
Although the available dose-response evidence for screenbased sedentary behaviours relates to TV viewing, it was felt that a recommendation specific to TV viewing would not be appropriate based on changing media consumption habits (Prince et al. 2020). While some potential benefits of Internet and computer use were identified for older adults, there was no evidence to suggest that this should exceed 3 h/day. For these reasons, and to be consistent with the recommendations for Children and Youth (Tremblay et al. 2016(Tremblay et al. , 2017b, our Guidelines refer to recreational screen time. The overview of reviews also suggested that breaking up long periods of sitting had beneficial impacts on markers of cardiometabolic risk and body composition . However, no specific threshold values were identified for the optimal timing or frequency of breaks in prolonged sitting. It was also noted that some individuals may not be able to break up their sitting behaviour at a specified frequency given their occupation or personal circumstances. Therefore, the CP recognized that the recommendation should be to break up long periods of sitting as often as possible, rather than provide a specific frequency. In summary, on the basis of these observations, the CP concluded that the sedentary behaviour recommendations should be rated as "strong" for both adults (18-64 years) and adults aged 65 years and older.

Sleep
For the sleep duration overview of reviews (Chaput et al. 2020a), the dose-response curves showed that a sleep duration of around 7-8 h per day was most favourably associated with the critical health outcomes that were examined. Most studies did not examine a possible modification of the effect by age. The overall quality of evidence was moderate for the critical health outcomes examined. The CP decided to recommend 7-9 h of sleep per day for adults (18-64 years) and 7-8 h for adults aged 65 years and older for several reasons. First, bringing the upper limit to 9 h instead of 8 h for adults aged 18-64 years was considered likely to be associated with more benefits than harms. There is no plausible biolog-ical mechanism by which an additional hour of sleep can harm health and the association between long sleep and poor health has been shown to be due to reverse causation and residual confounding (e.g., depression, chronic pain, obstructive sleep apnea) in previous studies among general and clinical populations (Knutson and Turek 2006;Stamatakis and Punjabi 2007;Chaput et al. 2018). We also do not want adults who typically sleep 9 h per day to restrict their sleep to 8 h, because there is large interindividual variability in sleep needs (as reflected in the measures of variability in the dose-response data) and this strategy would likely adversely impact their health. Adults also tend to measure their sleep in terms of "time in bed" rather than actual sleep duration. For example, if someone is in bed for 9 h but only sleeps 7.5 of those hours, we would not want them to restrict their time in bed if the upper limit was 8 h. Moreover, conveying the message that sleep duration varies across the lifespan and shows an inverse association with age was judged important by the CP (Chaput et al. 2018). In general, most retired adults aged 65 years and older have decreased or no employment-related responsibilities and less obligatory sleep schedule demands (Hirshkowitz et al. 2015). Long sleep duration in older adults (i.e., ≥9-10 h per day) is associated with comorbidities and mortality, and excessive sleep may be a marker signaling the need for medical evaluation (Hirshkowitz et al. 2015). This explains why we recommended 7-8 h of sleep per day for adults aged ≥65 years. Finally, our recommendations are consistent with those of the National Sleep Foundation in the United States (Hirshkowitz et al. 2015). Although their guideline development process differed from ours, it was robust; a multidisciplinary expert panel in the United States relied on a systematic assessment of the evidence, used a formal consensus and voting process, and used the RAND/UCLA Appropriateness Method to formulate their sleep duration recommendations.
Sleep quality was not specifically reviewed but was deemed an important additional consideration. The "good-quality sleep" qualifier was added to the guidelines because of the compelling body of evidence demonstrating that both sleep duration and sleep quality are important for overall health (Ohayon et al. 2017) and to be consistent with the Canadian 24-Hour Guidelines for other age groups (Tremblay et al. 2016(Tremblay et al. , 2017b. The National Sleep Foundation in the United States also has specific sleep quality recommendations (Ohayon et al. 2017).
For the sleep timing and consistency de novo systematic review (Chaput et al. 2020b), the available evidence indicated that earlier sleep timing and regularity in sleep patterns with consistent bedtimes and wake-up times were favourably associated with health, with no apparent modification of the effect by age. However, because most studies reported linear associations between sleep timing/consistency and health outcomes, it was not possible to identify thresholds for "late sleep timing" or "large sleep variability". The overall quality of evidence was very low based on GRADE. We thus recommended "consistent bed and wake-up times" in general terms given the absence of evidence for more specific thresholds. We did not specifically add a recommendation about earlier sleep timing such as going to bed and waking up earlier to respect the chronotype of people (Ritonja et al. 2018;Taylor and Hasler 2018). Moreover, this may not be possible for adults with young children and/or those who work atypical hours. Finally, by meeting the sleep duration recommendation (stronger evidence based on GRADE), sleep timing automatically needs to be adjusted (e.g., adults may have to go to bed earlier on workdays to achieve 7-9 h of sleep). The CP judged that the sleep recommendations should be rated as "strong" for both adults and older adults because the potential benefits of adhering to the guidelines far outweigh any potential harms. Findings from the stakeholder survey also indicated that using the sleep guidelines would be feasible (83.6%), cost-effective (65.6%), and equitable (85.4%), further supporting the CP decision to provide a "strong" recommendation.

Composition of movement behaviours
The systematic review of compositional data analysis studies reported that the composition of movement behaviours across the 24-h day is associated with health outcomes . This is an important observation and supports the notion that recommendations for sleep, sedentary behaviour, and physical activity can and should be combined into a single public health guideline that encompasses movement across the full 24-h day. Estimates from time reallocation models suggest that (i) health would improve if time was reallocated into MVPA irrespective of what other movement behaviour(s) that time was reallocated from; (ii) health would improve if some of the time spent in sedentary behaviour during waking hours was reallocated into LPA; and (iii) reallocating time from sedentary behaviour into sleep would benefit health while reallocating time from physical activity into sleep would be unfavourable to health. Based on these time reallocation findings, the CP included the following statement in the guidelines: "Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits." Because the overall pattern of results did not present a picture of the 24-h movement behaviour composition being a weaker or stronger predictor of health outcomes in adults younger than 65 years versus adults aged 65 or older, the integrated messages included in the guidelines are the same for both age groups.

Values and preferences of stakeholders
The CP considered the importance (values and preferences) of stakeholders and end-users when rating the identified outcomes as critical/important/not important at the first CP meeting. The stakeholder survey results revealed that the recommendations were important to almost all (87.5%) of the respondents, and that by comparison to separate movement guidelines, most (73.1%) indicated that the integrated 24-h movement guidelines are "more" or "much more" useful. The assessments of stakeholder values and preferences, together with the broad range of health indicators/outcomes included in the systematic reviews that informed these recommendations, provide support for the conclusion that there is little or no uncertainty about preferences regarding the main outcomes examined.

Resource requirements
In addition to the input via the stakeholder survey regarding cost and resource use, the CP considered a body of evidence that addressed savings to the health care system from increasing levels of physical activity and decreasing sedentary behaviour as an additional consideration that informed discussion on the resource implications of the recommendations. Evidence supports that there are substantial health savings possible to the health care system resulting from adherence to the guideline recommendations. There is evidence that the costs associated with the recommended behaviours are low, and the costs associated with not engaging in the recommended behaviours are high (Katzmarzyk et al. 2009;Janssen 2012;Bounajm et al. 2014). In addition, there is evidence that not following the guidelines can result in greater resource use. For example, the estimated direct, indirect, and total health care costs of physical inactivity in Canada in 2009 were $2.4, $4.3, and $6.8 billion, respectively, values that represent 3.8%, 3.6%, and 3.7% of the overall health care costs in Canada. These estimated cost savings are reinforced by a recent economic analysis in Australia demonstrating that the potential annual cost saving remains more than $1000 per adult ($1121) from meeting (≥150 min/week) versus not meeting (<150 min/week) the MVPA guidelines (Eckermann et al. 2020). Further, it is estimated that increasing physical activity and reducing sedentary behaviour would reduce Canada's health care costs "by $2.6 billion and in-ject $7.5 billion into the Canadian economy by the year 2040" (Bounajm et al. 2014). There is also evidence in adults that inadequate sleep has a substantial economic impact (e.g., via performance deficits, accident rates, and health care utilization) and significant public health implications (Institute of Medicine (US) Committee on Sleep Medicine and Research 2006; Hillman and Lack 2013).
The CP also received input via the stakeholder survey on opinions regarding cost and resource use. Most stakeholders (65.6%) agreed that the costs associated with implementing the recommendations would be small or negligible compared with not using the guidelines. Most stakeholders (69.9%) also agreed that the benefits of using the guideline recommendations are likely to outweigh the costs (e.g., time, financial) in their professional work. In the judgment of the CP, considering the available information, the cost-effectiveness of the recommendations is supported. Based on these observations the CP concluded that the guideline recommendations have beneficial implications from a resource perspective, in addition to the benefits with respect to health indicators.

Equity, acceptability, and feasibility
The CP recognized that achieving the target recommendation for any or all movement behaviours may be challenging for some adults. Meeting the recommendation for sitting may be difficult for some occupations (e.g., truck drivers) and for sleep (e.g., shift workers). The CP acknowledged this challenge and responded by including the observation within the Preamble of both the Adults aged 18-64 and Adults aged 65 years and older guidelines noting that "Following these Guidelines may be challenging at times; progressing towards any of the Guideline targets will result in some health benefits".
The CP also received input through the stakeholder survey regarding feasibility and applicability. Most stakeholders (85.4%) agreed that following these recommendations would benefit adult Canadians regardless of age, biological sex, race, ethnicity, or socioeconomic status. In the judgment of the CP, implementing these recommendations would likely increase health equity (i.e., decrease health inequity). Similarly, most stakeholders (68.3%) indicated that they would "always" or "frequently" use the recommendations. Therefore, the CP concluded that these recommendations are acceptable. Finally, most stakeholders (83.6%) indicated that the recommendations were "somewhat" to "very easy" to use. Based on this information, in the judgment of the CP, the recommendations are feasible to implement.

Surveillance recommendations
For each recommendation contained in the guideline, the Surveillance Subcommittee suggested specific measures and, if appropriate, cut-points to define adherence to the recommendation. A rationale was provided for each of these suggestions. For each guideline recommendation the Subcommittee also considered whether adherence to that recommendation should be a requirement for minimal inclusion for overall 24-h guideline adherence. Analytical recommendations, such as whether self-reported and/or objective data should be used for surveillance, were also made. The recommendations and suggestions made by the Subcommittee are provided in Table 4. It is recommended that for an adult to be considered to meet the new guidelines, they need to meet the specific time recommendations for sleep duration, sedentary time, recreational screen time, and MVPA. Overall guideline adherence can be assessed using self-reported data alone or a combination of self-reported and objectively measured data, but the mode of data collection should be reported with prevalence levels.

KT
Concurrent with the guideline development process, the KT Advisory Committee established the target audiences for guideline dissemination and implementation and conducted formative research to inform the design of dissemination and implementation efforts for the selected target audiences. Given the increased attention on KT from the onset of the guideline development process, the KT efforts for the new guidelines include novel contributions to enhance awareness and use of the new guidelines among Canadians. For example, in addition to development of the scientific guideline documents for health professionals, policymakers and researchers, a focus of the dissemination efforts was the creation of public-facing materials to resonate with members of the general public (Appendix B). Further, a theoretically informed implementation intervention is being collaboratively designed, representing the first multicomponent attempt to enhance use of the new guidelines. An evaluation plan of dissemination and implementation efforts is in place and will be reported following guideline release. Full details outlining the KT process and outcomes are found in Tomasone et al. (2020a).

Research gaps
Research gaps identified throughout the guideline development process including the systematic reviews, compositional analyses, CP meetings, and Leadership Committee meetings are listed in Table 5. Consistent with prior Canadian 24-Hour Movement Guidelines (Tremblay et al. 2016(Tremblay et al. , 2017b, numerous data and research gaps have been identified. This is a consequence of moving from the generation of guidelines based on the isolation of a single behaviour to those that integrate several behaviours. Importantly, the research gaps identified will help inform the research questions that underpin the future of guideline development and movement behaviour integration.

External review: AGREE II assessment
The initial summary evaluation from the AGREE II assessment is provided in Table 6. Four independent reviewers applied the AGREE II assessment, and domain score averages were computed using the AGREE II Instrument calculation (Brouwers et al. 2016).
The guideline development process was scored very high (Domain average ratings across the 4 external reviewers ranged from 87.5% to 93.8%), and all assessors indicated that they would recommend the guidelines for use.

Discussion
In this report we describe the process used to generate the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older, a world first. In doing so we complete the development of 24-Hour Movement Guidelines for Canadians across the lifespan. The guideline development process adhered to the framework used to develop previous 24-Hour Movement Guidelines for Children and Youth (aged 5 to 17 years; Tremblay et al. 2016) and the Early Years (aged 0-4 years; Tremblay et al. 2017).
The CP was tasked with the development of 2 guidelines: for adults aged 18 to 64 and for adults aged 65 years or older. The development procedures for both guidelines were comprehensive and transparent incorporating both de novo systematic reviews and overview of reviews to summarize and assess current knowledge ). The final guideline recommendations were informed by the best available evidence, expert consensus, stakeholder consultation, and consideration of values and preferences, applicability, feasibility, and equity. The guidelines (Figs. 2-3) are presented using a format consistent with previous 24-Hour Movement Guidelines (Tremblay et al. 2016(Tremblay et al. , 2017b, wherein the context for the guidelines is given through a preamble followed by the guidelines themselves. The preamble and guidelines as presented in Figs. 2-3 are intended for policy makers, health to be counted (i.e., obtained in bouts of 10 min or more). The evidence that informed this guideline indicated that both bouted and nonbouted moderate-to-vigorous physical activity can benefit health, so the 10-min bout stipulation was removed Although the evidence is primarily based on studies that used self-reported data, in recent years it has been corroborated based on evidence from accelerometer data The evidence that informed the guideline also indicated that moderate-to-vigorous physical activity does not need to be accumulated on every day or most days as long as the weekly total is achieved professionals, and researchers. User-friendly messaging materials targeting the general public were developed as outlined in the KT section of the Results. An implementation intervention aiming to enhance use of the 24-Hour Movement Guidelines among postsecondary students is planned. An evaluation of the dissemination and implementation activities is also in the development stage. The fundamental assertion of 24-Hour Movement Guidelines is that the integration of all movement behaviours throughout the day is associated with health, and provides unique, evidencebased opportunities to engage in movement behaviour compositions that reflect and respect the individuality, variability, and personal preferences of the end user. This paradigm shift away from a focus on a single movement behaviour to the integration of all movement behaviours reflects a growing body of evidence suggesting that the mixture of the movement behaviours that comprise a 24-hour day influences a range of health outcomes (Chastin et al. 2015;McGregor et al. 2018McGregor et al. , 2019. These early obser- Table 5. Research gaps identified through the guideline development process.

Research needs arising from overviews of systematic reviews and systematic reviews of primary studies
• Need for high-quality studies with stronger designs (e.g., randomized controlled trials or longitudinal studies, larger sample sizes, objective measures) • Examine possible dose-response relationships between movement behaviours and health outcomes, an examination of the effect of different doses (i.e., duration, frequency) of resistance training, balance and functional training, sedentary behaviour, and sleep on health outcomes is needed • Further examination of whether associations differ between demographic subgroups (i.e., based on age, sex, race/ethnicity, socioeconomic status, or weight status) • Examination of how smartphones, social media, or other forms of new media impact health • Examination of the relationship between occupational sedentary behaviour and health outcomes • Studies that compare the health impacts of mentally active and mentally passive forms of sedentary behaviour • Further research on the relationship between sedentary behaviour and sleep • Examination of the impact of sleep quality, sleep timing, sleep consistency, napping, and daytime alertness on health, including determining clear cut-points for public health guidance • Studies that examine sleep duration over multiple time points are needed to better capture the chronic effects of sleep duration over time, specifically related to long-term disease incidence • Exploration of the associations between resistance training and incident type 2 diabetes, incident depression, brain health, bone health, incident cancer, and fall-related injuries or falls are needed • Exploration of the associations between sleep duration and health-related quality of life, work productivity, physical activity, and sedentary behaviour are needed • Exploration of the associations between sleep timing and consistency and mortality, falls, and work productivity are needed

Research needs arising from compositional analyses • Longitudinal and intervention research to confirm cross-sectional findings
• Research utilizing valid approaches for measuring all intensities of movement not just moderate-to-vigorous physical activity to better examine the relative contribution of movement behaviours • Research further utilizing compositional data analysis statistical techniques to explore the associations between movement behaviours and a wider variety of health outcomes (there were findings for only 4 of the 15 critical health outcomes in this review) • Research examining whether associations differ between demographic subgroups (i.e., based on age, sex, race/ethnicity, socioeconomic status, or weight status)

Research needs arising from consensus panel meetings and discussions
• Physical activity ‫ؠ‬ Research examining different doses of resistance training e.g., varying frequencies or intensities of resistance training ‫ؠ‬ Research examining the benefits of resistance training independent of and in addition to, moderate-to-vigorous intensity aerobic physical activity for a number of health outcomes (e.g., mortality, mood, falls, bone health, cardiovascular disease, diabetes, harms, others) ‫ؠ‬ Research examining the acute effect of a single bout of physical activity on health ‫ؠ‬ Research examining the relationship between light-intensity physical activity and health outcomes ‫ؠ‬ Role of standing on health ‫ؠ‬ Research examining the impact of functional and balance training on health in adults aged 18-64 y and higher quality research examining effects of functional and balance training on physical function, quality of life, and harms

Other research needs • Cost effectiveness analyses of implementing the new guidelines at both organizational and individual levels
• Comparisons between jurisdictions of the prevalence of adults meeting the 24-h guidelines and examination of correlates and determinants that may explain differences • Examination of within and between family variance in meeting 24-h movement guidelines • Research into best practice for dissemination and implementation of guidelines at a national scale vations were reinforced by the systematic review regarding the composition of movement behaviours in this special supplement providing additional justification for the packaging of recommendations for sleep, sedentary behaviour, and physical activity into the Canadian 24-Hour Movement Guidelines . Key findings from the systematic review of compositional data analysis identify the potential health benefits of reallocating time from 1 behaviour to another. For this reason, the guidelines for both adults aged 18 to 64 years and adults aged 65 years or older include the statement that "Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits." These seminal messages have considerable implications for the promotion of public health and are unique to the fundamental principles that underscore 24-Hour Movement Guidelines.  Table 2 3. The population (patients, public, etc.) to whom the guideline is meant to apply is specifically described Process paper, preamble, Table 2 Domain 2. Stakeholder involvement 87.5 4. The guideline development group includes individuals from all the relevant professional groups Process paper, Table 1 5. The views and preferences of the target population (patients, public, etc.) have been sought Process paper, Stakeholder consultations, Table 3, Faught et al. (2020) paper 6. The target users of the guideline are clearly defined Process paper, guideline preamble Domain 3. Rigour of development 90.6 7. Systematic methods were used to search for evidence Process paper; Individual systematic reviews and overviews of reviews 8. The criteria for selecting the evidence are clearly described Process paper, individual systematic reviews and overviews of reviews 9. The strengths and limitations of the body of evidence are clearly described Process paper 10. The methods for formulating the recommendations are clearly described Process paper, guidelines recommendations 11. The health benefits, side effects and risks have been considered in formulating the recommendations Process paper, ETD summary 12. There is an explicit link between the recommendations and the supporting evidence Process paper, ETD summary 13. The guideline has been externally reviewed by experts prior to its publication Process paper, Table 6 14. A procedure for updating the guideline is provided Process paper, Discussion   Table 1 Note: ETD, evidence to decision; NA, not applicable. a Four independent reviewers applied the AGREE II assessment using available documents at the time of manuscript submission. The Initial Domain Scores (%) were calculated by summing up all the scores of the individual items in a domain and by scaling the total as a percentage of the maximum possible score for that domain (ref). Following receipt of these comments, we clarified reporting where possible.
b Item 16 was rated as "not applicable" by 3 reviewers and the assessment of the other reviewer was included in the scaled Domain 4 score. c Items 17 and 18 were rated as "not applicable" by 2 reviewers and the assessment of the other two reviewers were included in the scaled Domain 5 score. Item 19 was rated by a single reviewer (without having access to the public-facing documents) based on the knowledge that the relevant materials were in development by an experienced group.
The 24-Hour Movement Guidelines that append this report  reveal that with few exceptions, the physical activity components for both age groups are similar. The recommendation that adults of all ages strive to achieve at least 150 min per week of MVPA is consistent with previous Physical Activity Guidelines for Adults and Older Adults in Canada (Tremblay et al. 2011). The notable exception to the previous guidelines is the decision to omit the requirement that the accumulation of MVPA be acquired in bouts ≥10 min. This evidence-informed decision has important public health implications as it suggests that increasing MVPA, regardless of bout length, is likely associated with benefit across a variety of health outcomes Physical Activity Guidelines Advisory Committee 2018Jakicic et al. 2019). The CP acknowledged that this observation is particularly relevant for individuals who may be unable or unwilling to engage in MVPA bouts that are ≥10 min in duration. Encouraging participation in MVPA of any length throughout the day provides additional options for adults of all ages, which facilitates engagement and promotes opportunities to increase movement behaviour and thus, mitigate health risk.
The recommendation that a healthy 24-hour day for both adults aged 18 to 64 years and 65 years or older includes several hours of LPA is a new recommendation for adults that has several public health implications. The CP acknowledged that the evidence base for this recommendation is limited. However, it is encouraging that emerging evidence clearly demonstrates that LPA is associated with a substantially reduced risk of all-cause mortality in a dose-response manner Ekelund et al. 2019). The CPs confidence of the importance of LPA was reinforced by the results of the compositional analysis demonstrating that replacing sedentary time with LPA is associated with a decrease in mortality . These observations underscore the importance of 24-Hour Movement Guidelines that encourage the adoption of physical activity behaviours over the entire waking day regardless of duration and/or intensity. The CP also noted that the LPA recommendation would support public health initiatives that advocate for engaging in quiet standing (instead of sitting), and routine activities of daily living such as casual walking, taking a flight of stairs instead of the elevator and doing household chores.
The guideline recommendations for sedentary and sleep behaviour represent the first time Canadian adults regardless of age have evidence-based guidelines for either behaviour. For sedentary behaviour, the recommendation to limit sedentary time to less than 8 h per day is for adults of all ages . It is also recommended that adults regardless of age try and break up long periods of sitting and limit daily recreational screen time to 3 h or less. The CP had prolonged and thoughtful discussion regarding the threshold values for both recommendations and whether a recommendation specific to screen time should be included. In addition to the evidence reviewed , the Panel based the recommendations on the informed opinion of panel experts, stakeholder input, and the observation that the benefits associated with adherence to the recommendations outweighed any possible negative consequence. The CP also recognized that these recommendations would stimulate additional investigation that would advance the field and help refine future guidelines.
The recommendation for sleep differs slightly for the 2 age group guidelines. For adults aged 18 to 64 years, the recommendation is that adults attain 7-9 h of sleep per day whereas for adults aged 65 years and older, the recommendation is to achieve 7-8 h of sleep per day (Chaput et al. 2020a). The supporting rationale for the distinctive recommendations is given elsewhere in this special supplement (Chaput et al. 2020a). The CP recognized the importance of sleep as an integral part of a healthy day and sought to assure that sleep was not sacrificed with attempts to either increase physical activity or decrease sedentary behaviour. Accordingly, the guideline recommends replacing sedentary be-haviour with additional physical activity while preserving sufficient sleep.
The guideline recommending that both adult age groups perform muscle-strengthening activities using major muscle groups at least twice a week , and that adults greater than 65 years of age perform activities that challenge balance (McLaughlin et al. 2020) is consistent with the Physical Activity Guidelines for Adults and Older Adults in Canada released in 2011 (Tremblay et al. 2011). A notable exception to the wording of the muscle strengthening recommendation is the omission of a reference to bone strengthening, which was a part of the muscle strengthening recommendation in 2011 (Tremblay et al. 2011). The CP considered that the inclusion of "bone strengthening" with "using major muscle groups" within the same recommendation may be confusing to end users. It was also recognized that modalities of MVPA (e.g., impact exercise) could improve bone strength. Taken together the decision was made to omit bone strengthening from the muscle strengthening recommendation. It is noteworthy, however, that "improved bone health" is identified as a benefit of following the 24-Hour Movement Guidelines within the Preamble of both guidelines. The wording of the recommendation that a healthy 24-h day for adults aged 65 years or older include physical activities that challenge balance also differs from the physical activity guidelines for older adults released in 2011 (Tremblay et al. 2011); the associated rationale is provided earlier in this report (see Balance and functional training section).
Consistent with previous 24-Hour Movement Guidelines, the guidelines here do not provide precise recommendations for each behaviour that would sum to 24 h. To the contrary, ranges are provided for the behaviour components (e.g., no more than 3 h of recreational screen time, several hours of light physical activities, 7 to 9 h of good-quality sleep) reflecting best evidence, and respects that individual movement behaviour for any given day is influenced by numerous factors including personal motivation, health, social and socioeconomic issues, workplace, and the built environment in which the individual lives. To provide precise recommendations would undermine the extraordinary opportunities that are inherent to the 24-Hour Movement Guidelines that provide a variety of movement options that mitigate health risk regardless of age. In contrast to the restriction in movement options that result from a focus on a single movement behaviour, guideline recommendations based on the integration of movement behaviours cater to individual differences in ability and feasibility, provide a wide variety of daily movement options for the practitioner, and consequently promote a positive health message that will empower the end-user.
Early in the guideline development process the CP recognized that there was a need for a long-term plan for dissemination and implementation of the guidelines in an effort to avoid "launching and leaving". As a result, the decision was made to form a KT Advisory Committee to ensure that an integrated KT process was undertaken to engage relevant organizations, stakeholders, researchers, and end-users to guide all stages of the guideline KT process. Important outcomes of the KT procedure include (i) a governance structure, terms of reference, and decision-making criteria for a guideline KT team; (ii) selection of the target audiences for dissemination and implementation efforts, along with a series of formative research projects to ensure KT efforts met the needs of the selected target audiences; (iii) a robust rationale and evidence to inform the first Canadian public-facing versions of a 24-Hour Movement Guideline; (iv) a novel focus on developing an implementation intervention to enhance guideline use; (v) an evaluation structure; and (vi) a framework and sharing of lessons learned that can serve as a template for other groups seeking to enhance dissemination and implementation of their guidelines. These outcomes will hopefully result in an increase in the uptake of the guidelines and will serve as a template for future guideline development panels.

Strengths and limitations
Strengths of the guideline development process include strict adherence to guideline development standards that are well established (Tremblay and Haskell 2012) and consistent with past 24-Hour Movement Guidelines (Tremblay et al. 2016(Tremblay et al. , 2017b, independent assessment by methodological consultants, involvement of a broad range of relevant experts, international collaborators, stakeholders and end-users, and consideration of a range of health indicators as well as new systematic reviews and overviews to develop the knowledge base. The decision to form a KT committee early in the guideline development process with expertise in the dissemination, implementation, and evaluation of the guidelines will help ensure uptake of the guidelines across a wide range of stakeholders and end-users. Based on GRADE criteria, the quality of evidence for most of the guideline recommendations were rated as low or very low. However, thoughtful consideration was given to the wording of the recommendations and rating of their strength (strong or conditional/weak) was based on the balance between desirable and undesirable effects, the quality of evidence, the values and preferences of stakeholders, as well as acceptability, feasibility, and resource implications. Based on a careful consideration of these GRADE criteria collectively, the CP was confident in the favorable balance observed between the desirable and undesirable consequences and thus, rated all recommendations as strong despite low-or very-low quality evidence. Other limitations include a paucity of research that informed specific aspects of the guidelines (e.g., dose-response studies on behaviour frequency, intensity, or duration). The integrated analysis was primarily informed by a single systematic review that was limited to studies that used compositional analysis to examine how movement across the full 24-h day is associated with health. However, this is both a limitation and a strength. It is a weakness because compositional data analysis, while a well-established statistical technique, has only been used by a small group of movement behaviour scientists over the past 5 years. It is a strength because compositional data analysis allows researchers to simultaneously study the health effects of all movement behaviours in a manner that recognizes and statistically accounts for their inherent codependency. Accordingly, our conclusion that the composition of movement behaviours across a 24-h day is associated with health should be interpreted with this strength and limitation in mind.

Updating the guidelines
With the current release of the Canadian 24-Hour Movement Guidelines for Adults aged 18-64 and Adults aged 65 years or older, we complete the set of movement guidelines that now provide recommendations for the integrated movement behaviours across the life span. This series of three 24-Hour Movement Guidelines have been completed over a relatively short period of time (2015-2020). The next and last step in guideline development is to consider the strategy that will be implemented to update and revise the guidelines. Previous guideline development panels have recommended that the guidelines be updated and released every 10 years or whenever important new evidence is identified that could inform and/or suggest revisions to the existing guideline recommendations (Tremblay et al. 2016). A 10-year cycle would allow appropriate time for dissemination and implementation strategies to take hold among stakeholders and end-users across Canada, and for researchers to address important research gaps.
Unlike the commitment to update and revise Canada's Dietary Guidelines every 10 years (i.e., Canada's Food Guide), which is mandated under federal legislationthe Food and Drugs Act inclusive of Food and Drug Regulations, there is no existing federal legislation to support a regular cycle for updating the 24-Hour Movement Guidelines. Thus, there is no assurance that the guidelines will ever be updated despite public health importance. The CSEP has a long standing and proud history of leading the development and release of Physical Activity, Sedentary Behaviour, and more recently, 24-Hour Movement Guidelines in partnership with the federal government and scientific and policy experts. The CSEP remains committed to working with its partners to ensure that the 24-Hour Movement Guidelines are updated and revised on apredetermined cycle to ensure Canadians receive the best possible guidance and consequently mitigate health risk. Therefore, the CP calls on the federal government to pass legislation that would mandate the update and release of the 24-Hour Movement Guidelines every 10 years.

Conclusion
The Canadian 24-Hour Movement Guidelines for Adults aged 18-64 years and Adults aged 65 years or older: An Integration of Physical Activity, Sedentary Behaviour, and Sleep completes the set of 24-Hour Movement Guidelines that together provide recommendations for healthy movement behaviours for the whole day for all Canadians. The Guidelines were generated based on the best available evidence with extensive consultation and stakeholder feedback. The CP recognized that to adopt and sustain any movement behaviour in today's environment presents very real challenges for all adults. It is hoped that the shift in focus from movement behaviours in isolation to the integration of all movement behaviours over the whole day will provide movement options for adults, treatment options for practitioners, and greater opportunities for public health promotion.

Conflict of interest statement
Julie Carrier reports grants from Canopy Growth, grants from Rana, grants from Philipps/Respironics, grants from Merck, and grants from Eisai, outside the submitted work. Mary Duggan reports grants from the PHAC to CSEP. Michelle Kho reports receiving personal fees from the CSEP and Canada Research Chairs Grants, outside of the submitted work. Kaleigh Maclaren reports receiving grants from the PHAC to CSEP. Sharon Marr reports receiving stipends from the Department of Medicine (Geriatric Medicine) and RGPc, holds a patent with GCP (official trademark) and receives grant funding from CIHR, the Centre for Aging and Brain Health Innovation, the Physicians' Services Inc. Foundation, and the Provincial Geriatrics Leadership Office, outside of the submitted work. Veronica Poitras reports receiving personal fees from the CSEP and is an employee of the Canadian Agency for Drugs and Technologies in Health. Robert Ross reports receiving grants from CIHR, outside of the submitted work. Amanda Ross-White reports receiving personal fees from the CSEP and personal fees from ProQuest LLC, outside of the submitted work. Travis Saunders reports receiving grants from PHAC during the conduct of the study and personal fees from PHAC and the PEI Public Schools Branch. He has also received conference funding from Ergotron outside of the submitted work. Mark Tremblay reports leading similar guidelines for Canada for the Early Years (0-4 years) and Children and Youth (5-17 years) for the CSEP.
to thank Emma Faught and Alexandra Walters for their assiduous work on the stakeholder survey.
After reviewing the evidence, experts have produced draft versions of the Canadian 24-Hour Movement Guidelines for Adults and Older Adults. As a relevant stakeholder in Canada connected with physical activity, sedentary, and/or sleep behaviours, you are being invited to participate in a survey soliciting your opinion on these draft versions of the 24-Hour Movement Guidelines. You will be asked for your feedback and level of agreement with the content of the 24-Hour Movement Guidelines. This information is important for the alignment of strategic efforts in policy, practice, and the promotion of health to Canadian adults and older adults.
There are no direct risks associated with participating in the survey. You may benefit from early exposure to the 24-Hour Movement Guidelines and may become more equipped to promote and implement them. Participation in this survey is voluntary and should take approximately 20 minutes. You do not have to answer any questions you do not want to. You can stop participating at any time without penalty. The survey does not collect information about your name or email address and responses will be presented in group format only. Since the data are anonymous, withdrawal after completion of the survey is not possible. The study team will have access to your study data during and after collection. Queen's General Research Ethics Board (GREB) may request access to study data to ensure that the researcher(s) have or are meeting their ethical obligations in conducting this research. GREB is bound by confidentiality and will not disclose any personal information. Your data will be stored securely for at least five years as per Queen's University Policy. After 5 years, your data will be archived. The results of this survey will be shared with parties involved in the development and promotion of the 24-Hour Movement Guidelines for Adults and Older Adults.
If you have any questions about the research, please contact the principal investigator at tomasone@queensu.ca or 613-533-6000 ext. 79193.
If you have any ethics concerns, please contact the General Research Ethics Board (GREB) at 1-844-535-2988 (Toll free in North America) or email chair.GREB@queensu.ca.
You have not waived any legal rights by consenting to participate in this study.
Please note that the Guidelines are currently in draft form and stakeholder consultation is being sought. The final versions of the Guidelines will be released October 2020. As a valued and trusted stakeholder, we have shared confidential draft recommendations for your feedback. Please do not share the recommendations. If you have further inquiries, please contact the Guideline development Chair, Dr. Robert Ross, at rossr@queensu.ca.
By clicking "Next" to begin the survey, you are consenting to participate.
Thank you for your time!

Section 5
Please note that the purpose of the Preamble is to provide context for the Canadian 24-Hour Movement Guidelines.

PREAMBLE FOR ADULTS
These 24-Hour Movement Guidelines are relevant to adults (aged 18-64 years), irrespective of gender, cultural background, or socio-economic status. These Guidelines may be appropriate for adults who are pregnant or persons living with a disability or a medical condition; these individuals should consider consulting the Get Active Questionnaire, disability/condition-specific recommendations, or a health professional for guidance.
Adults should participate in a range of physical activities (e.g., weight bearing/non-weight bearing, sport and recreation) in a variety of environments (e.g., home/work/community; indoors/outdoors; land/water) and contexts (e.g., leisure, transportation, occupation, household) across all seasons. Adults should limit periods of prolonged sedentary behaviours and should practice healthy sleep hygiene (routines, behaviours, and environments conducive to sleeping well).
Following these 24-Hour Movement Guidelines is associated with a lower risk of mortality, cardiovascular disease, hypertension, type 2 diabetes, several cancers, anxiety, depression, dementia, weight gain, adverse blood lipid profile and improved bone health, cognition, quality of life and physical function. The benefits of following these Guidelines far exceed potential harms.
These 24-Hour Movement Guidelines were informed by the best available evidence, expert consensus, stakeholder consultation, and consideration of values and preferences, applicability, feasibility, and equity. More details on the Guidelines, the background research, their interpretation, guidance on how to achieve them, and recommendations for further research and surveillance are available at https://csepguidelines.ca/.

PREAMBLE FOR OLDER ADULTS
These 24-Hour Movement Guidelines are relevant to older adults (aged 65 years or older), irrespective of gender, cultural background, or socio-economic status. These Guidelines may be appropriate for older adults living with a disability or a medical condition; these individuals should consider consulting the Get Active Questionnaire, disability/condition-specific recommendations, or a health professional for guidance.
Older adults should participate in a range of physical activities (e.g., weight bearing/non-weight bearing, sport and recreation) in a variety of environments (e.g., home/work/community; indoors/ outdoors; land/water) and contexts (e.g., leisure, transportation, occupation, household) across all seasons. Older adults should limit periods of prolonged sedentary behaviours and should practice healthy sleep hygiene (routines, behaviours, and environments conducive to sleeping well).
Following these 24-Hour Movement Guidelines is associated with a lower risk of mortality, cardiovascular disease, hypertension, type 2 diabetes, several cancers, anxiety, depression, dementia, weight gain, adverse blood lipid profile, falls and fall-related injuries, and improved bone health, cognition, quality of life and physical function. The benefits of following these Guidelines far exceed potential harms.
These 24-Hour Movement Guidelines were informed by the best available evidence, expert consensus, stakeholder consultation, and consideration of values and preferences, applicability, feasibility, and equity. More details on the Guidelines, the background research, their interpretation, guidance on how to achieve them, and recommendations for further research and surveillance are available at https://csepguidelines.ca/.

Section 6
The drafted Canadian 24-Hour Movement Guidelines for Adults and Older Adults are shown below.

GUIDELINES FOR ADULTS
For health benefits, adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
A healthy 24-hours includes: Performing a variety of types and intensities of physical activity, which includes: • Moderate to vigorous aerobic physical activities such that there is an accumulation of at least 150 minutes per week • Muscle strengthening activities using major muscle groups at least twice a week • Several hours of light physical activities, including standing Limiting sedentary time to 8 hours or less, which includes: • No more than 3 h of recreational screen time, and • Breaking up prolonged sitting as often as possible Getting 7 to 9 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.
Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.

GUIDELINES FOR OLDER ADULTS
For health benefits, older adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
A healthy 24-hours includes: Performing a variety of types and intensities of physical activity, which includes • Moderate to vigorous aerobic physical activities such that there is an accumulation of at least 150 minutes per week • Muscle strengthening activities using major muscle groups at least twice a week • Physical Activities that challenge balance • Several hours of light physical activities, including standing Limiting sedentary time to 8 hours or less, which includes • No more than 3 hours of recreational screen time, and • Breaking up prolonged sitting as often as possible Getting 7 to 8 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.
Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.
We will ask for feedback on each recommendation in the questions to follow.

PHYSICAL ACTIVITY RECOMMENDATION FOR ADULTS
A healthy 24-hours includes: Performing a variety of types and intensities of physical activity, which includes:

SLEEP RECOMMENDATION FOR ADULTS
A healthy 24-hours includes: Getting 7 to 9 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.

SLEEP RECOMMENDATION FOR OLDER ADULTS
A healthy 24-hours includes: Getting 7 to 8 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.

INTEGRATED RECOMMENDATION FOR ADULTS
For health benefits, adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.

INTEGRATED RECOMMENDATION FOR OLDER ADULTS
For health benefits, older adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.

Section 7
The drafted Canadian 24-Hour Movement Guidelines for Adults and Older Adults are shown below.

GUIDELINES FOR ADULTS
For health benefits, adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
A healthy 24-hours includes: Performing a variety of types and intensities of physical activity, which includes: • Moderate to vigorous aerobic physical activities such that there is an accumulation of at least 150 minutes per week • Muscle strengthening activities using major muscle groups at least twice a week • Several hours of light physical activities, including standing Limiting sedentary time to 8 hours or less, which includes: • No more than 3 hours of recreational screen time, and • Breaking up prolonged sitting as often as possible Getting 7 to 9 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times.
Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.

GUIDELINES FOR OLDER ADULTS
For health benefits, older adults should be physically active each day, minimize sedentary behaviour and achieve sufficient sleep.
A healthy 24-hours includes: Performing a variety of types and intensities of physical activity, which includes • Moderate to vigorous aerobic physical activities such that there is an accumulation of at least 150 minutes per week • Muscle strengthening activities using major muscle groups at least twice a week • Physical Activities that challenge balance • Several hours of light physical activities, including standing Limiting sedentary time to 8 hours or less, which includes • No more than 3 hours of recreational screen time, and • Breaking up prolonged sitting as often as possible Getting 7 to 8 hours of good-quality sleep on a regular basis, with consistent bed and wake-up times Replacing sedentary behaviour with additional physical activity and trading light physical activity for more moderate to vigorous physical activity, while preserving sufficient sleep, can provide greater health benefits.
Progressing towards any of the above targets will result in some health benefits.
We will ask for feedback on each recommendation in the questions to follow. 16. In your opinion, who are the key intermediaries to implement the 24-Hour Movement Guidelines (e.g., primary care physicians)?
17. In your opinion, what supports do these intermediaries need to implement the 24-Hour Movement Guidelines (e.g., materials, training)?
18. In the box below, application et des recommandations sur la recherche et la please enter any comments you have regarding the 24-Hour Movement Guidelines.

Section 8
Thank you for your interest in the Canadian 24-Hour Movement Guidelines for Adults and Older Adults. The recommendations are currently in draft form and stakeholder consultation is being sought. The final versions of the Guidelines will be released in October 2020. As a valued and trusted stakeholder, we have shared confidential draft recommendations for your feedback. Please do not share this information with anyone. If you have further inquiries, please contact the Guideline development Chair, Dr. Robert Ross, at rossr@queensu.ca. Please click "Next" to ensure your responses are recorded.

Section 5
Veuillez prendre note que l'objectif du préambule est de fournir du contexte pour les Directives canadiennes en matière de mouvement sur 24 heures.
OE Fortement en accord OE Plutôt en accord OE Ni en accord, ni en désaccord OE Plutôt en désaccord OE Fortement en désaccord OE Je ne sais pas 13. Dans la zone de texte ci-dessous, veuillez indiquer tout commentaire concernant la question précédente.
OE Fortement en accord OE Plutôt en accord OE Ni en accord, ni en désaccord OE Plutôt en désaccord OE Fortement en désaccord OE Je ne sais pas 15. Dans la zone de texte ci-dessous, veuillez indiquer tout commentaire concernant la question précédente.