Too Much Sitting Is Not the Same as Too Little Physical Activity

Travis Saunders MSc CSEP-CEP PhD (c)

egardless of age, gender or body weight, living an active lifestyle is associated with a higher quality of life and reduced risk of disease and death. Although it is well-established that physical activity is important for good health, recent evidence suggests that physical activity is only part of the story. It is increasingly clear that the amount of sedentary behaviour you engage in has a large impact on health, regardless of your level of physical activity.

sitting Too Much Is not the same as Exercising Too little

Sedentary behaviour is characterized as any behaviour with extremely low energy expenditure (1). Activity-related energy expenditure is quantified using metabolic equivalents (METs). One MET is equivalent to 3.5 mL of oxygen consumption per kilogram of body weight, and represents the resting metabolic rate while sitting at rest. Sedentary behaviour is defined as any behaviour with an energy expenditure of 1.5 METs or less (1). This means that anytime you are sitting or lying down, you are engaging in sedentary behaviour. There are few exceptions when an individual can be sitting or lying down but still have a high level of energy expenditure (e.g. riding a stationary bike). This definition of sedentary behaviour is different from its traditional usage. In the past, referring to someone as sedentary meant they did not meet physical activity guidelines. In this new context, a sedentary lifestyle is one that is characterized by high levels of sedentary behaviour, irrespective of an individuals level of moderate or vigorous physical activity. This definition recognizes that sedentary behaviour is a risk factor for chronic disease and that it is possible for an individual to accumulate high levels of both physical activity and sedentary behaviour. As sedentary behaviour researcher Marc Hamilton has argued sitting too much is not the same as exercising too little (2).

Health risks associated with sedentary lifestyles

Recent epidemiologic findings suggest that sedentary

behaviour is an independent risk factor for both morbidity and mortality. A cohort of 17 000 Canadian adults was examined and found that individuals who spent the majority of their day sitting were roughly 50% more likely to die during the follow-up period than individuals who sat less than a quarter of the day, even after controlling for age, smoking and physical activity levels (3). A similar longitudinal study from Australia found that each hour of daily television viewing (a proxy of sedentary time) was associated with an 11% increase in the risk of all-cause mortality, regardless of age, sex, waist circumference and physical activity level (4). Other studies have also linked sedentary behaviour to increased risk of chronic diseases, including obesity, diabetes and cardiovascular disease. During a 6-year longitudinal study of nearly 70 000 women in the Nurses Health Study, Hu and colleagues report that each 2-hour increase in daily TV time was independently associated with a 23% increased risk of developing obesity and a 14% increased risk of developing type 2 diabetes (5). These results are supported by a similar study in men (6), as well as recent findings suggesting that sedentary time is also associated with prospective risk of cardiovascular events (7). The studies described above have examined the health impact of chronic sedentary behaviour, but there is evidence that even short episodes of sedentary behaviour may negatively impact metabolic health. For example, Stephens and colleagues at the University of Massachusetts found that 1 full day of sitting reduced insulin action by 39% in a group of 14 healthy adults (8). Similarly, Hamburg and colleagues reported that 5 days of bed rest resulted in a 50% increase in insulin resistance and a 35% increase in plasma triglyceride levels in 20 adults (9). These findings are supported by work in animal models, which suggest that just 4 to 6 hours of sedentary behaviour may result in dramatic metabolic adaptations in skeletal muscle, resulting in reduced uptake of triglycerides and glucose (10,11). These results suggest that even short bouts of sedentary behaviour have a measurable impact

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on metabolic health, and help to explain the consistent associations between sedentary behaviour and disease risk observed at the population level.

living a less sedentary lifestyle

It likely comes as no surprise that current lifestyles promote extremely high levels of sedentary behaviour. We drive to and from work, and accumulate large amounts of uninterrupted sedentary behaviour during the workday. After driving home we may relax in front of the television. Canadian adults average nearly 10 hours per day of sedentary behaviourwell over half their waking hours. The situation is no better for Canadian children, who are sedentary for more than 70% of their school day (12), and spend an average of 6 hours per day using screen-based entertainment devices (13). While sedentary behaviour is ubiquitous in Canadian society, it is also a behaviour that lends itself to simple and inexpensive interventions. Commuting actively (e.g. travelling by foot, bike or transit) whenever possible is a simple way to reduce sedentary behaviour. Setting daily limits for television and computer use (including smart phones and other screen-based devices) can also reduce sedentary behaviour during discretionary time. A recent randomized trial suggests that this approach may not only reduce sedentary behaviour, but may also help to reduce body weight (14). The Canadian Society for Exercise Physiology recently released the worlds first evidence-based sedentary behaviour guidelines for children and youth (15), which suggest that children should accumulate less than 2 hours of screen time per day, although lower levels of screen time are associated with additional health benefits. While sedentary behaviour guidelines have yet to be released for other age groups, it is safe to conclude that limiting screen time is likely to be associated with health benefits in all populations. Although modern office-based work is largely sedentary, it does not have to be. For example, simple activities like talking on the phone or holding small meetings can be done just as well while standing. With a proper workplace setup, even traditionally sedentary activities such using a computer dont have to include sitting. Most of this review was written standing up, using a standing workstation. When workplace sedentary behaviour cannot be avoided, it is worth exploring ways in which it can at least be broken up. It has been reported

that for a given amount of total daily sedentary time and physical activity, individuals who take more frequent breaks (e.g. standing, or walking down the hall at a leisurely pace) have lower body weight, waist circumference, triglycerides and higher oral glucose tolerance (16). This suggests that simply breaking up sedentary time may help mitigate the health risks when sedentary behaviour is unavoidable.

assessing sedentary Behaviour in the Clinical setting

Currently there is no objective tool for assessing sedentary behaviour in the clinical setting. Accelerometers are the preferred tool for research, but can cost $500 per unit. While pedometers offer an inexpensive means of quantifying physical activity, they give no information related to sedentary time. At present the best ways for assessing sedentary time in the clinical setting are questionnaire-based approaches. Regardless of the questionnaire used, it is important to quantify the amount of sedentary behaviour throughout the day (morning, afternoon and evening, both weekdays and weekends), and the modality of sedentary behaviour (driving, watching television, using a computer, playing videogames and reading). Once the amount of daily sedentary behaviour and its distribution across modalities has been assessed, appropriate targets and action plans can be developed. Clinicians should discuss the importance of limiting sedentary behaviour with their clients as part of any lifestyle intervention. Most individuals are not aware that sedentary behaviour influences health, independent of physical activity levels. Thus, simply educating clients on the health impact of sedentary behaviour may be an important step in reducing their chronic disease risk.

Conclusions
Rapidly increasing evidence suggests that sedentary behaviour is associated with increased risk of both morbidity and mortality independent of physical activity levels. Interventions aimed at reducing sedentary behaviour are simple and cost little to implement. Until more cost-effective tools allow for objectively assessing sedentary behaviour in the clinical setting, practitioners should ask patients about the quality and quantity of sedentary behaviour they accumulate on a regular basis.

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Once this has been done, clinicians should work with patients to reduce levels of sedentary behaviour, as they would with other risk factors.

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references
1. Tremblay MS, Colley RC, Saunders TJ, et al. Physiological and health implications of a sedentary lifestyle. Appl Physiol Nutr Metab. 2010;35:725-740. Hamilton MT, Healy GN, Dunstan DW, et al. Too little exercise and too much sitting: inactivity physiology and the need for new recommendations on sedentary behavior. Curr Cardiovasc Risk Rep. 2008;2:292-298. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009;41:998-1005. Dunstan DW, Barr ELM, Healy GN, et al. Television viewing time and mortality: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Circulation 2010;121:384-391. Hu FB, Li TY, Colditz GA, et al. Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. JAMA. 2003;289:1785-1791. Hu FB, Leitzmann MF, Stampfer MJ, et al. Physical activity and television watching in relation to risk for type 2 diabetes mellitus in men. Arch Intern Med. 2001;161:1542-1548. Stamatakis E, Hamer M, Dunstan DW. Screen-based entertainment time, all-cause mortality, and cardiovascular events: population-based study with ongoing mortality and hospital events follow-up. J Am Coll Cardiol 2011;57:292-299. Stephens BR, Granados K, Zderic TW, et al. Effects of 1 day of 10.

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inactivity on insulin action in healthy men and women: interaction with energy intake. Metabolism. In press. Hamburg NM, McMackin CJ, Huang AL, et al. Physical inactivity rapidly induces insulin resistance and microvascular dysfunction in healthy volunteers. Arterioscler Thromb Vasc Biol. 2007;27:2650-2656. Bey L. Suppression of skeletal muscle lipoprotein lipase activity during physical inactivity: a molecular reason to maintain daily low-intensity activity. J Physiol. 2003;551:673-682. Henriksen EJ, Rodnick KJ, Mondon CE, et al. Effect of denervation or unweighting on GLUT-4 protein in rat soleus muscle. J Appl Physiol. 1991 May;70:2322-2327. Nettlefold L, McKay HA, Warburton DER, et al. The challenge of low physical activity during the school day: at recess, lunch and in physical education. Br J Sports Med. In press. Active Healthy Kids Canada. Its time to unplug our kids: Canadas report card on physical activity for children and youth 2008. http://www.activehealthykids.ca/ecms.ashx/ ArchivedReportCards /2008-AHKC-Long-Form-EN.pdf. Accessed May 25, 2011 Epstein LH, Roemmich JN, Robinson JL, et al. A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Arch Pediatr Adolesc Med. 2008;162:239-245. Canadian Society for Exercise Physiology. Canadian sedentary behaviour guidelines. http://www.csep.ca/english/view. asp?x=804. Accessed May 25, 2011. Healy GN, Dunstan DW, Salmon J, et al. Breaks in sedentary time: beneficial associations with metabolic risk. Diabetes Care. 2008;31:661-666.

BENEFITS oF YoGACoNTINUED FRoM PAGE 8

in their studies. Table 1 gives the recommended asanas from 3 sources. There is much agreement regarding which asanas to include, but salabhasana (locus posture) is the exceptionone source recommended it (6) and another indicated it worsens diabetes control (4). Unfortunately, no detail was given as to how this was documented or how it was determined which asanas would be beneficial. Multiple sources also recommend Pranayama (4-6). Prana means breath, life, vitality, energy or strength, and ayama means length, expansion or stretch. Pranayama then refers to the extension of breath and its control. Slow, rhythmic breathing calms the mind, strengthens the respiratory system, soothes the nervous system, and reduces cravings (6). The reviews report positive effects of yoga on short-term parameters of diabetes. It is unclear about the long-term benefits due to the short duration of the trials and the small number of participants. In order to be conclusive about the effect of yoga on managing diabetes, well-designed randomized con-

trol trials are needed. In the meantime I feel comfortable in encouraging my friend to continue his yoga practice to help him manage his diabetes. Namaste.

references
1. Aljasir B, Bryson M, Al-shehri B. Yoga practice for the management of type II diabetes mellitus in adults: a systemic review. Evid Based Complement Alternat Med. 2010;7:399-408. 2. Innes KE, Vincent HK. The influence of yoga-based programs on risk profiles in adults with type 2 diabetes mellitus: a systematic review. Evid Based Complement Alternat Med. 2007;4:469-486. 3. Gordon LA, Morrison EY, McGrowder DA, et al. Effect of exercise therapy on lipid profile and oxidative stress indicators in patients with type 2 diabetes. BMC Complement Altern Med. 2008;8:21. 4. 5. Sahay BK. Role of yoga in diabetes. J Assoc Physicians India. 2007;55:121-126. Kosuri M. Sridhar GR. Yoga practice in diabetes improves physical and psychological outcomes. Metab Syndr Relat Disord. 2009;7:515-517. 6. Iyengar BKS. Light on yoga. London: Harper Collins Publishers. 1991.

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