Stand by me: Too much sitting is bad for you, but what can we do about it? Stuart Biddle Professor of Physical Activity & Health School of Sport, Exercise & Health Sciences Loughborough University & NIHR Leicester-Loughborough Diet, Lifestyle and Physical Activity Biomedical Research Unit

2 Establish links between behaviour & health Measure behaviour Interventions Determinants or correlates Translation into practice Is sedentary behaviour associated with health outcomes? Can we change sedentary behaviours? What is sedentary behaviour and how do we measure it? What factors are associated with sedentary behaviours? Behavioural epidemiology framework Can we ‘roll out’ behaviour change solutions?

3 Content today  Introduction & definition  Health outcomes  Behaviour change

Introduction and definition 4 So what is sedentary behaviour?

5 Sedentary and active behaviours Sleep Sedentary behaviour Light movement Moderate PA Vigorous PA Sitting, lying, very low EE Physical activity research EE

6 TV Sitting at school or work ComputersSocialising Motorised transport Sedentary behaviours Homework Screen time Reading; Listening to music

Sedentary time per day: US adults by accelerometry 7 Matthews et al: Am J Epi, 2008 NHANES N=6,329

Health outcomes of sedentary behaviour 8 Is sedentary behaviour bad for you?

9 Establish links between behaviour & health Is sedentary behaviour associated with health outcomes?  All-cause mortality  Obesity  Metabolic health markers & diabetes risk  Physical fitness  Mental health

10 Establish links between behaviour & health Is sedentary behaviour associated with health outcomes?  All-cause mortality  Obesity  Metabolic health markers & diabetes risk  Physical fitness  Mental health

11 All-cause mortality: Risk ratios for sitting time for adults Canada Fitness Survey (Katzmarzyk et al., MSSE, 2009)

TV viewing and all-cause mortality: Meta-analyses 12

Systematic Review and Meta-Analysis 13

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15 Establish links between behaviour & health Is sedentary behaviour associated with health outcomes?  All-cause mortality  Obesity  Metabolic health markers & diabetes risk  Physical fitness  Mental health

16 Risk of overweight/obese by sedentary and PA levels in Australian adults who are ‘sufficiently active’ (Sugiyama et al., IJBNPA, 2008)

17 Risk at 26y from TV viewing at 5-15y Hancox et al., The Lancet, 2004

Is it sitting or eating, or both?  Pearson & Biddle (2011). Sedentary behavior and dietary intake in children, adolescents and adults: a systematic review. American Journal of Preventive Medicine, 41(2), 178 – 188  Children (k=24 independent samples)  Adolescents (k=72)  Adults (k=14) 18

What about sedentary behaviour and nutrition?  Key findings:  Studies show clear associations between sedentary behaviour (usual screen time, and often TV viewing) and:  elements of a less healthy diet including – lower fruit and vegetable consumption higher consumption of energy-dense snacks, drinks and fast foods higher total energy intake  Strength of associations: small-to-moderate 19

20 Establish links between behaviour & health Is sedentary behaviour associated with health outcomes?  All-cause mortality  Obesity  Metabolic health markers & diabetes risk  Physical fitness  Mental health

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Meta-analysis of sedentary time and metabolic syndrome  Edwardson et al., (2012). Association of sedentary behaviour with metabolic syndrome: a meta-analysis. PLoS ONE, 7(4), e doi: /journal.pone

Meta-analysis of sedentary time and metabolic syndrome 23

Sedentary behaviour and health outcomes  What might be the mechanisms?  Low EE and weight gain  Unhealthy diet  Metabolic effect of muscle activity required for standing v sitting  Clustering of unhealthy risk factors 24

Interventions for behaviour change 25 Can we change sedentary behaviour?

26 Sedentary and active behaviour shifts Sleep Sedentary behaviour Light movement MPAVPA 1 2 PA Guidelines

Interventions to reduce sedentary behaviour in young people  Meta-analysis  K=17 (n=4976)  Only studies that specified their primary goal was to reduce sedentary behaviour  All targeted screen time 27 (Biddle et al., B J Sports Med, 2011)

Results  Hedges’ g =  A small but significant effect  [Maniccia et al, Pediatrics, 2011: Hedges’ g = −0.14] 28

Conclusions & issues - 1  Interventions produced small effect  Is this meaningful? But … what about small effects across a large population??  Sedentary behaviour may be difficult to change  There may be a strong habitual element 29

Conclusions & issues - 2  Most focus only on children  Interventions focus on screen-time only  Intervention fidelity and process evaluations are lacking 30

What kind of interventions are being attempted?  Example: Education (Gortmaker et al., Arch Pediatr Adolesc Med, 1999):  Planet Health programme - curriculum focusing on 4 behaviours inc. reducing TV viewing  Example: Family-based (Epstein et al., Arch Pediatr Adolesc Med, 2008)  Television/video and computer use was monitored and budgeted by a TV allowance device

Displacement? Targeted sedentary behaviour Physical activity Non-targeted sedentary behaviours

Are workplace interventions to reduce sitting effective?  6 studies met the inclusion criteria (5 randomised trials and one pre–post study)  The primary aim of all 6 was to increase physical activity  All had reducing sitting as a secondary aim

Are workplace interventions to reduce sitting effective?  Conclusion:  “While reducing sitting time is emerging as a new workplace-health priority, there is currently a lack of evidence to show that workplace interventions for reducing sitting are effective”

Emerging evidence with adults  Australian adults aged 60 years and over  45 minute face-to-face meeting to assist participants in reducing their sitting time and to increase their breaks in sitting  Various strategies offered, including goal setting and self- monitoring  Sedentary time was reduced by 3.2% (~20 mins)  Number of breaks from daily sedentary time increased  Time spent in light and moderate-to-vigorous physical activity increased  Participants reduced their sedentary time mainly between 10.00h-21.00h, and increased their breaks in sedentary time after 19.00h. 36 Gardiner et al., Am J Prev Med 2011

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Behavioural Choice Theory for Sedentary Behaviour Environmental Modifiers Behavioural Choice: Sedentary Behaviour Access/ availability Reinforcement value

Need to promote MORE PA and LESS sedentary behaviour  ‘Sedentary behaviour’ is “new” and needs greater attention  Need to think about it differently (from PA)  Ubiquitous  Habitual  Reinforcing  Cultural and environmental shifts required!  Do we need to be standing ‘all or most of the time’ or just breaking up prolonged sitting? 39

What’s possible? At work  Standing/modified desks  Screen prompts  Standing meetings  Regular standing breaks At home  TV restrictions  Habit breaking (needs prompts and environmental change)  Alternative activities  Goals and self-monitoring 40

Challenges and Opportunities  Convergent technology  Mobile technology  Technology is not going away  Create rules and time budgets for sedentary technology use  How can we use technology to promote and support behaviour change?  How can we break the dependence on door- to-door car travel? 41

Bottom Line  ‘Move more, sit less’! 42

Stand by me: Too much sitting is bad for you, but what can we do about it? Stuart Biddle