Posted: November 30th, 2022

School of Exercise and Nutrition Sciences

Review
Too much sitting A health hazard
David W. Dunstan a,b,c,d,e,
*, Bethany Howard a
, Genevieve N. Healy a,b
, Neville Owen a,b,c
a Baker IDI Heart and Diabetes Institute, Melbourne, Australia b School of Population Heath, The University of Queensland, Brisbane, Australia c School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia d School of Exercise and Nutrition Sciences, Deakin University, Melbourne, Australia e ECU Health and Wellness Institute, Edith Cowan University, Perth, Australia
Contents
1. Sedentary behavior and cardio-metabolic health emergence of a new paradigm. . . . . . . . . . . . . . . . . . . . . . . . . . . 369
2. The particular health hazards of too much sitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370
3. Sedentary behavior and premature mortality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
4. Prolonged unbroken sitting is a contributor to poor health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
5. Experimental models addressing the metabolic consequences of prolonged, unbroken sedentary time . . . . . . . . . . 372
6. Public health and clinical implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 373
7. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 374
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6
a r t i c l e i n f o
Article history:
Received 17 May 2012
Accepted 17 May 2012
Published on line 9 June 2012
Keywords:
Sitting time
Breaks in sedentary time
TV viewing time
Sedentary behavior
Mortality
a b s t r a c t
In contemporary society, prolonged sitting has been engineered into our lives across many
settings, including transportation, the workplace, and the home. There is new evidence that
too much sitting (also known as sedentary behavior which involves very low energy
expenditure, such as television viewing and desk-bound work) is adversely associated with
health outcomes, including cardio-metabolic risk biomarkers, type 2 diabetes and premature mortality. Importantly, these detrimental associations remain even after accounting
for time spent in leisure time physical activity. We describe recent evidence from epidemiological and experimental studies that makes a persuasive case thattoo much sitting should
now be considered an important stand-alone component of the physical activity and health
equation, particularly in relation to diabetes and cardiovascular risk. We highlight directions for further research and consider some of the practical implications of focusing on too
much sitting as a modifiable health risk.
# 2012 Elsevier Ireland Ltd. All rights reserved.
* Corresponding author at: Physical Activity Baker IDI Heart and Diabetes Institute, Australia. Tel.: +61 3 8532 1873.
E-mail addresses: [email protected], [email protected] (D.W. Dunstan).
Contents available at Sciverse ScienceDirect
Diabetes Research
and Clinical Practice
journal homepage: www.elsevier.com/locate/diabres
0168-8227/$ see front matter # 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.diabres.2012.05.020
1. Sedentary behavior and cardio-metabolic
health emergence of a new paradigm
Physical activity has been shown to be consistently associated
with reduced risk of type 2 diabetes [1], cardiovascular disease
[2] and premature mortality [3]. Public-health recommendations on participation in regular moderate-to-vigorous intensity physical activity (sometimes referred to as health
enhancing exercise) have been widely promulgated, with
the aim of reducing type 2 diabetes risk, cardiovascular
disease and some cancers [4]. US Federal Guidelines [5]
recommend at least 30 min of moderate intensity physical
activity on at least five days of the week. It is emphasized that
this is in addition to the light intensity activities of daily living
(referred to as baseline activity), which includes activities
such as standing, walking slowly and lifting light objects. Of
concern, however, is that due to changes in personal
transportation, communication, workplace and domesticentertainment technologies, there are significantly-reduced
demands to be active [6]. As a consequence, this background
level of physical activity is declining. Much of the reduction in
activity can be attributed to exposure to environments that
demand or encourage prolonged sitting.
Time spent in sedentary behaviors (typically in the
contexts of television viewing, computer and game-console
use, workplace sitting, and time spent in automobiles) are a
new focus for research in the physical activity and health field
[79]. Sedentary behaviors are defined by both their posture
(sitting or reclining) and their low energy expenditure
typically in the energy-expenditure range of 1.01.5 METs
(multiples of the basal metabolic rate) [10]. In contrast,
, such as brisk walking or running involve an energy expenditure of atleast 3 METs
[11]. In this perspective, light-intensity activities are those
with an energy expenditure range of 1.62.9 METs. They can
include some occupational duties, household tasks, caring
and social activities, and a range of other behaviors. These
light-intensity activities are the predominant determinant of
daily energy expenditure [12]. However, environmental, social
and technological changes have resulted in a high proportion
of such normal daily activity being displaced by time spent
sedentary [13].
The use of sophisticated activity monitors (that provide
valid and reliable duration, amount, frequency, and time of
day data on sedentary and activity time) in population-based
studies has provided insights into how most adults spend their
day, and more specifically, the large contribution that
sedentary time makes to adults overall waking hours [14].
For example, analysis of accelerometer data from over 6000
participants (aged 20+ years) in the 20032006 US National
Health Nutrition Examination Survey (NHANES) found that
mean accelerometer-derived sedentary time across 10 year
age categories ranged between 7.3 and 9.3 h/day, with older
adults generally the most sedentary [15]. In proportional
terms, it can be estimated that some 5168% of adults total
waking hours are spent sedentary [15,16]. In contrast,
moderate to vigorous physical activities accounted for only
5% of the total time across the sample [17], with the remainder
(some 2744%) being spent in light intensity physical activity
(LIPA) or baseline activity.
The enhanced measurement capacity provided by activity
monitors has also highlighted the strong relationship that
sedentary time has with light intensity physical activity.
Because time spent in
is such a small component of overall waking hours, almost all
of the variation in sedentary time across the population is
related to the extent to which the sedentary time displaces
light intensity physical activity [13]. For example, Fig. 1 shows
data from NHANES indicating that sedentary time ranged
from 6.3 h in the lowest quartile of sedentary time to 10.2 h in
the highest quartile of sedentary time. Nearly all of the
Fig. 1 Distribution of time (h/day) spent in sedentary, light-intensity physical activity and moderate-intensity physical
activity according to quartiles of sedentary time US National Health and Nutrition Examination Survey (NHANES). Based
on 1 week of accelerometer data in 1712 adults from the US National Health and Nutrition Examination Survey (NHANES)
[73], the stacked column graphs show the allocation of waking hours spent sedentary, in light activity and in , from the lowest to the upper quartile of overall sedentary time.
Source: Owen et al. [13].
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6 369
variation in sedentary time can be attributed to less time spent
in LIPA. Indeed, one study [18] has reported an almost perfect
inverse correlation (!0.98) of the time spent in light intensity
physical activity with sedentary time: the more time participants spend in light-intensity activity, the less time they
spend sedentary. This suggests that promoting light-intensity
physical activity may be a feasible approach to ameliorating
the deleterious health consequences of too much sitting.
Additionally, epidemiological evidence suggests that having a
positive balance between light intensity and sedentary time is
desirable because light intensity activity has an inverse linear
relationship with a number of cardio-metabolic biomarkers
[19].
The distribution of activity time, and the strong relationship between sedentary and light-intensity time, raises novel
and significant population health implications, which now
require a rethink of the accepted physical activity and health
paradigm [20]. As illustrated in Fig. 2, at least half, and up to
two-thirds, of adults waking hours are spent sedentary
which may impart a unique biological stimulus that has
deleterious health consequences. Light-intensity activity
accounts for the remainder of the time, which in spite of
the overwhelming proportion of waking hours occupied by
sedentary behaviors contributes a large volume of activity
relative to the small proportion of time but most adults are
involved in MVPA. Yet, the impact of LIPA as a biological
stimulus contributing to better health probably has been
underestimated significantly.
Within this perspective, the established scientific focus on
the health benefits of moderate-to-vigorous intensity physical
activity could be likened to hunting in a rapidly changing
environment where prolonged sitting is so ubiquitous and
moderate-to-vigorous physical activity so uncommon for a
creature that is small, rare and almost-extinct.
2. The particular health hazards of too much
sitting
The notion that prolonged sitting is hazardous to ones health
is not new. Ramazzini [21], a distinguished occupational
physician, noted as early as the 17th century that a
relationship between sedentary behavior and deleterious
health consequences were evident in workers whose occupations required them to sit for long hours. In the 1960s, Morris
and colleagues [22] reported that workers in occupations
requiring primarily sitting (London bus drivers and mail
sorters) had a higher incidence of cardiovascular disease than
did workers who were required to stand and ambulate (bus
conductors and postal delivery workers). In the preceding
decade, Homans [23] reported clinical cases of venous
thrombosis in the legs following prolonged sitting by theatre-goers and among those spending long hours watching
television. Homans recommended that such matters are
important enough to suggest the advisability of making
movements of the toes, feet, and lower legs when one is
sitting for long periods and of getting up and exercising when
opportunity offers.
Over the past decade there has been a rapid accumulation
of epidemiological evidence from both cross-sectional and
prospective observational studies to indicate that time spent
in sedentary behaviors is a distinct risk factor for several
health outcomes. Prominent within this evidence are relationships of sedentary time with both biomarkers of diabetes risk
[2430], particularly obesity [31,32], 2-h plasma glucose [33],
lipids and abnormal glucose tolerance [34], and with diabetes
as a health outcome [3538]. Furthermore, these detrimental
relationships of sedentary time with health extend beyond
markers of diabetes risk. In our recent systematic review ofthe
Fig. 2 Accelerometer measured time spent in sedentary, light-intensity physical activity and moderate-vigorous physical
activity in Australian adults (AusDiab) [16]: time to re-think the physical activity and health paradigm? At least half, and up
to two-thirds, of adultswaking hours are spent sedentary which may impart a unique biological stimulus that has
deleterious health consequences. Light-intensity activity accounts for the remainder of the time, which in spite of the
overwhelming proportion of waking hours occupied by sedentary behaviors contributes a large volume of activity relative
to the small proportion of time but most adults are involved in MVPA. Yet, the impact of LIPA as a biological stimulus
contributing to better health probably has been underestimated significantly.
370 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6
evidence from longitudinal studies published between 1996
and 2011 [39], we highlighted the growing body of evidence
relating time spent in sedentary behaviors with poor health
outcomes in adults (see Fig. 3). Importantly, in many of these
studies, the associations of sedentary behavior with these
adverse outcomes have been shown to persist even when
participation in leisure-time moderate-to-vigorous physical
activity had been accounted for.
3. Sedentary behavior and premature
mortality
Over the past 3 years, nine separate studies have reported on
the prospective relationships with premature mortality of
self-reported sitting time [4042]; on TV viewing time and
other screen-time behaviors [4346]; and, on TV viewing time
plus other sedentary behaviors [47,48]. Consistently, these
studies indicate that time spent in sedentary behavior may be
independently associated with increased risk for all-cause and
CVD-related mortality in both men and women. Importantly,
associations with mortality risk do not appear to be mediated
by two important confounders body mass and time spent in
leisure-time moderate-to-vigorous physical activity.
The notion that participation in leisure-time physical
activity does not fully mitigate the health risks associated
with prolonged sitting is best exemplified in a recent analysis
by Matthews et al. [48] of the NIH-AARP Diet and Health study
involving the examination of more than 240,000 adults aged
5071 years. One of the most striking findings of this analysis
was that those who reported participating in more than 7 h/
week of moderate-to-vigorous physical activity during leisuretime but who also watched television “7 h/day had a 50%
greater risk of death from all causes and twice the risk of death
from cardiovascular disease relative to those who undertook
the same amount of physical activity but watched television
<1 h (see figure below). This prompted the authors to question
whether leisure-time moderate-to-vigorous physical activity
is protective for those who spend large amounts of time in
sedentary behaviors; they emphasized the importance of not
only engaging in regular physical activity, but also avoiding
prolonged periods of sitting.
4. Prolonged unbroken sitting is a contributor
to poor health
As already noted, the development of device-based measures
of physical activity has provided researchers with sophisticated tools to account accurately for the entire range of activity,
from sedentary through to highly vigorous activities in free
living participants over a number of days. The most commonly
used device-based measure in population-based studies to
date has been the accelerometer.
Initial findings from the 2004 to 2005 Australian Diabetes,
Obesity and Lifestyle Study (AusDiab) reported that accelerometer-derivedsedentary time wasdeleteriously associated witha
number of cardiovascular risk factors, including waist circumference, blood glucose, and triglycerides [16,49]. Intriguingly,
adults whose sedentary time was mostly uninterrupted
(prolonged unbroken sitting) had a poorer cardio-metabolic
health profile compared to those who interrupted, or had more
frequent breaks in their sedentary time [49]. These associations
were observed even when accounting for total sedentary time
and time spent in moderate-to-vigorous-intensity physical
activity. When these analyses were replicated using accelerometer data obtained in 4757 participants (“20 years) from the
2003/04 and 2005/06 population-representative US National
Health and Nutrition Examination Survey (NHANES), similar
findings were observed. Here, total sedentary time was
deleteriously associated with cardio-metabolic biomarkers
and the inflammatory biomarker C-reactive protein [18]. Again,
there were significant beneficial associations observed with
frequent breaks in sedentary time, with breaks in sedentary
time favorably associated with waist circumference and Creactive protein. Importantly, these associations were consistent across age, sex, and race/ethnicity subgroups. The
relationship of breaks in sedentary time with waist circumference was also observed in adults with newly diagnosed type 2
diabetes [50]. These epidemiological findings prompted the
Fig. 3 Summary of the evidence from prospective studies 1996January 2011 showing the number of studies reporting the
associations of sedentary time with health outcomes [39].
Source: Thorp et al. [39].
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6 371
inclusion of recommendations specifically addressing frequent
breaks fromprolonged sitting withinthe 2011 AmericanCollege
of Sports Medicines Guidelines on Exercise for Health Professional
[51].
5. Experimental models addressing the
metabolic consequences of prolonged, unbroken
sedentary time
The highest priority for the new sedentary behavior and health
research agenda is to gather additional evidence from prospective studies, and importantly, new evidence from human
experimental work and intervention trials [10]. Understanding
the biological mechanisms that underlie associations of
prolonged sitting with adverse health outcomes is required in
order to identify the specific causal nature of these relationships. To date, few examples exist of human experimental
models that specifically address the impact of prolonged
sedentary time on cardio-metabolic health parameters.
In a recent review summarizing the data over the last 60
years on the metabolic adaptations to bed rest in healthy
subjects, Bergouignan et al. [52] noted that while bed rest
provides a unique model to investigate mechanisms underlying defects induced by physical inactivity in healthy subjects,
it is important to remember that bed rest induces a level of
physical inactivity likely different (quantitatively and qualitatively) from that observed in the general population. Indeed,
it was acknowledged that bed rest may be seen as an
experimental model that is too extreme to provide insights
relevant to what exists in the general population where time
spent sitting with some level of movement occurs rather than
enforced periods of lying down.
On the other end of the activity spectrum, recent studies
have reported the deleterious metabolic consequences of
transient reductions in physical activity in healthy, active
young adults [53,54]. Within this model, active individuals
(based on a pedometer step count >10,000 steps per day) were
instructed to reduce the number of daily steps (between #1500
and 5000 steps) with outcomes measured 314 days following
reduced activity. While such findings have been informative
for understanding the rapid alterations that occur in metabolic
parameters following reduced activity, the model essentially
evaluates the effect of transitioning from an active to a less
active state. For modern societies in which for many people
the default is excessive sitting and little or no physical activity,
it is likely to be more applicable from a population perspective
to examine the metabolic effects of sitting and the impact of
transitioning from sitting to more active states.
Recent experimental studies have examined the acute
impact of prolonged sitting. Among young, non-obese, fit and
healthy men and women, significant alterations in wholebody insulin sensitivity were observed after one day of
prolonged sitting [55]. The decline in insulin action observed
following prolonged sitting (approximately 17 h, measured
objectively) was significantly attenuated but not completely
prevented through the reduction of energy intake by
10,000 kcal/day, so as to approximate low energy expenditure
during prolonged sitting. This prompted the authors to
conclude that factors other than energy surplus are involved
in the detrimental impact of sitting on insulin action.
Interestingly, in this study, the detrimental effect on insulin
action induced through prolonged sitting was compared to a
similar episode (24 h) in which sitting was minimized (#6 h/
day) and substituted with more standing (9.8 h/day versus
0.2 h/day) and stepping time (2.2 h/day versus 0.1 h/day).
While acknowledging the need for longer term studies, the
authors concluded that maintaining at least daily lowintensity activity may assist in minimizing the harmful effects
of prolonged sitting on metabolic health.
Building on this evidence and the observational-study
findings on breaking up sedentary time described above, we
recently examined the acute effects of uninterrupted sitting on
postprandial plasma glucoseandseruminsulin, compared with
sitting interrupted by short 2-min bouts of activity (treadmill
walking) in overweight middle-aged adults [56]. Using a crossover design, each participant completed each trial condition
over a 7-h period in a randomized order: (1) uninterrupted
sitting; (2) sitting interrupted by light-intensity (3.2 km/h)
treadmill walking for 2 min every 20 min during the last 5 h;
(3) sitting interrupted by moderate-intensity (5.86.4 km/h)
treadmill walking for 2 min every 20 min during the last 5 h. For
all 3 trials, a standardized test drink (200 mL, 75 g carbohydrate,
50 g fat), afteraninitial 2-hperiod,withthepositiveincremental
area under curves (iAUC)for glucose and insulin for the 5 hafter
the test drink calculated for the respective treatments. Fig. 4
illustrates the glucose and insulin iAUC for each individual
(ordered by plasma glucose response) across the 3 treatment
conditions. Relative to uninterrupted sitting, the glucose iAUC
was reduced after both activity-break conditions (light: 24%;
moderate 30%). Similarly, the iAUC for insulin was reduced by
23% after the activity-break conditions compared to uninterrupted sitting [56]. Notably, no statistically-significant differences were observed in the glucose and insulin iAUC between
the two activity conditions, suggesting that brief interruptions
to sitting can lead to significant reductions in postprandial
glucose and insulin irrespective of activity intensity. Whilst
the findings are restricted to one-day exposure to prolonged
uninterrupted sitting versus interrupted sitting and thus the
implications cannot be extrapolated to long-term exposures,
the dramatic attenuation in post-prandial glucose and insulin
observed in the activity break conditions suggests the importance of briefly breaking up prolonged periods of sitting with
activity of at least light-intensity.
The promising findings from these two experimental
studies that have specifically addressed the cardio-metabolic
consequences of prolonged sitting pointto the need for further
research. In addition to examining the impact of long-term
exposure beyond one day, the various perturbations in the
length (short versus long), type (ambulation versus standing)
and frequency (high versus low) of activity interruptions to
prolonged sitting and possible moderating factors such as sex
and adiposity status need to be examined.
Understanding the biological mechanisms underlying
the associations observed between prolonged sitting and
adverse health outcomes is a research priority. Research
from animal studies [57] has suggested that loss of muscle
contractile stimulation induced through prolonged sitting
has been shown to suppress lipoprotein lipase (LPL) activity,
which is necessary for the uptake of the constituents of
372 d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6
triglyceride-rich lipoproteins by skeletal muscle and the
productionof key substrates for thematurationofHDL particles
[58]. Examination of skeletal muscle metabolic regulatory
pathways at the epigenetic, gene expression and protein level
will likely yield insights into the mechanisms underlying the
impact of prolonged sitting on cardio-metabolic risk.
Additionally, it is imperative that the science also moves
beyond observational studies to intervention studies conducted in real-world settings targeting the feasibility,
acceptability and efficacy of reducing and breaking up
occupational, transit and domestic sedentary time. Initiatives
such as Project STAND (Sedentary Time ANd Diabetes), a
randomized controlled trial which aims to reduce sedentary
behavior in younger adults at high risk of type 2 diabetes [59],
provide a new direction of behavior change intervention
research beyond the conventional approach of encouraging
increases in moderate-to-vigorous physical activity in at risk
populations. The results of the study, expected in upcoming
years, will help to inform future public health initiatives
addressing the problem of prolonged sitting the rapidly
expanding high risk populations.
6. Public health and clinical implications
On the strength of the evidence that we have reviewed
showing that prolonged sitting time appears to be an important
determinant of major health outcomes we posit that there is
now sufficient evidence to assistpractitionersand publichealth
experts to expand their thinking beyond justpurposeful health
enhancing exercise.There are goodreasonsnow to give serious
consideration to advocating reductions in sedentary time.
Already, some leading health agencies have taken a proactive
stance on this issue through the release of new recommendations/advice within physical activity recommendations on the
likely importance of reducing sedentary behavior.
$ From the United Kingdom, the 2011 Start Active, Stay Active
document [60] presents guidelines on the volume, duration,
frequency and type of physical activity required across the
life course to achieve general health benefits. In addition to
the well-accepted advice relating to moderate and vigorous
physical activity, attention is also directed at reducing
sedentary behavior across all age groups, with the nonspecific, and sufficiently broad message to minimize the
amount of time spent being sedentary (sitting) for extended
periods applied across the various age groups from as the
early years to older adults.
$ From the USA, the 2011 Quantity and Quality of Exercise for
Developing and Maintaining Cardiorespiratory, Musculoskeletal, and Neuromotor Fitness in Apparently Healthy
Adults: Guidance for Prescribing Exercise position stand of
the American College of Sports Medicine acknowledges that
in addition to exercising regularly, there are health benefits in
concurrently reducing total time spent in sedentary pursuits and
also by interspersing frequent, short bouts of standing and physical
Fig. 4 The acute effect on the (5-h postprandial) glucose positive incremental area under the curve (iAUC) resulting from
uninterrupted sitting, sitting interrupted by light-intensity physical activity breaks and sitting interrupted by moderateintensity physical activity breaks in the 19 participants of the experimental study [55]. The effect of three trial-conditions:
(1) uninterrupted sitting; (2) sitting interrupted by light-intensity (3.2 km/h) activity breaks; and (3) moderate: sitting
interrupted by moderate-intensity (5.86.4 km/h) activity breaks for each participant on positive (5-h postprandial) glucose
iAUC. *Participants ordered according to sedentary glucose iAUC.
Source: Dunstan et al. [56].
d i a b e t e s r e s e a r c h a n d c l i n i c a l p r a c t i c e 9 7 ( 2 0 1 2 ) 3 6 8 3 7 6 373
activity between periods of sedentary activity, even in physically
active adults [51].
$ Both the UK Start Active, Stay Active and the American
College of Sports Medicine position stand documents do,
however, indicate that in the absence of a coherent body of
experimental evidence allowing stronger causal inferences
about the health effects of too much sitting, such recommendations relating to sitting will remain general and
tentative. Furthermore, the 2010 Global Recommendations on
Physical Activity for Health document from the World Health
Organization [61] is explicit about the potential importance
for health outcomes of too much sitting, yet stops short of
making specific recommendations around sitting.
Stronger evidence is therefore needed to inform specific
recommendations on sitting within future global physical
activity guidelines; to develop the relevant clinical and public
health guidelines; and, to inform a range of related initiatives
[62]. Evidence is required not only on doseresponse relationships
of sitting time with risk biomarkers and health outcomes, but
also on the underlying mechanisms leading to deleterious health
consequences, the feasibility of changing prolonged sitting in
specific contexts, the maintenance of the relevant behavioral
changes and the health benefits of doing so.
It is likely that the expertise and experience from sectors
other than health may be drawn upon in order to develop
relevant and effective initiatives aimed at reducing sitting time.
For example, the accumulation of additional rigorous scientific
evidence onthedeleterioushealthimpacts of sitting time inkey
contexts, such as the workplace, may provide added persuasiveness for occupational health and safety bodies to address
the potentialimplications ofprolongedunbrokensitting time in
the workplace. Given that workers represent half the global
population [63], and most ofthe population spend an average of
one third of the adult life at work [64], the workplace is a fertile
setting in which to introduce strategies to reduce sitting time
and break up periods of prolonged sitting to improve cardiometabolic health [65].
In particular, office-based workers are one of the largest
occupational groups [66,67] and also highly sedentary [68],
making them a key target group for intervention. For many
office workers, the bulk of their daily sitting time occurs at
work [69,70]. The office is thus a key setting to reduce
prolonged sitting time [62,71,72]. This is an important
consideration in the context of the duty of care obligations
of employers to ensure, so far as is reasonably practicable, the
provision and maintenance of a work environment for
employees without risks to health and safety. Strategies
individuals could consider include:
$ standing and taking a break from the computer every 30 min
$ taking standing breaks in sitting time during the long
meetings
$ standing during phone calls
$ walking to a colleagues desk instead of phoning or emailing
$ using a height-adjustable desk to enable frequent transitions between working in a standing or seated position
$ using a headset or the speaker phone during teleconferences
to enable more standing during the meeting
The evidence base linking prolonged sitting with a number
of adverse health outcomes, including premature mortality, is
now sufficiently strong to suggest that physicians should be
advising patients to reduce daily sitting time and avoid
prolonged unbroken sitting periods. Within the clinical and
broader healthcare practice it may be a feasible option to
advise patients on reducing their sitting time and increasing
their routine light intensity activities as the initial catalyst
towards more active living in many patients. Nevertheless,
this new perspective on the deleterious health consequences
of too much sitting should be seen as being an addition to, and
not as an alternative to the well-recognized benefits of
participation in health enhancing moderate-to-vigorous intensity physical activity.
7. Conclusions
There is every reason to continue to emphasize the importance of regular moderate-to-vigorous physical activity in the
prevention and treatment of chronic disease. However, new
evidence linking prolonged sitting time with significant
compromises to cardio-metabolic health, indicates that even
in physically active adults, concurrent reductions in the
amount of time spent sitting is likely to confer health benefits.
At present, no definitive recommendations on how long
people should sit for or how often people should break up their
sitting time exist more experimental evidence and intervention studies (to provide the relevant doseresponse data) are
needed to inform specific guidelines and advice that can be
given to patients and the general population. At this stage,
advice can nevertheless be given with reasonable confidence,
to encourage adults to create opportunities to limit their
sitting time whilst at home, at work and during transportation
and break-up prolonged periods of sitting through frequent
transitions from sitting to standing/ambulating throughout
the day. A simple strategy message that could be put forward
is: Stand Up, Sit Less, Move More, More Often.
Conflict of interest
There are no conflicts of interest.
Acknowledgements
D.W. Dunstan is supported by an Australian Research Council
Future Fellowship. N. Owen is supported by a National Health
and Medical Research Council (NHMRC) Senior Principal
Research Fellowship. G.N.Healy is supported by an NHMRC
(no. 569861)/National Heart Foundation of Australia (PH 08B
3905) Postdoctoral Fellowship.
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