JustStand Summit 2013 - Dr. Genevieve Healy

DR. GENEVIEVE HEALY, Ph.D, MPH
School of Population Health—The University of Queensland, Australia
Dr. Healy’s PhD research reported some of the first evidence regarding the
importance of regularly interrupting sitting time for heart health. Her current
research builds on this work to examine how sitting time varies across
populations, as well as the feasibility and acceptability of reducing this
behavior in key settings, such as the workplace. This includes being a main
investigator for “Stand Up Australia” and “Stand Up Comcare” – programs of
research focused on understanding and reducing prolonged sitting time in
Australian office workers.
Dr. Healy’s research receives extensive worldwide recognition, with over
1,000 articles throughout more than 30 countries.
Getting office workers to stand up, sit less and move more—
what works?
For most office workers, the majority of their workday is spent sitting.
Dr. Healy will present evidence on how all that sitting may be impacting on their health.
She will also present findings from the Stand Up Australia program of research.
Across several studies, this program is investigating how much office workers sit, and
what strategies are effective at reducing and changing their sitting time.

Getting office workers to
Stand Up, Sit Less and Move More
Why? What works?

Before we start…
 Please feel free to stand,
 and move
 and sit
 and stand
 and sit etc…

Too much sitting is bad for our health

Why all this interest in sitting?

It has personal relevance
 Everyone sits
 Everyone has a sitting story
 … I get aches and pains when I sit too long (83 yr old women)
 … In my new job I am run off my feet – I’ve lost 8kg (51 yr old women)
 … Going back to work after paternity leave – sitting all day – I felt so achy
and flat (40 yr old man)

45 ± 14 kcal/day
27 ± 9 kcal/day
80 ± 28 kcal/day
54 ± 19 kcal/day
Lanningham-Foster et al., Obesity Research, 2003

Physical activity expended at the workplace
has dropped dramatically
Church et al., PLoS One 2011
1 in 2 men 1 in 5 men

Incidence of coronary heart disease
Conductors
Morris JN et al. Lancet 1953: ii 1053-1057
2.7
per 1000 p.a.
1.9
per 1000 p.a.
Drivers

Health risks of too much sitting
 Diabetes
 Cardiovascular diseases
 Cardiovascular and all-
cause mortality
 Musculoskeletal symptoms
 Chronic kidney disease
Wilmot et al., 2012 & 2013 Diabetologia; Thorpe et al., AJPM 2011;
http://www.who.int/occupational_health/publications/en/oehmsd3.pdf;
 Breast & colon cancer
 Weight gain &
development of obesity
 Metabolic syndrome
 ++++

Scientific interest in “sedentary”
Source: Scopus database July 2013

More accurate measurement
7164
GT1M
GT3x+
activPAL3

Data from an activPAL monitor
Time Sitting
Time Standing
Time Moving
Night
Morning

We spend most of our day sitting
 ~60% of the day spend sitting
 Very little time in moderate & vigorous activity
 Consistent findings around the world
Sedentary
(60%)
Moderate-vigorous activities
(5%)
Light-intensity
(35%)

You can be active & highly sedentary!
Average 2 hours of moving BUT 11 hours of sitting!

But we all need to sit…
“Man is designed for movement,
in other words to switch between
sitting, standing, walking and all
postures in between”
Source: German Federal Institute for Occupational Safety and Health (2008)
Up and Down – Up and Down.
How dynamic sitting and standing can improve health in the office.

Not just about total sitting time
Sitting accumulation & health
 Prolonged sitting and musculoskeletal outcomes1
 More breaks associated with lower waist
circumference2
 Experimental evidence
 Interrupting prolonged sitting associated with better
postprandial glucose & insulin response3
 One hour of exercise does not offset the negative
effects on inactivity on insulin & lipids if the rest of the
day is spent sitting4
1 http://www.who.int/occupational_health/publications/en/oehmsd3.pdf; 2 Healy et al., EHJ, 2011;
3 Dunstan et al., Diabetes Care, 2012; 4 Duvivier et al., PLoS ONE, 2013
Glucose
Insulin

How much sitting is too much?
Stay tuned…
Sit less throughout the day
Stand up at least every 30 minutes

Can we change prolonged sitting time?

A simple solution?
April Fools Day 2013
 See the video:
SFU launches ‘healthy campus’ initiative
http://www.youtube.com/watch?v=sMWCw9G8Txg

Multiple influences on health behaviors
Sitting
Policy
Context
Physical
Environment
Interpersonel
Intrapersonel
Owen et al., AJPM 2011

The workplace is a key setting to address these influences
Social /
Cultural
Workplace
Design
Workplace
Arrangements/
Conditions
Organisational
& Policy
Individuals
Reducing
prolonged
sitting in the
workplace

Epidemiology  Experimental laboratory  Interventions
Translational research
Program of research investigating benefits from reducing sitting time in the workplace
The Stand Up Australia program of research
A National collaboration between the
Baker IDI Heart & Diabetes Institute
University of Queensland,
University of Melbourne,
Deakin University
Government & Non-Government Partner
Organizations

Program of research investigating benefits from reducing sitting time in the workplace
The Stand Up Australia program of research

Key Research Questions
 What is the extent of the problem?
 What are the health risks?
 Who are the target population(s)?
 What can we do to reduce it?
 What is the translation and uptake?
Australia

What is the extent of the problem?
 Office workers spend a lot of time sitting
 A lot of this sitting time is unbroken (30mins+)
Proportion of prolonged (≥30 mins)
sedentary time (%)
Activity distribution (%)
Thorp et al., IJBNPA, 2012
Work time
77.0%
21.1%
1.9%
Sedentary Light MVPA
55.5%
21.5%
Sitting <30mins Sitting 30mins+

What are the health risks?
Detrimental associations with:
 overweight and obesity1
 risk of obesity and type 2 diabetes2
Workplace settings with high sedentary behaviour (ie. call
centres) report:
 weight gain3
 high prevalence of musculoskeletal symptoms4-5
Systematic review6 concluded:
 Not enough evidence / heterogenity
 Need more studies with better measures
1Mummery et al. 2005; 2Hu et al. 2003; 3Boyce et al. 2008; 4Karlqvist et al. ; 5Toomingas et al. 2003; 6van Uffelen et al., 2010

What about sitting and work outcomes?
Interventions typically had a beneficial or
neutral impact on productivity, absenteeism
and injury costs.
No studies suggested likely harm from sensibly
implemented breaks from or reductions in
workplace sitting time
Healy et al., 2012

Who are the target populations?
Population groups that are most at
risk of prolonged sitting include
those working in
offices, transportation, and highly
mechanised trades.
Healy et al., 2012

How have we addressed workplace sitting?
Australia

Social /
Cultural
Workplace
Design
Workplace
ArrangementsCon
ditions
Organisational &
Policy
Individuals
Reducing
prolonged sitting
in the workplace
Health and Work
Building the case

Reducing workplace sitting
 Whole of workplace environment
Vancouver workplace study
 Multicomponent
Stand Up Comcare, Stand up Victoria
 Individual environment vs. multicomponent
Stand Up UQ
Australia

Study 1: Whole of workplace environment
Macquarie Bank
(Australia)
Sydney Office

What is the impact on workplace sitting,
health & work outcomes when…
Office workers move from a
conventional workplace environment
to a
innovative, movement oriented environment?

Vancouver workplace study
 Natural experiment with pre-post design (n=24)
 No other health advice given
Benefits of design
 Intervention ongoing
 Potential benefits for all employees
Erin Gorman
With thanks to A/Prof
Maureen Ashe

Staircase comparisons
Conventional
vs.
Innovative

Standing options in innovative workplace
A. Individual offices
B. Meeting rooms
C.Multipurpose room
A
B
C C

What were the findings? (n=24)
 ~19 minute switch between sitting & standing
 No significant / meaningful impact on health
0
100
200
300
400
500
600
Conventional Innovative
Minsper8-hrworkday
Sitting Standing Stepping
Gorman et al., 2012 under review

But…
 All enjoyed the new workplace
 Most believed that it increased their productivity
Implication
 Just providing the broader physical environment may not be
enough for substantial changes in sitting

We use an multicomponent approach, incorporating
organisational, environmental, and individual change elements
Social /
Cultural
Workplace
Design
Workplace
Arrangements/
Conditions
Organisational
& Policy
Individuals
Reducing
prolonged
sitting in the
workplace
What is the impact on workplace sitting, health
and work outcomes when…

Key message
Stand Up, Sit Less, Move More
Aiming to:
 Reduce total workplace sitting time (Sit Less)
 Reduce the number of sitting bouts (Sit Less)
 Reduce the length of the sitting bouts (Stand Up)
 particularly those 30mins+
Stand Up Australia

Key message
Stand Up, Sit Less, Move More
Aiming to:
 Increase standing and moving time (Move More)
 Make changes throughout the day
 both in and out of the workplace
Achieve this via organizational, environmental &
individual strategies
Stand Up Australia

Organizational strategies
1. Senior management consultation (~30-45mins)
• Background & rationale
• Identification of relevant OHS policies & organizational structures, team champions & any
additional resources
2. Representatives consultation workshop (~2-4hrs)
• Participatory approach: reps from various levels
• Identification of organizational-appropriate strategies to support key message “Stand Up, Sit
Less, Move More”
• Manager emails, champion for change
Stand Up Australia

Organizational strategies
1. Senior management consultation (~30-45mins)
• Background & rationale
• Identification of relevant OHS policies & organizational structures, team champions & any additional
resources
2. Representatives consultation workshop (~2-4hrs)
• Participatory approach: reps from various levels
• Identification of organizational-appropriate strategies to support key message “Stand Up, Sit Less, Move
More”
• Manager emails, champion for change
3. Staff information & brainstorming (~30-45mins)
• Background & intervention details to all staff
• Build on strategies identified in (2)
• Summary email & electronic info book post-session
Stand Up Australia

Environmental change
Height adjustable workstation: WorkFit-S: Ergotron
Product kindly donated by Ergotron for Stand Up Comcare & Stand Up UQ

Individual strategies
Face-to-face coaching session (~30mins)
 Delivered by motivational interviewing trained health
coach
 Individual feedback reviewed in relation to key
messages
 Specific goals for each key message developed &
documented (workstation tracker)
 Email summary post session
Stand Up Australia

Example: individual feedback
24%
56%
11%
9%
Focus on reducing
prolonged, unbroken sitting
≥30 minutes
Sitting
Standing
Stepping
Stand Up Australia

Example: identifying strategies

Documenting goals: workstation tracker

One face-to-face coaching session (~30mins)
 Delivered by MI trained health coach
 Individual feedback reviewed in relation to key
messages
 Specific goals for each key message developed &
documented (workstation tracker)
 Email summary post session

Four support telephone calls (~10mins each)
 Delivered by health coach
 Staggered intervals (e.g. 1, 3, 6, 10 weeks post
coaching)
 General check-in & identification of barriers,
problem solving, potential adjustment of goals
 Phone call 3: strategies outside workplace
Stand Up Australia

Delivery of the intervention
Stand Up
Comcare
Feasibility study
Stand Up Victoria
Cluster-RCT
“Reducing Prolonged Workplace
Sitting Time in Office Workers:
A Cluster-Randomised
Controlled Trial”
- The Stand Up Victoria Study
Prof David Dunstan

Stand Up Comcare
Aim: to assess the short term feasibility and efficacy of a
multicomponent intervention to reduce workplace sitting
DESIGN:
Intervention: Multicomponent (n=18)
Control: Assessment only (n=18)
PARTICIPANTS: Comcare office staff, Melbourne, Australia
2 ASSESSMENTS: Baseline, 4 weeks
Healy et al., Prev Med, July 2013

Phase 1
1-2 weeks
Phase 2:
4 -weeks
Intervention:
Baseline
Reps consult Group
consult
Work-
station
install
Individual consult
(Day 1-3)
Call 1
(wk 2)
Call 2
(wk 3)
Call 3
(wk4)
Assessment 2
(end of Ix)
Control:
Baseline Assessment 2
Study timeline: Stand Up Comcare
Stand Up Comcare

Representatives‟ input
 “laps” around office - defined circuit
 introduction of more standing into meetings (initiated by Chairperson
from the outset)
 use printers further away
 ergonomically sound exercises at scheduled times
 wireless headsets for conference calls (to enable standing)
Stand Up Comcare

Representatives‟ input
 breaks compliance software
 use the stairs (reduced access during intervention period)
 “no bins” policy – no personal bins
 timed walking routes in vicinity of building
Stand Up Comcare

Common individual change strategies
Stand Up
 Set a timer (e.g. outlook)
 Stand up when someone enters the office /
phone rings
 Stand up when someone else does
Sit Less
 Determine certain „standing times‟, i.e.
morning; after lunch
 Standing meetings
Stand Up Comcare
Move More
 Use the stairs instead of the lift
 Walking laps
 More active lunch breaks (e.g. walking around
the block)
 Fill water bottle / pick up printing more often
 iMails

Changes in sitting, standing and stepping
 Participants sat ~70% of the workday at baseline
 Sitting reduced by >2 hrs per 8hr workday in Ix compared to
control group
 Sitting mostly replaced with standing
0
2
4
6
8
10
Baseline Follow-up
Hoursattheworkplace
Stepping
Standing
Sitting
Intervention group
Healy et al., Prev Med, 2013

Further evaluation of intervention
 All Ix participants reduced sitting time
 (range -262 to -29 mins per 8-hr workday)
 Sitting ≥30 mins reduced by 45% (~73 minutes)
 Sitting reduced across the day
 No significant Ix effects on health or work outcomes
Healy et al., Prev Med, 2013; Stevens et al., in preparation

Comcare: since the research study…
Sedentary work practices toolkit
http://www.comcare.gov.au/safety__and__prevention/your_working_environment/s
edentary_work_practices_toolkit
Installing activity permissive desks for all employees

Stand Up Victoria
CIs: David Dunstan, Genevieve Healy, Neville Owen, Elizabeth Eakin, Anthony LaMontagne, Marj Moodie
• 3-year cluster-randomised controlled trial
 320 participants (160 per group)
 14+ worksites from one organisation
• 3 months of intervention + 9 months maintenance
• Cost-effectiveness analysis
• Baseline completed end 2013
Stand Up  Sit Less  Move More

Stand Up Victoria – Partner Organization

Study 3: Multicomponent vs. workstation only

Height-adjustable desks only
VS
Multicomponent workplace programs
Maike Neuhaus
What is the impact on workplace sitting,
health and work outcomes when…

Participants & assessment
N=44
• n= 16
• Multi-component
intervention group
• n= 14
• Height-adjustable
workstations only
• n= 14
• Control group
• Assessments at baseline, 3 months (all groups), and 12 months (Ix only)
Neuhaus et al., under review

Results: sitting, standing, stepping
Control Sitting
Standing
Stepping
78%
14%
8%
76%
16%
8%
Baseline
76%
17%
7%
74%
18%
8%
72%
19%
9%
50%
43%
7%
3 months 12 months
71%
18%
11%
55%38%
7%
~33 mins
~89 mins

Results: health, work & acceptability
 No significant or meaningful changes in health and work
related outcomes
 Acceptability of workstations high
 3.9/5 in multicomponent; 3.7/5 in workstation only
 Some limitations noted (e.g. reduced desk space)
 Mixed qualitative feedback on impact on productivity
 Desks need to be tailored to tasks
 Acceptability of other intervention elements high
 All rated either as useful or very useful
Neuhaus et al., under review

Qualitative feedback: participants
 … just having the option to sit or stand was great
 … everyone now more aware of sitting/standing; everyone
still walking to colleagues to talk; there is more standing in
meetings (when prompted) [Multicomponent participant]
 …. The manager emails were very useful, bringing
everyone onto the same page and encourage to try things
(tips of the week), reinforcing support; thinks if [manager]
did that again it would help her group to get into better
habits again [Multicomponent participant]

Qualitative feedback: participants
What are the advantages / disadvantages of standing more at work?
 … just having the option to sit or stand was great
 … physical health, but also mental – being able to concentrate better
 Decreased lower back pain and increased productivity
 Disadvantages: desk design and choosing which shoes to wear in the morning
Has your workplace culture changed around sitting/standing?
 Yes: more accepted to stand while working
 Yes: everyone more aware; everyone still walking to colleagues to talk; stands
when answering the phone; more standing in meetings (when prompted)
[Multicomponent participant]
 -No-

Stand Up UQ: since the research study
Study groups
 Workstation only: purchased height adjustable desks
 Multicomponent: looking to refurbish
UQ wide
 Working with OHS: prolonged sitting as part of risk assessment
training
 Enabling height adjustable desks to be an option as part of a
refurbishment / replacement
 Gradual dissemination of practice

Getting office workers to Stand Up, Sit Less, Move More:
What worked?
Australia

SUA summary: what worked?
Changing the individual physical environment
…. with complementary support
Key support elements
• Information
• Participatory approach
• Champions for change
• Visible support (e.g. signs, emails)
• Individual coaching

Easy to start the change
 Become a champion
 Online materials
 Juststand.org
 Sedentary work practices toolkit (Comcare)
 Post signs
 “This is a stand friendly workplace”
 “We support standing meetings”
 “Stand up for your health”
 Walking office tracks
http://www.interiorsbygreenstreet.com/blog.html

Evaluate the impact
make the business case for change
 Partner with research
 Existing measures
 Absenteeism, productivity, engagement surveys
 Technology
 Social media

What are the opportunities?
Scientific, media, workplace
and industry interest

Multidisciplinary partnerships are key
Consistent message, consistent language
Reducing
prolonged
sitting
Public Health
Health
Promotion
Physical
activity
Ergonomists OHS
Industry
Occupational
psychologists
+++

Multidisciplinary partnerships are key
Consistent message, consistent language
Reducing
prolonged
sitting
Public Health
Health
Promotion
Physical
activity
Ergonomists OHS
Industry
Occupational
psychologists
+++
Rapidly advance the science, the
translation, and the uptake

Thank you
Dr Genevieve Healy
g.healy@uq.edu.au
Acknowledgements
 Ergotron
 Investigators and participants
 Funding bodies: NHMRC, VicHealth, Heart Foundation, UQ, Ergotron
 Particular thanks: Prof David Dunstan, Prof Elizabeth Eakin, Prof
Anthony LaMontagne, Prof Neville Owen, A/Prof Maureen Ashe, Dr
Glen Wiesner, Dr Elisabeth Winkler, Maike Neuhaus, Erin Gorman

JustStand Summit 2013 - Dr. Genevieve Healy

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