758843

research-article2018
SJP0010.1177/1403494818758843M. Balling et al.Total sitting time, leisure time physical activity and low back pain

Scandinavian Journal of Public Health, 1–8

Original Article

Total sitting time, leisure time physical activity and risk of

hospitalization due to low back pain: The Danish Health
Examination Survey cohort 2007–2008

MIE BALLING1,2, TERESA HOLMBERG2, CHRISTINA B. PETERSEN2,

METTE AADAHL3,4, DAN W. MEYROWITSCH4 & JANNE S. TOLSTRUP2

1University of Copenhagen, Denmark, 2National Institute of Public Health, University of Southern Denmark, Copenhagen,
Denmark, 3Centre for Clinical Research and Prevention, Frederiksberg Hospital, and 4Department of Public Health,
University of Copenhagen, Denmark

Abstract
Aims: This study aimed to test the hypotheses that a high total sitting time and vigorous physical activity in leisure time
increase the risk of low back pain and herniated lumbar disc disease. Methods: A total of 76,438 adults answered questions
regarding their total sitting time and physical activity during leisure time in the Danish Health Examination Survey 2007–
2008. Information on low back pain diagnoses up to 10 September 2015 was obtained from The National Patient Register.
The mean follow-up time was 7.4 years. Data were analysed using Cox regression analysis with adjustment for potential
confounders. Multiple imputations were performed for missing values. Results: During the follow-up period, 1796 individuals
were diagnosed with low back pain, of whom 479 were diagnosed with herniated lumbar disc disease. Total sitting time was
not associated with low back pain or herniated lumbar disc disease. However, moderate or vigorous physical activity, as
compared to light physical activity, was associated with increased risk of low back pain (HR = 1.16, 95% CI: 1.03–1.30 and
HR = 1.45, 95% CI: 1.15–1.83). Moderate, but not vigorous physical activity was associated with increased risk of herniated
lumbar disc disease. Conclusions: The results suggest that total sitting time is not associated with low back pain,
but moderate and vigorous physical activity is associated with increased risk of low back pain compared with
light physical activity.

Keywords: Back pain, epidemiology, exercise, longitudinal studies, lumbar disc herniation, physical activity, sedentary behaviour,
sitting time

Introduction
The global one-year prevalence of low back pain is
high, ranging from 22% to 65% in adults [1]. In
2013, the number of individuals with low back pain
was estimated to be 651 million worldwide, and low
back pain was the leading cause of years lived with
disability according to the Global Burden of Disease
Study [2]. Moreover, low back pain is costly for soci-
ety, due to the many contacts with the health system,
medicine, sick days and early retirement resulting in
lost production [3].
Low back pain is a disease with a number of pos-
sible aetiologies [4]. In previous studies many risk
factors for low back pain have been suggested, among
them are smoking, female gender, age, body mass
index (BMI), psychological distress, e.g. anxiety and
depression, low level of education, hard physical
work including heavy lifting, pushing, pulling and
prolonged walking and standing at work [4].
Furthermore, a few studies with contrasting
results have assessed the role of total sitting time as a

Correspondence: Mie Balling, National Institute of Public Health, University of Southern Dermark, Studiestræde 6, 1455 Copenhagen, Denmark.
E-mail: mie.balling.01@regionh.dk

Date received 8 May 2017; reviewed 17 December 2017; accepted 12 January 2018

© Author(s) 2018
Reprints and permissions: sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/1403494818758843
https://doi.org/10.1177/1403494818758843
journals.sagepub.com/home/sjp
2    M. Balling et al.
risk factor for low back pain [5–9]. Herniated lumbar
disc disease is a subcategory of low back pain. To our
knowledge, no previous studies have focused on the
possible association between total sitting time and
the risk of symptomatic herniated lumbar disc dis-
ease. Hypotheses that may explain why sedentary
behaviour impacts the risk of low back pain include
increased intradiscal load [10], decreased back mus-
cle activity leading to transmission of the load to pas-
sive structures [11], and reduced oxygen levels in the
musculature of the low back [12]. In contrast sitting
may also hypothetically protect against low back
pain, as time spent sitting displaces time engaging in
other potentially deleterious activities, such as heavy
lifting.
Moreover, physical activity is found either to pro-
tect against or not be associated with low back pain in
several studies in the general population, whereas low
back pain is common in athletes [13–15]. However,
more knowledge is needed about whether the sug-
gested protective effect of physical activity in the gen-
eral adult population is related to a specific level of
physical activity [16]. A limited number of studies
have examined whether self-reported physical activity
or objectively measured physical fitness is associated
with herniated lumbar disc disease [17,18]. Since one
of the studies only included Caucasian men [18], and
the other study only included patients from Chinese
hospitals [17], more knowledge about both genders
in the Caucasian population is still needed. It is sug-
gested that physical activity might prevent low back
pain by increasing the blood supply to the spine and
paravertebral structures and improving the strength
of the muscles of the back and trunk [16,19]. On the
other hand, repetitive subclinical injuries during
physical activity could possibly cause back pain [16].
We examined the association between total sitting
time, different levels of leisure time physical activity
and low back pain and herniated lumbar disc disease.
We aimed to test the hypotheses that a high total sit-
ting time and vigorous physical activity in leisure
time increase the risk of low back pain and herniated
lumbar disc disease.
Methods
Design and study population
The design was a prospective cohort study. The study
population included individuals who participated in
the Danish Health Examination Survey 2007–2008
(DANHES 2007–2008) and consisted of men and
women aged 18–99 years. In 13 of 98 municipalities
in Denmark, every citizen of 18 years or more was
invited to fill in a self-reported questionnaire focus-
ing on diet, smoking, alcohol and physical activity.
The questionnaire was completed by 76,438 indi-
viduals (total response rate 14%). DANHES has
been described in detail elsewhere [20].
Total sitting time and physical activity during
leisure time
Total sitting time was measured by the Danish ver-
sion of the long International Physical Activity
Questionnaire (IPAQ-L). The participants were
asked: ‘How much time did you spend sitting during
the last seven days on weekdays and weekends?
Include sitting time at work and in leisure time, but
exclude sitting time during transportation.’ The fol-
lowing examples of sitting behaviour were given: at
the desk, with family and friends when reading or
watching TV. In another question the participants
were asked about time spent driving during transpor-
tation (e.g. in a car, a bus or a train). Initially, sitting
time was calculated in minutes as the sum of sitting
time during weekdays multiplied by five and week-
ends multiplied by two, divided by seven. Time spent
driving during transportation in minutes was added
to the former estimate. If the average sitting time
exceeded 1440 min per day (more than 24 hours),
the value was truncated to 1440 min per day, and if
time spent driving exceeded an average of 2520 min
per week, the value was truncated to 2520 min per
week. Finally, total sitting time was summarised, con-
verted to hours per day and, as suggested by others,
categorised into 0 to <6 h/day, 6 to <10 h/day and
10+ h/day (21).
Physical activity during leisure time was measured
by a self-reported, four-level question asking partici-
pants to describe their physical activity during the
last year. The possible answers were: (1) vigorous
(strenuous activities usually involving competition or
endurance training, performed regularly or several
times per week); (2) moderate (exercise, endurance
training or heavy gardening for at least 4 h per week);
(3) light (walking, bicycling (including cycling/walk-
ing during transportation), or other light activities for
a minimum of 4 h per week); (4) inactive (reading,
TV-watching or other sedentary activities). Different
versions of the four-category question about leisure
time physical activity proposed by Saltin and Grimby
have been shown to have a high predictive validity,
e.g. concerning cardiovascular disease, cancer, frac-
tures, type 2 diabetes, obesity, all-cause mortality and
morbidity [22].
In addition, physical activity during leisure time
was also measured by the Danish version of the
IPAQ-L. Physical activity was classified according to
the World Health Organization recommendation
into: (1) <150 min, (2) 150 to <300 min and (3)
 Total sitting time, leisure time physical activity and low back pain   3
≥300 min weekly [23]. Physical activity during lei-
sure time was calculated as transportation time by
bike plus physical activity during leisure time.
Physical activity was calculated as minutes per day. If
the time reported for engaging in physical activity
during leisure time or biking for transportation was
more than 180 min per day, it was truncated to 180
min as recommended by the Guidelines for Data
Processing and Analysis of the International Physical
Activity Questionnaire Short and Long forms
(IPAQ-S and IPAQ-L) [24]. The IPAQ-L definition
of leisure time physical activity is used for the sensi-
tivity analyses.
Follow-up information
Information on low back pain was obtained from the
Danish National Patient Register (NPR), and this
contains complete information on all patients who
have been examined at Danish hospitals [25]. Low
back pain was defined according to the International
Classification of Diseases, 10th Revision codes M51-
519, M53.3, M53.8, M53.9, M54.0, M54.1, M54.3,
M54.4, M54.5, M54.6, M54.8 and M54.9. Herniated
lumbar disc disease, which is a specific subcategory
of low back pain, was defined with the ICD-10 code:
M51.1. Information on death and emigration during
the study period was obtained from The Danish Civil
Registration System where information on all Danes
is registered [26].
Final study population
A total of 17,081 individuals with self-reported cur-
rent or previous back disease at baseline were
excluded. A further 1713 were registered in the
Danish NPR with back disease diagnosed prior to
baseline and were therefore excluded. Finally, 163
individuals with very poor self-reported health were
excluded. This left a study population of 57,504 indi-
viduals for the analysis.
Potential confounders
Potential confounders included were sex, age, any
mental disorder, education level, smoking, BMI and
physically activity at work. All the potential con-
founders were self-reported. Mental disorder was
dichotomised into having experienced metal disor-
ders at baseline or not. Education level was grouped
according to the International Standard Classification
of Education (ISCED) in <10, 10–12, 13–14 and
15+ years. Smoking was grouped as daily, occasional
smoker, ex-smoker and never smoked. BMI was cat-
egorised as <19 kg/m2, 19 to <25 kg/m2, 25 to <30
kg/m2 and 30+ kg/m2. Hard physical activity at work
was dichotomised into physical activity at work and
no physical activity at work.
Ethics
DANHES was approved by the Danish National
Data Protection Board (J.nr. 2007-54-0017). This
type of study does not require further ethical approval
as well as informed consent according to Danish law.
Statistical analysis
Cox regression analyses were performed. The risk
estimates were adjusted for mental disorder, educa-
tion, smoking status, BMI, physical activity at work
and total sitting time/physical activity during leisure
time. To ensure adjustment for confounding by age,
age was used as the underlying time variable in the
Cox regression analyses. This is a preferable control
of age since age is most likely a much stronger deter-
minant for low back pain than time-on-study (follow-
up time since study baseline) [27]. Sensitivity analyses
with leisure time physical activity measured by the
IPAQ-L questions were performed.
Around 5% of the values for the four-category
physical activity question were missing, while around
19% of the values of total sitting time were missing
(17% for transportation, 6% for sitting during week-
ends and 6% for sitting during weekdays). Multiple
imputation by chained equations with 20 imputa-
tions was used to account for missing values [28].
The exposure and the potential confounders with
missing values were imputed. The 20 imputation
models included variables that were assumed to pre-
dict the missing values. These variables were sex, age,
BMI, smoking, education, physical activity at work,
physical activity during leisure time, total sitting time
(sitting time during weekends and weekdays, time
spent during transportation) and the outcomes low
back pain and herniated lumbar disc disease.
Estimates were performed on every single imputa-
tion and afterwards were combined using Rubin’s
rules [29].
A statistical test for proportional hazard assump-
tion was done by obtaining Schoenfeld residuals and
scaled Schoenfeld residuals to test if the residuals
were correlated with survival time [27]. The global
tests and the separate tests for the covariates total sit-
ting time and physical activity during leisure time
were not violated (all p-values > 0.18). Tests for effect
modification between total sitting time per day (0 to
<6 h; 6 to <10 h; 10+ h)/physical activity during lei-
sure time and BMI (<19 kg/m2; 19 to <25 kg/m2; 25
to <30 kg/m2; 30+ kg/m2) and tests for interaction
4    M. Balling et al.
Table I.  Characteristics of 57,504 participants in the DANHES 2007–2008 by total sitting time.

Daily sitting time <6 ha 6 to <10 ha 10+ ha Alla Allb

Total, n (%) 20,755 (44.3) 18,816 (40.2) 7,255 (15.5)  

Gender, men, n (%) 7987 (38.5) 7387 (39.3) 3418 (47.1) 22,820 (39.7) (39.7)
Age, mean (SD) 48.4 (15.4) 45.9 (15.3) 44.0 (15.8) 47.6 (15.8) 47.6
Mental disorder, n (%) 2301 (11.1) 2193 (11.7) 911 (12.6) 6278 (10.9) (10.9)
Education, n (%)  
<10 years 1694 (8.5) 1124 (6.2) 336 (4.8) 4336 (8.2) (8.5)
10–12 years 4387 (21.9) 3501 (19.2) 1336 (19.2) 11,119 (21.0) (21.1)
13–14 years 4857 (24.2) 4387 (24.1) 1733 (24.9) 12,759 (24.1) (24.1)
15+ years 9119 (45.5) 9231 (50.6) 3563 (51.1) 24,681 (46.7) (46.3)
Smoking, n (%)  
Daily 2321 (11.2) 2299 (12.2) 1105 (15.2) 7249 (12.7) (12.7)
Less than daily 1093 (5.3) 1172 (6.2) 437 (6.0) 3322 (5.8) (5.8)
Ex-smoker 6322 (30.5) 5304 (28.2) 1962 (27.1) 16,906 (29.6) (29.6)
Never smoked 11,002 (53.1) 10,034 (53.4) 3750 (51.7) 29,567 (51.8) (51.8)
Leisure time physical activity, n (%)  
Inactive 1975 (9.6) 2623 (14.0) 1754 (24.3) 7609 (13.9) (13.9)
Light 12,115 (58.7) 10,406 (55.5) 3553 (49.2) 31,046 (56.7) (56.6)
Moderate 5591 (27.1) 4871 (26.0) 1615 (22.3) 13,734 (25.1) (25.0)
Vigorous 959 (4.7) 860 (4.6) 307 (4.3) 2390 (4.4) (4.4)
Physical activity at work, n (%) 6159 (32.0) 3673 (21.0) 1218 (17.8) 12,249 (24.1) (24.1)
BMI, mean (SD) 24.7 (4.0) 24.8 (4.2) 25.2 (4.5) 24.8 (4.2) 24.8

aDue to different numbers of missing values, the total number of individuals varies in each covariate.
bTheshown numbers are the proportions (%) for categorical variables and means for continuous variables after multiple imputation was
performed.

between physical activity during leisure time and
physical activity at work (yes; no) were done.
Furthermore, tests for effect modification between
total sitting time per day (0 to <6 h; 6 to <10 h; 10+
h)/physical activity and gender were performed.
Finally, interaction between total sitting time and
physical activity during leisure time was explored.
STATA program software version 14 was used for all
the statistical analysis.
Results
Table I gives the baseline characteristics of the study
population by categories of daily total sitting time.
Among a total of 46,826 individuals, 44.3%, 40.2%
and 15.5% were sitting for <6 h, 6 to <10 h and 10+
h, respectively. In general, individuals with higher sit-
ting time had a lower mean age, higher education,
more often smoked daily, were less physically active
in leisure time, had a higher BMI, more often had
mental disorder and did not engage in physical activ-
ity at work.
During a mean follow-up period of 7.4 years
(range 0–8.5 years), 1796 individuals (3.8%) were
diagnosed with low back pain, of whom 479 individ-
uals (1.0%) had herniated lumbar disc disease.
There was no statistically significant association
between total sitting time and low back pain or her-
niated lumbar disc disease, neither in the total
population, nor in analyses stratified for gender
(Table II).
For men and women combined, moderate and
vigorous physical activity was significantly detrimen-
tally associated with low back pain (hazard ratio
(HR) = 1.16 (95% confidence interval (CI): 1.03–
1.30) and 1.45 (95% CI: 1.15–1.83)) compared to
engaging in light physical activity (Table III). The
HR for low back pain among women doing moderate
and vigorous physical activity was HR = 1.17 (95%
CI: 1.01–1.36) and HR = 1.69 (95% CI: 1.21–2.35),
respectively, as compared to those doing light physi-
cal activity (Table III). Among men no significant
association between physical activity and low back
pain was found (Table III). Moreover, the HR of her-
niated lumbar disc disease in men and women com-
bined who reported moderate physical activity was
HR = 1.28 (95% CI: 1.03–1.59), and in men sepa-
rately HR = 1.40 (95% CI: 1.03–2.89), as compared
to those doing light physical activity (Table III). No
significant association between physical activity and
herniated lumbar disc disease in women was found
(Table III). The unadjusted results were nearly the
same as the adjusted results (data not shown).
Estimates with physical activity during leisure time
measured by IPAQ showed similar results (data not
shown).
Physical activity at work did not modify the asso-
ciation between physical activity during leisure time
 Total sitting time, leisure time physical activity and low back pain   5
Table II. Adjusted hazard ratios (95% confidence interval) for low back pain and herniated lumbar disc disease by total sitting time in
57,504 men and women in the DANHES 2007–2008a.

Total sitting Low back pain Herniated lumbar disc disease

time (h/day) 
Cases Person years HR (95% CI)b Cases Person years HR (95%CI)b

Total  
0 to <6 829 192,338 1 220 194,453 1
6 to <10 700 168,610 0.99 (0.89–1.10) 194 170,414 1.02 (0.83–1.25)
10+ 267 65,545 0.99 (0.86–1.16) 65 66,256 0.88 (0.65–1.19)
Men  
0 to <6 290 72,444 1 90 73.152 1
6 to < 10 273 65,394 1.09 (0.91–1.31) 91 66,079 1.21 (0.88–1.65)
10+ 114 30,629 1.02 (0.80–1.29) 36 30,886 1.08 (0.70–1.66)
Women  
0 to <6 540 119,893 1 130 121,301 1
6 to <10 427 103,216 0.93 (0.81–1.07) 103 104,335 0.90 (0.69–1.19)
10+ 153 34,915 0.99 (0.81–1.20) 29 35,370 0.75 (0.48–1.16)

aThe values in the table are estimated with imputed values for missing data.
bAdjusted for age, sex, mental disorder, education, smoking status, BMI, leisure time physical activity and physical activity at work.

Table III.  Hazard ratios (95% confidence interval) for low back pain and herniated lumbar disc disease by leisure time physical activity in
57,504 men and women in the DANHES 2007–2008a.

Physical Low back pain Herniated lumbar disc disease

activity during
leisure time Cases Person years HR (95% CI)b Cases Person years HR (95% CI)b

Total
Inactive 255 58,653 1.03 (0.89–1.19) 68 59,337 1.12 (0.84–1.48)
Light 980 241,791 1 252 244,404 1
Moderate 472 107,135 1.16 (1.03–1.30) 144 108,192 1.28 (1.03–1.59)
Vigorous 89 18,914 1.45 (1.15–1.83) 16 19,189 0.90 (0.53–1.54)
Men
Inactive 90 24,308 0.91 (0.71–1.17) 24 24,562 0.83 (0.52–1.31)
Light 319 80,528 1 99 81,315 1
Moderate 218 51,761 1.13 (0.94–1.36) 86 52,216 1.40 (1.03–1.89)
Vigorous 49 11,872 1.27 (0.91–1.76) 8 12,024 0.68 (0.32–1.42)
Women
Inactive 165 34,345 1.10 (0.92–1.32) 43 34,775 1.38 (0.97–1.96)
Light 661 161,263 1 153 163,090 1
Moderate 253 55,374 1.17 (1.01–1.36) 59 55,976 1.14 (0.83–1.58)
Vigorous 41 7,042 1.69 (1.21–2.35) 7 7,165 1.42 (0.67–3.10)

aThe values in the table are estimated with imputed values for missing data.
bAdjusted for age, sex, mental disorder, education, smoking status, BMI, total sitting time and physical activity at work.

and low back pain. Furthermore, there was no statis- Discussion

tically significant interaction between BMI and total
sitting time, or BMI and physical activity during lei-
sure time. There was also no statistically significant
interaction between total sitting time and physical
activity during leisure time. Among the three sitting
groups (0 to <6 h/day, 6 to <10 h/day and 10+ h/
day), HR for low back pain was highest in those
engaging in vigorous physical activity during leisure
time, and then less in those who were moderately
active during leisure time, followed by those who
were inactive, when compared to those with light
physical activity during leisure time (Figure 1).
We observed no statistically significant association
between total sitting time and low back pain or herni-
ated lumbar disc disease. In general, previous studies
on sitting time at work, sitting in front of a computer
or watching TV were not found to be associated with
low back pain [30]. A few studies with contrasting
results have examined the association between total
sitting time and low back pain (a study found a pro-
tective effect, another found an increased risk and
three studies found no association) [5–9]. The con-
trasting results in earlier and present studies are
6    M. Balling et al.
Figure 1.  Hazard ratio of low back pain by different combinations of total sitting time and physical activity during leisure time.
The model is adjusted for age, sex, mental disorder, education, smoking status, BMI and physically activity at work.
possibly due to different epidemiology designs, study
populations, ways to measure sitting time and/or dif-
ferent definitions of low back pain.
Doing vigorous and moderate physical activity, as
compared to doing light physical activity, was associ-
ated with increased risk of low back pain in men and
women. Former studies have found physical activity
either to be protective against or not to be associated
with low back pain [14,15]. However a systematic
review described that low back pain was common in
young athletes [13], which corresponds to our find-
ing that vigorous leisure time physical activity was
associated with increased risk of low back pain.
Moreover, we also found that moderate leisure time
physical activity was associated with increased risk of
low back pain. In a review by Vuori it was concluded
that prolonged heavy sports activities seem to
increase the risk of low back pain but a dose-response
relationship concerning volume and intensity is not
known [16]. If a dose–response relationship exists
then moderate physical activity may be sufficient to
increase the risk of low back pain.
In the present study moderate physical activity in
men and women and in men was positively associ-
ated with herniated lumbar disc disease while no
association was seen for vigorous physical activity
and no association was seen among women. A
possible explanation could be that the individuals
who performed vigorous physical activity may have
engaged in specific types of physical activity which
are not associated with herniated lumbar disc dis-
ease. The same could be the case for women, who in
general might practice other specific types of physical
activity in leisure time than men.
Furthermore, in present study there was no statis-
tically significant interaction between total sitting
time and physical activity during leisure time, as
shown in Figure 1. This means that the higher risk of
low back pain seen in groups who are engaged in
moderate and vigorous physical activity in leisure
time is unlikely to be explained by total sitting time.
Important advantages of the present study were
the prospective design, the large sample size and the
use of national registers, enabling full information to
be obtained on participants during follow-up. The
national registers used in this study, the Danish Civil
Registration System and the Danish NPR, are both
considered to be of high quality and with a high cov-
erage [25,26].
Moreover, a strength was that individuals who had
self-reported back disease or back disease registered
in the Danish NPR at baseline were excluded.
Individuals with self-reported very bad health at
baseline were also excluded, as a consequence of this
 Total sitting time, leisure time physical activity and low back pain   7
group most likely being extra vulnerable and proba-
bly also physically inactive and sedentary due to bad
health.
However, a number of study limitations have to be
taken into consideration when evaluating the results.
The Danish NPR included only patients diagnosed
in hospitals and not patients diagnosed by their gen-
eral practitioner, or those with low back pain who
were not diagnosed at all. It is likely that individuals
diagnosed in the hospital had more severe low back
pain as compared to those diagnosed by their general
practitioner or not diagnosed at all. The association
between total sitting time/physical activity and low
back pain observed in the present study may there-
fore not be generalisable to individuals with less
severe low back pain. Furthermore, a non-differential
misclassification of the individuals diagnosed by the
general practitioner and not diagnosed at all most
likely has taken place. If a non-differential misclassi-
fication has occurred, it could have led to an under-
estimation of the association between total sitting
time, physical activity and low back pain.
The study has a large cohort and therefore objec-
tive measurements were not feasible. Although the
IPAQ questionnaire is demonstrated to be a reliable
and valid tool in developed countries [31], the limita-
tions according to self-reporting should be taken into
account. More studies have found poor agreement
between objectively measured sitting time and self-
reported questionnaires, e.g. Gupta et  al. who have
reported a mean bias of 204 min/day for sitting time
compared with accelerometer measures [32]. It has
also been shown that sitting measured by IPAQ com-
pared with objective measurements may underesti-
mate the strength of the association with metabolic
and vascular risk factors [33]. If the same is the case
for low back pain it could potentially have led to a
type 2 error. Furthermore, the correlation between
self-reported physical activity and objectively meas-
ured physical activity is demonstrated to be signifi-
cant but low [22]. This could have led to an
underestimation of the association between physical
activity in leisure time and low back pain and herni-
ated lumbar disc disease.
The total proportion answering the DANHES
questionnaire was 14% [20]. There were sociodemo-
graphic differences between the respondents and the
non-respondents of the DANHES questionnaire
[20]. The respondents had higher education, higher
income and were more often married and a higher
proportion of women were represented compared
with the population in Danish municipalities [20].
Low back pain is described to be more common
among women than men [4]. This could result in an
overestimation of the incidence of low back pain in
the present study as compared to the general popula-
tion since more women were represented in the pre-
sent study.
This study can contribute to the understanding of
how total sitting time and physical activity impact the
risk of hospitalization due to low back pain and her-
niated lumbar disc disease. Further prospective stud-
ies using objectively measured total sitting time are
needed to confirm the findings.
In conclusion, this study found that total sitting
time was not associated with low back pain, but mod-
erate and vigorous physical activity was associated
with increased risk of low back pain.
Acknowledgements
Thanks are due to the individuals in the 13 munici-
palities who participated in the survey.
Declaration of conflicting interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/
or publication of this article.
Funding
The authors disclosed receipt of the following finan-
cial support for the research, authorship, and/or pub-
lication of this article: DANHES 2007–2008 was
funded by The TrygFoundation and the Danish
Ministry of Health and Prevention.
References
[1] Walker BF. The prevalence of low back pain: a systematic
review of the literature from 1966 to 1998. J Spinal Disord
2000;13:205–17.
[2] Murray CJ, Barber RM, Foreman KJ, et al. Global, regional,
and national disability-adjusted life years (DALYs) for 306
diseases and injuries and healthy life expectancy (HALE)
for 188 countries, 1990–2013: quantifying the epidemio-
logical transition. Lancet 2015;386:2145-91.
[3] Flachs EM, Eriksen L, Koch MB, et  al. Sygdomsbyrden i
Danmark: sygdomme. Sundhedsstyrelsen, 2015.
[4] Manchikanti L, Singh V, Falco FJ, et  al. Epidemiology of
low back pain in adults. Neuromodulation 2014;17(Suppl
2):3–10.
[5] Levangie PK. Association of low back pain with self-
reported risk factors among patients seeking physical ther-
apy services. Phys Ther 1999;79:757–66.
[6] Gupta N, Christiansen CS, Hallman DM, et  al. Is objec-
tively measured sitting time associated with low back pain?
A cross-sectional investigation in the NOMAD study. PLoS
One 2015;10:e0121159.
[7] Kopec JA, Sayre EC and Esdaile JM. Predictors of back pain
in a general population cohort. Spine 2004;29:70–8.
[8] Lunde LK, Koch M, Knardahl S, et  al. Associations of
objectively measured sitting and standing with low-back
pain intensity: a 6-month follow-up of construction and
healthcare workers. Scand J Work Environ Health 2017;43:
269–78.
[9] Korshoj M, Hallman DM, Mathiassen SE, et  al. Is objec-
tively measured sitting at work associated with low back
8    M. Balling et al.
pain? A cross sectional study in the DPhacto cohort. Scand
J Work Environ Health 2018;44:96-105.
[10] Nachemson AL. Disc pressure measurements. Spine
1981;6:93–7.
[11] Morl F and Bradl I. Lumbar posture and muscular activ-
ity while sitting during office work. J Electromyogr Kinesiol
2013;23:362–8.
[12] McGill SM, Hughson RL and Parks K. Lumbar erector
spinae oxygenation during prolonged contractions: implica-
tions for prolonged work. Ergonomics 2000;43:486–93.
[13] Mortazavi J, Zebardast J and Mirzashahi B. Low back pain
in athletes. Asian J Sports Med 2015;6:e24718.
[14] Henchoz Y and So AK-L. Exercise and nonspecific low
back pain: a literature review. Joint Bone Spine 2008;75:
533–9.
[15] Bakker EW, Verhagen AP, van Trijffel E, et  al. Spinal
mechanical load as a risk factor for low back pain: a sys-
tematic review of prospective cohort studies. Spine 2009;34:
E281–93.
[16] Vuori IM. Dose-response of physical activity and low back
pain, osteoarthritis, and osteoporosis. Med Sci Sports Exercise
2001;33(6 Suppl):S551–86.
[17] Zhang YG, Sun Z, Zhang Z, et al. Risk factors for lumbar
intervertebral disc herniation in Chinese population: a case-
control study. Spine 2009;34:E918–22.
[18] Jorgensen MB, Holtermann A, Gyntelberg F, et  al. Physi-
cal fitness as a predictor of herniated lumbar disc disease:
a 33-year follow-up in the Copenhagen male study. BMC
Musculoskeletal Disord 2013;14:86.
[19] Linton SJ and van Tulder MW. Preventive interventions for
back and neck pain problems: what is the evidence? Spine
2001;26:778–87.
[20] Eriksen L, Gronbaek M, Helge JW, et al. The Danish Health
Examination Survey 2007–2008 (DANHES 2007–2008).
Scand J Public Health 2011;39:203–11.
[21] Bjork Petersen C, Bauman A, Gronbaek M, et al. Total sit-
ting time and risk of myocardial infarction, coronary heart
disease and all-cause mortality in a prospective cohort of
Danish adults. Int J Behav Nutr Phys Act 2014;11:13.
[22] Grimby G, Borjesson M, Jonsdottir IH, et  al. The “Sal-
tin–Grimby Physical Activity Level Scale” and its appli-
cation to health research. Scand J Med Sci Sports 2015;
25(Suppl 4):119–25.
[23] World Health Organization. Global recommendations on physi-
cal activity for health. Geneva, Switzerland: WHO, 2010.
[24] IPAQ Research Committee. Guidelines for data processing and
analysis of the International Physical Activity Questionnaire
(IPAQ). IPAQ, 2005.
[25] Lynge E, Sandegaard JL and Rebolj M. The Danish
National Patient Register. Scandi J Public Health 2011;39(7
Suppl):30–3.
[26] Pedersen CB. The Danish Civil Registration System. Scand
J Public Health 2011;39(7 Suppl):22–5.
[27] Kleinbaum DG. Survival analysis, a self-learning text. Bio-
metrical J 1998;40:107-8 .
[28] Spratt M, Carpenter J, Sterne JA, et al. Strategies for mul-
tiple imputation in longitudinal studies. Am J Epidemiol
2010;172:478–87.
[29] Rubin DB. Multiple imputation for nonresponse in surveys.
New York: John Wiley & Sons, 2004.
[30] Chen SM, Liu MF, Cook J, et al. Sedentary lifestyle as a risk
factor for low back pain: a systematic review. Int Arch Occup
Environ Health 2009;82:797–806.
[31] Craig CL, Marshall AL, Sjostrom M, et  al. International
physical activity questionnaire: 12-country reliability and
validity. Med Sci Sports Exercise 2003;35:1381–95.
[32] Gupta N, Christiansen CS, Hanisch C, et  al. Is question-
naire-based sitting time inaccurate and can it be improved?
A cross-sectional investigation using accelerometer-based
sitting time. BMJ Open 2017;7:e013251.
[33] Celis-Morales CA, Perez-Bravo F, Ibanez L, et al. Objective
vs. self-reported physical activity and sedentary time: effects
of measurement method on relationships with risk biomark-
ers. PLoS One 2012;7:e36345.