Stand up, sit less, move more, more often: joining the scientific dots on sedentary behaviour and health

1. Stand Up, Sit Less, Move More, More
Often: Joining the Scientific Dots on
Sedentary Behaviour and Health
Associate Professor David Dunstan
Head – Physical Activity
ARC Future Fellow
Baker IDI Heart & Diabetes Institute
Melbourne, Australia
David.Dunstan@bakeridi.edu.au

2. Outline
• State of knowledge (evidence base)
– Sedentary behaviour (too much sitting) as a unique public
health problem – paradigm shift
– Evidence linking sedentary behaviour with mortality, even in
people who are physically active
• Current & future research directions towards
building the evidence-base in relation to sitting
– Controlled laboratory studies
– Settings-based interventions

3. Acknowledgements
• Prof Neville Owen, Dr Alicia Thorp, Prof Bronwyn Kingwell, Dr
Robyn Larsen, Beth Howard: Baker IDI Heart and Diabetes Institute
• Dr Genevieve Healy, Prof Elizabeth Eakin, Dr Elisabeth Winkler,
Dr Paul Gardiner, Dr Bronwyn Clark: The University of Queensland
• Australian Research Council
• Victorian Health Promotion Foundation
• Ergotron

4. The Aussie Brisbane, Queensland
Sedentary Behaviour
Team
Prof Elizabeth Dr Genevieve
Eakin Healy
Melbourne, Victoria
Prof Neville Owen

5. Modern Society: Minimising Daily Muscular Activity!
Then Now
Transport
Domestic
Work

6. Our technologically advanced, ‘sitting orientated’ society
   
Work on
Breakfast
computer Transport Watch TV
15 mins
3.5 hrs From work 4 hrs
45 mins
Lunch
Awake 30 mins Sleep
Transport to
7 am 11pm
work
45 mins Evening
meal
Work on 30 mins
computer
4 hrs Exercise – 30 min
Sitting Opportunities 15.5 hrs

7. Sedentary Behaviours
• Sedere – “to sit”
• Different activities that
involve sitting and low
levels of energy
expenditure
• Includes sitting during
commuting, in the
workplace, the domestic
environment and during
leisure time
“Sitting time” = what these sedentary behaviours primarily involve

8. Sitting Induces Muscular Inactivity
4 STEPS GETTING OUT
OF A CHAIR
SITTING STANDING
Source: Hamilton, M.T., Hamilton, D.G. and Zderic, T.W. (2007) Diabetes, 56, 2655-2667

9. Thanks to Paul Gardiner – University of Queensland

10. Owen N, Healy GN, Matthews CE, Dunstan DW.
Exerc Sports Sci Rev 2010 Volume 38: 105-113
Commentary: Medical Hazards of Prolonged Sitting
Page: 101-102

11. rapidly-strengthening evidence base modest evidence base limited evidence base
i) Identifying relationships of sitting time with health outcomes
ii) measuring sitting time
iii) characterising prevalence and variations of sitting time in populations
iv) identifying the determinants of sitting time
v) developing and testing interventions to influence sitting time
vi) using the relevant evidence to inform public health guidelines and
policy

12. AusDiab: TV time and all-cause mortality
(hazard ratios)
3.0
Hazard ratios all-cause
2.5
mortality
2.0
46% ↑ risk
1.5
1.0
0.5
<2 >=2 to <4 >=4
TV time (hours/day)
Adjusted for age, sex, smoking, education (≥12 years), total energy intake, diet quality index, leisure-time exercise,
waist circumference, hypertension (blood pressure ≥140/90 mmHg or anti-hypertensive medication use), total
plasma cholesterol, HDL-cholesterol (mmol/L), serum-triglycerides (mmol/L, log), lipid-lowering medication use,
previously reported cardiovascular disease (angina, myocardial infarction or stroke), glucose tolerance status).

13. Sedentary Behaviour and Health Outcomes
Associations reported from prospective studies: 1996-2011
Thorp et al. Am J Prev Med 2011
Time 1 Time 2
OUTCOME
MEASURE
EXPOSURE EXPOSURE
MEASURE MEASURE
(Baseline) (Follow-up)

14. Sedentary Behaviour and Health Outcomes
Associations reported from prospective studies: 1996-2011
Thorp et al. Am J Prev Med 2011
Obesity risk/incidence:
Weight gain:
Diabetes:
Cancer:
Cardiovascular disease:
Mortality (all-cause & CVD):
+ve association mediated by BMI / one gender no association

15. Sitting Time and All-Cause Mortality
Risk in 222,497 Australian Adults
Hidde P van Der Ploeg, Tien Chey, Rosemary J Korda, Emily Banks, Adrian Bauman
Arch Intern Med. 2012; 172 (6) : 494-500
Adjusted for:
age, sex, education,
marital status,
urban/rural residence,
physical activity,
BMI, smoking

16. Deaths in Adults with CVD/Diabetes at Baseline
H van der Ploeg et al. Arch Intern Med 172: 694-500
Hazard of Too Much Sitting Regardless of
Exercise-like Leisure Time Physical Activity

17. Hot Off the Press
Key Finding
The analyses indicate
that population life
expectancy in the USA
would be 2.00 years
higher if adults reduced
their sitting time to < 3
hours per day and 1.38
years if they reduced
their television viewing
to < 2 hrs/day

18. rapidly-strengthening evidence base modest evidence base limited evidence base
1. Identifying relationships of sitting time with health outcomes
2. measuring sitting time
3. characterising prevalence and variations of sitting time in populations
4. identifying the determinants of sitting time
5. developing and testing interventions to influence sitting time
6. using the relevant evidence to inform programs and policy

19. Device-Based Measurement of Movement
and Posture
Inclinometer
Accelerometer
From whose output
The ‘market dominator’
we can derive
from whose output
posture-based indices
(counts of less than 100
of ‘sitting’ time
pm) we infer ‘sedentary’
time

20. How Australian Adults’ Overall Daily Behaviour
Patterns Are Distributed Between Physically-Active
and Sedentary Time
Moderate-vigorous activities
0.7 hrs/day (5%)
Light-intensity Mix of working &
Sedentary time
6.5 hrs/day (35%) non-working adults
9.3 hrs/day (60%)
aged 30-87 years
95 Healy et al., 2008

21. Consistent Observations4%
3% 38%
58%
40%
57%
5%
35%
60%
Sedentary/Inactivity LIPA MVPA

22. You Can Be ‘Active’, But Mostly Sit
The ‘Active’ Couch Potato
Activity Energy
Morning
Intensity Expenditure
Moderate/vigorous Very High
Time (minutes)
Light
Night
Sedentary Very Low
Mean mod-to-vigorous time = 31 mins/day
% Waking hours spent in Sedentary = 71%

23. Accelerometer Measured Sedentary Patterns During Work Hours
in Office Workers
Work Hours WORKPLACE SITTING
2.4%
= 33.5 hrs/week
20.6% = 1,608 hrs/year (67 full days)
= 75,576 hrs/working life
75.8% 8.6 YEARS
Sedentary Light Exercise
8.6
Thorp et al., Manuscript currently under review.

24. The ‘Breaks In Sedentary Time’ Hypothesis
• ‘Breaking-up’ sedentary time (frequent transitions from sitting to
standing) has beneficial associations with health outcomes
(independent of sedentary time)
“Prolonger” “Breaker”
Sedentary
CPM < 100
Not sedentary
CPM 100+
Healy GN, Dunstan DW et al. Diabetes Care 2008; 31: 661-666

25. Sedentary Time & Breaks in Sedentary Time
NHANES 03-06
Sedentary time: detrimental
HDL-C, triglycerides, insulin,
HOMA-%B, HOMA-%S
Breaks: beneficial
Waist circumference, HDL-C,
C-reactive protein
4.3cm difference
Adjusted for age, sex, race/ethnicity, moderate-vigorous intensity activity + other potential confounders
Breaks in sedentary time additionally adjusted for total sedentary time
Healy G.N., Matthews, C.E., Dunstan, D.W., Winkler, E.A.H., Owen, N. (2011). Sedentary time and cardio-
metabolic biomarkers in US adults: NHANES 2003-06. European Heart Journal, 32, 590-597

26. rapidly-strengthening evidence base modest evidence base limited evidence base
1. Identifying relationships of sitting time with health outcomes
2. measuring sitting time
3. characterising prevalence and variations of sitting time in populations
4. identifying the determinants of sitting time
5. developing and testing interventions to influence sitting time
6. using the relevant evidence to inform programs and policy

27. Thinking About Multiple Influences On Health
Behaviours
Policy Context
Physical Environment
Interpersonal
Intrapersonal
biological
psychological
skills
conventional
‘comfort zone’
for causation
and explanation

28. rapidly-strengthening evidence base modest evidence base limited evidence base
1. Identifying relationships of sitting time with health outcomes
2. measuring sitting time
3. characterising prevalence and variations of sitting time in populations
4. identifying the determinants of sitting time
5. developing and testing interventions to influence sitting time
6. using the relevant evidence to inform programs and policy

29. AIM: To examine the acute effects of postprandial
glucose and insulin levels of uninterrupted
sitting compared with sitting interrupted by brief
bouts of light- or moderate-intensity walking
Dunstan et al. (2012) Diabetes Care 35: 976-983

30. The Hazards of Post-Prandial (dys)metabolism?
(hyperglycemia, hyperlipidemia)
• Independent risk factor for future cardiovascular
events1
• Exaggerated post-prandial spikes in glucose and
lipids oxidative stress endothelial
dysfunction atherosclerosis2,3
• When repeated multiple times throughout the day:
environment conducive for CVD risk factors and
CHD1,3
1O’Keefe JH & Bell DSH 2008 Am J Cardiol
2Ceriello A 2000 Diabetes Metab Res Rev
3Heine RJ et al. 2004 Diab Med

31. CONDITION 1: A single bout of prolonged sitting
Standardised mixed meal:
~75g CHO and ~50g Fat
Blood sample: glucose, insulin,
triglycerides, FFA’s
Muscle and adipose tissue
-2 -1 0 1 2 3 4 5 hrs biopsy (optional)
EXPERIMENTAL SET UP
ACTIVPAL PROFILE

32. CONDITIONS 2 & 3: Sitting + light/moderate-intensity activity bouts
Light-intensity walking (2mins):
Treadmill Speed = 3.2 km/hr
Moderate-intensity walking (2mins):
Treadmill Speed = 5.8-6.4 km/hr
-2 -1 0 1 2 3 4 5 hrs
EXPERIMENTAL SET UP
ACTIVPAL PROFILE

33. Results: Glucose 20
> 24% 
Dunstan et al. (2012) Diabetes Care 35: 976-983

34. “The workplace provides an ideal opportunity to engage
individuals in taking more control of their own health”.
“The results suggest that simple interventions that can be
implemented in the workplace and domestically to decrease
passive sitting time and increase the number of breaks can also
lead to substantial health improvements.”

35. Workplace Health Promotion & Chronic Disease:
Looking Through a Workplace Sitting Lens
DUTY OF CARE
“A person conducting a
Organisational business or undertaking must
ensure so far as is reasonably
Policy & Culture practicable the provision and
maintenance of a work
environment without risks to
health and safety”
Workplace 23/06/2011 Safety Bill
Model Work Health and
Individuals Physical
Environment

36. Stand Up Australia
To Improve Health and Productivity
Program of research investigating benefits from reducing sitting time in the workplace
AUSTRALIA
Stand Up  Sit Less  Move More

37. Population groups that are most at risk
of prolonged sitting include those
working in offices, transportation, and
highly mechanised trades.
Healy et al., VicHealth Report, 2012

38. Workplace
Arrangements/
Conditions
Workplace
Organisational Design
& Policy Reducing
prolonged sitting
in the workplace
Social /
Individuals Cultural
Health and Productivity

39. Stand Up Australia: Intervening on the
problem
What happens when we intervene on the…
• Environment
• Individual environment
• Individual behaviour
• Organisation
• Objective measures of sitting/standing time
• Focus on measures of health and productivity

40. AUSTRALIA
Initial Pilot Study – Melbourne, Victoria
(Completed)
Comcare

41. Stand Up Comcare
• One month pilot study (to inform the main
Stand Up Victoria trial currently ongoing)
• One site (Comcare, Victoria), two floors
• Participants (18 Ix, 18 C) randomised by floor
WorkFit-S
Kindly donated by Ergotron

42. Study Design
Pre-Intervention 4 week Intervention
(1-2 week prior)
Unit Group Work- Individual Call 1 Call 2 Call 3 Assessment 2
Baseline
Intervention: reps consult station consult (wk 2) (wk 3) (wk4) (end of Ix)
consult install (Day 1-3)
Baseline Assessment 2
Comparison:
OHS,
management,
general staff
• role
• brainstorm

43. Comcare Unit 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)
– Breaks compliance software
– Use the stairs (reduced access during intervention period)
– “No bins” policy – no personal bins
– Timed walking routes in vicinity of building

45. All Ix participants Face-to-Face
• Information • Instruction
Study Design • Refinement
• Group feedback
• Feedback
• Goal setting
• Tracking
Pre-Intervention 4 week Intervention
(1-2 week prior)
Unit Group Work- Individual Call 1 Call 2 Call 3 Assessment 2
Baseline
Intervention: reps consult station consult (wk 2) (wk 3) (wk4) (end of Ix)
consult install (Day 1-3)
Support bhr change
Baseline Assessment 2
Comparison:
OHS,
management,
general staff
• Role
• Brainstorm

46. Example Feedback: Workplace Hours
Average proportion of time at the workplace spent
sitting (bouts ≥30min & <30mins), standing and moving
Time Sitting ≥30mins Time Sitting < 30mins Time Standing Time Moving
9% Focus on reducing
24% prolonged,
11%
unbroken sitting
≥30 minutes
56%
Assessment Period: 12/03/2012 – 19/03/2012
Average work time: 8.3 hours per day
Average number of sitting bouts
3 per day
≥30mins:

47. All days (from 6am to 10pm)
Daily patterns of time spent sitting, standing and moving
Assessment Period: 12/03/2012 – 19/03/2012
Time Sitting
Time Standing
Time Moving
Day 1 2 3 4 5 6 7
8:00- 7:45- 9:30- 8:30- 8:30-
Work hours NA NA
16:30 19:00 16:00 18:30 17:15

48. Goal setting: Key messages
We recommend that you...
Stand Up Sit Less Move More
At least every 30 Use your Throughout the
min! workstation! day!

49. Favorite Behaviour Change
Strategies
Stand Up
 Set a timer (online, through outlook, etc)
 Stand up when the phone rings or when someone enters the office
 Stand up when someone else does
Sit Less
 Determine certain ‘standing times’, i.e. every morning and after lunch
 Stand up when someone else does
 Stand during meetings
Move More
 Use the stairs instead of the lift
 Walking laps
 More active lunch breaks (e.g. walking around the block)
 Fill water bottle more often
 Pick up printing more often
 iMails

50. Results: At the Workplace (%)
Baseline Follow-up
Sitting
10.5 11.0 Standing
Stepping
Comparison 24.4 21.9
(n=18)
65.1 67.1
≥30m: 21.7% ≥30m: 26.3%
10.0 10.5
Intervention 22.6 42.0
(n=18)
67.4 47.5
≥30m: 24.3% ≥30m: 12.7%
*Based on 8h workday

51. Changes in overall sitting time
600
Average sitting time (mins/16h day) Baseline
580
Follow-up
560
- 76 min
540
520
500
480
460
Comparison
Control Intervention
No between group differences in health and work-related outcomes

52. Comments on Workstations
Positive
 enjoying being able to work while standing
 being less stiff
 significant reductions in back/ neck/ shoulder discomfort
 feeling less tired and lethargic
 feeling better/ more energetic
 improved concentration
Negative
 no flexibility to move WS back and forth on desk
 no flexibility to move keyboard back and forth relative to monitor
 sore feet/legs in beginning
 keyboard/mouse shelf too small
 workstation shelf too small
 takes up too much room on desk
15/18 wanted to keep their workstations!

53. www.comcare.gov.au

55. Studies Currently Recruiting….

56. AUSTRALIA

57. Stand Up Victoria
Stand Up  Sit Less  Move More
CIs: David Dunstan, Genevieve Healy, Neville Owen, Elizabeth Eakin,
Anthony LaMontagne, Marj Moodie
• 3-year cluster-randomised controlled trial
– 320 participants (160 per group)
– 15+ worksites from one organisation
• 3 months of intervention, 9 months of follow-up
• Organisational, individual, environmental
elements
• Cost-effectiveness analysis

58. Stand Up Victoria – Partner Organisation

59. AUSTRALIA
Maike Neuhaus
(PhD Student)

60. Aims WorkFit-S
Stand Up  Sit Less  Move More
Kindly donated
by Ergotron
1) To evaluate the effectiveness of height-adjustable workstations
in the workplace to reduce sitting time.
2) To evaluate whether the addition of an individual and
organisational support component leads to greater
reductions in sitting time than the workstations alone.
 Non-randomised controlled trial (N=42)
Group 1: Workstations (n=14)
Group 2: Workstations + Individual Support + Organisational Support (n=14)
Group 3: Control Group (n=14)

61. University of Queensland
• HR/Payroll at UQ St Lucia Campus
• Centre for Clinical Research (UQCCR) at UQ
Herston Campus
• Various departments from the UQ Gatton
Campus.

62. Take Home Messages
• Create opportunities within your waking hours to
limit sitting time
• Avoid prolonged sitting periods - break up sitting
time on a regular basis (“Stand Up, Sit Less,
Move More, More Often”)
• Remember:
95 8.6 20

63. Thank You for Listening
Contact Details
A/Prof David Dunstan
Head – Physical Activity
Baker IDI Heart & Diabetes Institute
Melbourne, Australia
Email: David.Dunstan@bakeridi.edu.au
Web: www.bakeridi.edu.au/research/physical_activity/

64. Other participant feedback
• “I feel much more alert, especially after the lunch
break.”
• “We love it – do you mind if we post a photo of us
standing at our workstations on yammer?
• “My lower back pain is getting much better!”
• “I feel more energetic!”
• “I feel so much healthier, which
means that I can eat more
chocolate, right?”

65. What’s next...
Baseline Intervention 3 months No Contact 12 months
Jan – Mar 2013