Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up Sedentary Behavior

*Imtiyaz Ali Mir*

## **Abstract**

Sedentary behavior (SB) is one of the common leading modifiable risk factor for cardiovascular (CV) morbidity and all-cause mortality. However, not much is known concerning the relationship between SB and CV risk factors. This chapter aimed to explore the scientific knowledge that examines the association between SB and CV risk factors and its association with the development of CVD. Besides, the focus on preventing the SB by avoiding prolonged sitting and breaking-up the extended periods of sitting, and participating in physical activity (PA) are usually highlighted in this chapter, explaining how these intervention protocols can reduce the burden of CVD due to SB. Regardless of the known benefits of both PA and taking frequent breaks when engaging in sedentary tasks, the adaptation of a physically active lifestyle has remained very low because of various reasons; habitual behavior, insufficient or lack of time, misconceptions of CVD related health benefits from PA. Thus, it is very important to break these barriers associated with PA and encourage the physically inactive population, especially those who practice prolonged sitting to actively participate in PA and break the prolonged sitting time with regular interval breaks. Therefore, promotion of PA and limiting the sedentary tasks which would lead to improved levels of cardiorespiratory fitness (CRF) and better quality of living is necessary among all age groups, gender and ethnicities to prevent many chronic illnesses, specifically CVD and its associated risks related to SB.

**Keywords:** sedentary behavior, cardiovascular disease risk, prolonged sedentary time, moderate-to-vigorous physical activity, cardiorespiratory fitness

## **1. Introduction**

The advancement of sedentary behavior (SB) research in health science has increased rapidly which has led to numerous terminologies and definitions about SB. With this fast development, a standardized, clear, and common definition is to be formulated to address these issues. The "Sedentary Behaviour Study network" (SBSN) carried out a project to overcome this issue and developed a comprehensive conceptual model based on movement, structured around 24 hour period (**Figure 1**), and defines SB as "any waking behaviour in which the energy expenditure is low, generally ≤1.5 metabolic equivalents (MET's) while in sitting, reclining or lying position" [1]. The SBRN definition of SB includes two parts; posture and energy expenditure. The postural element is very easily operationalized and broadly utilized to determine SB by use of inclinometers, questionnaires, and direct observation, but dismisses the energetic part. Nevertheless, it requires to be mentioned that accelerometers usually measure movement rather than energy expenditure and represents an indirect approach to assess energy expenditure. Some of the common examples of SB include television (TV) viewing, sitting in the classroom, computer use, desk-based occupations, and passive commuting.

It is very important to emphasize that SB differs from physical inactivity (PI), in which an individual usually does not perform any of the recommended moderate-to-vigorous physical activity (MVPA). Although SB and PA are on the opposite ends of energy expenditure continuum, the inclusion of a postural element is a requirement for this to be considered sedentary, suggesting that this is a distinctive and unique behavior that can be intervened on. A person could be is actually physically active for the recommended 75–150 minutes of moderate PA each week or 150–300 minutes of vigorous PA every week [2], yet he or she may sit for several hours a day in a sedentary occupation or during their leisure time. The

#### **Figure 1.**

*"Movement-based terminology conceptual model based on 24 hours period. Picture organizes the movements that take place throughout the day, inner ring showing the energy expenditure and the outer ring displaying the posture. Courtesy - Tremblay et al. 2017.*

#### *Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

adult population in the United States and the United Kingdom spend 60%–70% of the waking hours at sedentary activates, 25%–35% in light-intensity exercise, and the reminder little proportion of time on MVPA.

Time spent in SB is essential because it displaces the time spent in MVPA causing a decrease in overall PA energy expenditure. Displacement of 2 hours each day of light activity (2.5–3.0 MET's) by sedentary tasks (1.5 MET's) is predicted to decrease the PA energy expenditure by about 2 METs per hour each day or around the amount of energy expenditure while walking for 30 minutes per day. Research on PA and wellness has focused mostly on calculating the amount of time spent in PA carried out at 3 MET's or more, characterizing people that have no involvement in activates at such level as sedentary. Nevertheless, this explanation overlooks the considerable effect light-intensity PA can have daily on the overall expenditure energy [3] as well as the positive health-related outcome benefits by taking part in the light-intensity PA instead of simply sitting and doing nothing. Furthermore, although people could be both physically inactive and sedentary, additionally there is a higher chance of more time spent in sedentary tasks and PA to coexist. A good example could be an employee who jogs or bicycles to his or her workplace, but subsequently sits all day long at the workplace and spends many hours viewing TV at night after returning from work. Therefore, SB is not simply the absence of MVPA, but instead is a unique behavior with specific environment determinants and a variety of potentially distinctive wellness consequences.

Compared to previous generations, people are spending much more time in an environment which not merely restricts the PA, but also spent prolonged periods sitting at workplace, at home, in communities, and driving. Workplaces, schools, homes and common public areas are re-engineered in a manner that reduces body movements and muscle activity leading to dual influence on individuals behavior; move little and sit longer. Humans were made to locomote and take part in every form of manual labour on day to day basis. The recent change from a challenging and active life to one with only a few physical demands and challenges has been fast. The increased development of SB and its associated decrease in energy expenditure in the previous few years have become surprising. In the 1970s, 2 in 10 working people in America had been in occupations needing just light activity (primarily in sitting position), whereas 3 in 10 had been in occupations needing high energy expenditure like farming, manufacturing production, and construction [4]. By 2000, it was found more than 4 in 10 adults were in jobs that required light-to-moderate activity, whereas 2 in 10 had been at jobs that needed high energy expenditure. Furthermore, in the past 2 decades, the amount of screen time using computers and smartphones, playing video games and TV viewing has increased significantly. In 2003, about 6 in 10 working people used a computer at the job and 9 out of 10 children used a computer in schools and colleges. By 2016, more than 89% of households had a computer including a smartphone rendering it a common feature for everyday activity [5, 6].

Watching TV is associated with more than some other sedentary behaviors with higher CVD risk factors. It is hypothesized that watching TV results in lower energy expenditure than other sedentary activities like reading quietly in sitting, as a result of a slower resting metabolic rate. It is possible that watching TV requires less muscle contraction and activation than pursuits like driving, and this muscular inactivity is thought to be associated with a decrease in lipoprotein lipase [7], a protein that play an important role in managing lipid metabolism [8]. Therefore, more passive behavior of TV watching could have a strong association with higher CVD risk factors than various other sedentary activities because of reduced lipoprotein lipase. Another possible reason is that watching TV is connected with unhealthy nutritional habits, like decreased usage of fruits and vegetables and more intake of

energy-dense food including fast food and sugar-sweetened beverages [9]. This may lead to increased snacking behavior while watching TV or expose people particularly young children to beverage and food advertising that attract them to make a harmful and unhealthy dietary choice [10]. Finally, a third feasible explanation is that people could be able to recall the period spent watching TV in comparison to the time allocated to other sedentary activities [11].

This chapter aimed to synthesize the scientific knowledge about the relationship between SB and CV risk factors and its association with the development of CVD. From the above findings it is very clear how people nowadays are spenting more time in SB, particularly extended period of time spent in watching TV, using computer and other electronic gadgets, administrative work, and passive commuting. All these sedentary tasks decrease the energy expenditure drastically and can negatively impact the health related outcome measures, and impose a higher risk of developing CVD and cardiometabolic disease. Furthermore, this chapter will explore the strategies that would help to prevent or minimize the SB by avoiding the prolonged sitting and breaking-up the extended periods of sitting, and engagement in physical activities, describing how these intervention protocols can reduce the burden of CVD due to SB.

## **2. Objective measurement of sedentary behavior**

The uncertainty encircling the necessity for posture in the definition of SB poses challenges for measuring and evaluating measures of SB, as well as the difficulty in quantifying individual behavior. Most commonly used assessment options for SB consist of questionnaires, recalls, and behavioral logs, all of which possess methodological limitation of measurement errors. These assessment methods have fair to good reliability but reduced validity in comparison with criterion measures. However, objective assessment on SB can decrease measurement error and offer information regarding patterns of activities like time spent in sedentary tasks, breaks and MVPA. However, the drawbacks of objective based measurement include the cost of these objective tools, participant burden, converting data into the functional summary, devices failing to register position and intensity of some specific kind of activities (e.g. riding on a stationary bike), and insufficient information with regards to specific behavioral domains. Accelerometers (count the number of steps), heart-rate monitors, inclinometers along with other devices are used to offer an objective measurement of various variables such as intensity, volume, and frequency of a task that could be downloaded and converted into a purposeful activity interpretation. National Health and Nutrition Survey (NHANS) have been collecting accelerometer data from a large population of adults in the United States. The NHANS demonstrated that the degree of participation in MVPA's are lower and around 60% or even higher percentage of the adult population spent waking hours in sedentary activities [12, 13]. In a recently available validity study which was carried among 40 university employees aged 18–70 years, SB was evaluated by an accelerometer (<100 counts per minute [cpm]) that captured coded images by a very small wearable digital camera. The study demonstrated that some particular behaviors (watching TV, using computer and administrative routines) were properly classified utilizing the standard 100 cpm threshold by simpler accelerometry. Nevertheless, when tested for standing still position, it captured only 9% of the total time and generated <100-cpm 72% of that time, indicating that most of the time spent in standing will be categorized not as sedentary. However, scientists debate on what usually is the best-suited activity cut-off points to recognize time spent in sedentary tasks and time spent on the

#### *Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

light-intensity activity. Besides, various cut-off points could be befitting populations of various ages, ethnic background, and adiposity status. **Figure 2** depicts a cluster heat map, displaying accelerometer information for a single individual during 1 week. The accelerometer value counts are recorded each minute, are usually represented by various colors. The darkish blue color represents accelerometer data information which is significantly less than the currently utilized, cut-off of 100 cpm for the sedentary tasks, and is mostly indicative of sitting behavior. Light blue through yellow color indicates some kind of light-to-moderate intensity activities, dark blue color indicates a very low level of expenditure of energy, and red color showing a high energy expenditure levels such as MVPA. What strikes the most is the degree to which this individual spends the time either in very light-intensity tasks as shown in pale-blue to white-color or mostly being sedentary as indicated by dark blue color.

Both self-reported and objective assessment methods could be essential to progress forward when quantifying the SB. Healy et al. [14] demonstrated that objective and self-reported sedentary behaviors are usually complementary and each provides distinct information. For instance, the TV viewing period was comparable for Mexican American citizens and non-Hispanic blacks (self-report), whereas overall time engaged in SB was shown to be increased in non-Hispanic blacks in comparison to Mexican Americans when assessed objectively. Therefore, understanding and possibly enhancing the reliability and validity of both self-report and objective assessment methods is a priory. Furthermore, due to the different information provided by each evaluation method, a better knowledge of the efficiency characteristics across both measurement approaches is needed.

#### **Figure 2.**

*1 week of accelerometer data - 31 minutes MVPA (> 1951 counts each minute), 71% waking hours being sedentary (> 100 counts every minute). Courtesy - Owen et al. 2010.*

## **3. Sedentary behavior and risk of cardiovascular disease**

Scientific research has been mostly centered on finding the association between SB and cardiometabolic morbidity and all-cause mortality. Little is known about the association between SB and higher cardiovascular (CV) risk and its advancement to CVD. The question that comes to mind is what are the possible mechanisms that contribute to the independent relation of SB with higher CVD morbidity and mortality? Probably the most likely and apparent explanation pertains to the influence of SB on risks associated with conventional CVD. Studies have established that in healthy adults, there is an association found between SB and higher conventional CV risk factors. Stamatakis et al. [15] reported the relationship of SB with conventional CV risks (Blood pressure [BP], high density lipoprotein cholesterol [HDL-C], WC, body mass index [BMI]) among 5948 healthy middle-age population. In another study, carried among 2328 young adult participants, prolonged sitting was observed to be independently and positively correlated with adiposity and heart rate and had a negative association with physical fitness as indicated by cardiorespiratory fitness (CRF) [16]. In a healthy population, very little scientific evidence is available on the relationship between SB and total cholesterol or lowdensity lipoprotein cholesterol (LDL-C) levels [17]. Nevertheless, evidence exists on the positive relationship between SB and triglycerides and HDL-C among the asymptomatic population which is mostly independent of PA [17, 18].

In addition to increased CV risks, SB is highly related to other adverse healthrelated outcomes, which include CV disease mortality, all-cause mortality, diabetes, increased insulin resistance, high BP, and obesity [15, 19, 20]. Researchers have noticed associations between SB and markers of CVD risk factors (high BP, decreased HDL-C, high triglyceride, and increased WC), which are usually independent of PA levels [15, 17]. Whitaker et al. [21] investigated the relationship between SB and higher CDV risks, authors discovered that the time spent in SB had deleterious associations with risks of CVD. The main factor of the association between SB and increased risk of CVD was time spent watching TV and other electronic gadgets. It was discovered that replacing time spent watching TV with any other kind of sedentary activities (use of the computer, sitting and reading, use of telephone, paperwork), led to a comparatively lower CDV risk. Besides, further findings revealed that the relationship of sedentary tasks with WC, glucose, insulin, and levels of triglyceride was consistent with results from the total CDV risk score, but a strong influence was found on triglyceride levels. Furthermore, the authors noticed that when computer time was replaced by using telephone or reading, this resulted in a high levels of BP. Another research study reported that watching TV had a positive association with numerous risks of CVD, such as BMI, waist to hip ratio, BP, total cholesterol, triglycerides and LDL-C [22]. This association was noticed in either gender and adjusted for age, alcohol consumption, cigarette smoking and dietary practices. There was no association found between PA and BP, LDL-C and total cholesterol. In fact, BP, LDL-C and total cholesterol had a strong association with PI, represented by TV viewing. A systematic review reported the risk of CVD disease in children and adolescents. A positive relationship was observed between screen-time (personal computer, video gaming, TV) and higher BP, reduced degrees of HDL-C, and higher degrees of LDL-C and triglycerides in children and adolescents. Even though not all of the studies support this association in the systematic review, there is growing evidence which indicates that SB is related with detrimental effects of health outcomes and there is a higher risk of developing CVD in children and adolescents. Additionally, not taking frequent breaks during the sedentary tasks and extended periods of sedentary bouts specifically watching TV and using other electronic gadgets actually compromise the cardiometabolic profile [23].

#### *Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

People with CV risk or disease seem to have an apparent relationship between SB and CV risk factors. In hypertensive patients, prolonged periods spent in SB were observed to be associated with higher BP readings [24]. Similarly, in the overweight and obese population, extended periods of sitting was found to have a positive and independent relationship with BP, a 14% increase in risk of developing hypertension with every additional one hour of sitting [25]. Beunza et al. [26] carried out a prospective cohort study among 6742 healthy university students over 40 months to assess the incidence of hypertension. Authors discovered that compared to nonsedentary adults, sedentary participants had a 48% increased risk of developing hypertension which was independent of PA.

A study among 945 participants in a cross-sectional examination found that after adjusting the BMI and BP, every 30 minutes of sedentary tasks were associated with a minimal ankle-brachial index [27]. In another research study among healthy participants, it was noticed that after adjusting for the vigorous PA, resting heart rate, metabolic syndrome, and adiposity, weekend breaks were positively connected with arterial stiffness [16]. These data sets provide proof that SB is positively associated with altered vascular functionality and structure. Further research is needed to explore and fully understand the connection between these complex relationships and examine if these detrimental effects on arterial health are independent of risk factors of CVD.

In short, it is evident from the growing scientific findings that there is a higher risk of CVD (high BP, arterial stiffness, increased BMI, higher levels of blood lipids, and deseased physical fitness) associated with SB as indictaed in **Figure 3**.

### **3.1 Effect of short periods of sitting on cardiovascular health**

Recently studies have examined the effect on CV outcome measures related to short duration (3–6 hours) of continuous sitting. Padilla et al. [28] observed

#### **Figure 3.**

*Impact of sedentary behavior on risks associated with cardiovascular system: A. vasculature – Thickness and stiffness of intima-media increases. B. Anthropometric – Increased body mass index. C. Decrease in physical fitness (CRF). D. Increase in the blood pressure. E. Increase in insulin resistance. F. Increase in the blood lipids. Courtesy - Carter et al. 2017.*

that continuous 3 hours of sitting resulted in an upsurge in the BP, together with a reduction in shear rate and blood flow in the popliteal artery. Similarly in another study, after 3 hours of continuous uninterrupted sitting, a reduction in the endothelial function of the superficial femoral artery (SFA) was observed, along with the simultaneous decrease in shear rate and antegrade [29]. These findings suggest that endothelial function in the lower limbs deteriorates with the practice of prolonged uninterrupted sitting. Compared to the lower limbs, uninterrupted sitting for 3 hours does not seem to have any effect on the endothelial function of upper limbs as no effect was reported in the brachial artery shear rate and endothelial function. Recently studies have explored the hypothesis that even little body movements, particularly the lower limb movements that are practiced during prolonged sitting prevent the impairment in the CV health outcomes. Larsen et al. [30] reported that during 7 hours of sitting, with a break given every 20 minutes to carry out light-tomoderate PA for 2 minutes, a significant reduction in both systolic and diastolic BP was seen. These findings point out that intervening on the SB may be appropriate and relevant, especially in a population with a high risk of CVD. Scientists have also examined the effect of regular breaks during prolonged sitting (5 hours to 3 days) on parameters such as lipids and triglycerides but did report any significant changes in any of these outcome measures [31, 32]. Perhaps longer duration break time coupled with some light-to-moderate PA is required to see the effect on these parameters. Because of the very limited information available on the impact of break time on uninterrupted prolonged sitting, further scientific research needs to be carried out to have a better understanding of the effects of break time and PA during prolonged sitting on CV risk factors.

The effect of break time and PA on uninterrupted prolonged sitting has also been investigated to find out its association with endothelial function. In normal healthy non-obese adults, after 3 hours of interrupted sitting, 5 minutes of light PA (walking on a treadmill at a speed of 2 miles per hour) every 60 minutes helped to prevent the reduction in the shear rate and dilation in SFA [29]. Another study also reported similar findings in a cohort of healthy young girls, in which the benefits of regular breaks and mild PA on SFA flow-mediated dilation were seen [33]. These findings suggest that sitting induced endothelial impairment can be offset when appropriate interventional strategies are implemented, particularly the use of lowintensity PA at regular intervals.

#### **3.2 Effect of long periods of sitting on cardiovascular health**

Currently, there is very little published literature available to support the claim that effects of long duration, acute exposure (usually more than 1 day) of SB on risk factors associated with higher CVD devlopment. Lyden et al. [34] evaluated effects on lipids and markers of insulin resistance in 10 healthy adults by imposing 7 days of prolonged sitting with little breaks in between. In comparison to the baseline, there was no change seen in fasting plasma lipids, BMI, and WC after 7 days of SB. But, when measured for 2 hours plasma insulin using oral glucose tolerance test and region under the curve were significantly increased after 7 days of prolonged sitting, indicating a detrimental capability of SB to lead to insulin resistance within 1 week [34]. In another study, the authors examined the effect of 3 days of intervention, using either 7 hours of sitting per day with 2 minutes light-intensity walks every 20 minutes or 7 hours per day of uninterrupted sitting without any breaks [31]. As measured by a mixed meal tolerance test, a significant decrease in glucose and insulin area under the curve was found after 3 days of uninterrupted sitting when compared with the group that was given breaks. As described above in this chapter, triglyceride levels did not differ between the 2 groups. Therefore, literature findings

#### *Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

on short-term effects, usually between 3 to 7 days or immediate effects, between 3 to 6 hours of SB suggest the presence of quite significantly impaired insulin resistance, even in absence of such changes in the lipid levels. Research work carried out by Graves et al. [35] documented that using standing workstations in comparison to sitting workstations showed an average reduction of 90 minutes in sitting time every day over a period of 8 weeks. Further findings of a significant reduction in total cholesterol support the idea that extended periods of PI is required to cause an alteration in the lipid levels. To conclude, both short term and long term SB can alter vascular health such as endothelial function, peripheral blood flow, and BP.

Mechanisms underlying the SB induced vascular changes are thought to a result of haemodynamic stimuli, most probably the shear stress that causes structural and functional changes in vascular health [36]. Likewise, extended periods of uninterrupted sitting are found to be related to variations in the shear stress which could also induce vascular dysfunction. **Figure 4** summarizes the possible mechanisms associated with sitting induced risks of CVD. Hydrostatic pressure in the lower limbs is found to increase with prolonged sitting, specifically in the popliteal artery. When sitting for more than 3 hours without a break, a decrease in minimum, maximum and mean shear rate is observed in the popliteal artery [28]. Some studies have examined how alterations in shear can cause a decrease in the endothelial function related to extended periods of uninterrupted sitting. Investigations among young healthy adults revealed popliteal artery endothelial impairments caused by 3 hours of an extended period of sitting was effectively reduced by manipulating the popliteal artery perfusion via small fidgeting leg movements or by application of local heat [37, 38]. Both of these interventional strategies effectively prevented any decrease in mean shear which is associated with extended periods of uninterrupted sitting and appropriately prevented any decrease in endothelial function of the

#### **Figure 4.**

*Overview of mechanisms that mediate risk of cardiovascular disease in association with sedentary behavior: A. arterial structure and function while walking, increased shear stress and normal blood flow. B. Arterial structure and function after a period of SB, shear stress and blood flow is decreased, subsequently causing an increase in nitric oxide production leading to vascular dysfunction. Courtesy - Carter et al. 2017.*

popliteal artery. It is believed that patterns of the shear may be equally important in addition of reduction in shear rate; it seems that shear patterns play an important role in maintaining the vascular function by increasing the endothelial function by activating the nitric oxide production or by preserving the antegrade shear stress; even though oscillatory and low shear stress can induce inflammation, increased oxidative stress and atherosclerosis [36].

The hypothesis related to changes in the shear rate and patterns is currently not well known. One of the possible reasons is that exposure to the prolonged periods of gravitational forces can elevate the hydrostatic pressure in the lower extremities, resulting in the pooling of venous blood followed by a reduction in the shear force and blood flow [39]. It has been observed that prolonged sitting causes an increase in calf circumference, reduced blood flow, and calf pooling [39]. Furthermore, an increase in the activity of the sympathetic nervous system and variations in the blood viscosity may also attribute to the alterations in the shear rate and patterns which can lead to further endothelial dysfunction [39]. All these factors may individually or in whole play a role in contributing to this relationship between prolonged sitting and dysfunction of vascular health.

## **4. Sedentary behavior and mortality**

A nationwide cohort study in the United States revealed how sedentary time is strongly associated with all-cause mortality [40]. Over four years in a sample of 7985 middle-aged and elderly population, there had been 340 deaths reported overall. Further analysis demonstrated that longer SB with a sedentary time of more than 12 hours per day and sedentary bouts of more than 10 minutes per bout had the highest mortality risk [40]. However, the findings from a Canada fitness survey mortality follow up to underscore the adverse cardiometabolic health consequences associated with prolonged sitting. Those participants who spent most of the day sitting were seen to have a significantly poor long-term mortality outcome in comparison to those who reported spending less time sitting [41]. Further analysis showed these associations with mortality were consistent with overall sitting time measured across all levels of self-reported data of participants. Surprisingly, the relationship between sitting time and mortality was found to be stronger among those participants who were overweight and obese [41]. In another study during 6.5 years of follow-up, it was found that watching TV for a long time had a significant association with all-cause mortality rate and higher CVD mortality rate [42]. Every 1 hour increase of watching TV was seen to be associated with 11% higher risk of all-cause mortality and 18% greater risk of CVD mortality rates. Besides, compared to those who watched TV less (< 2 hours every day), there was a 80% higher risk of CVD mortality and a 46% high risk of all-cause mortality among those who watched TV 4 hours or more every day. Both these risks were found to be independent of conventional risk factors like BP, cholesterol, smoking, WC, and diet indicating a strong relationship between SB and its detrimental effects on CV and overall health. In another study in the United States, the authors examined the relationship of SB with CVD mortality outcomes based on 21 years of follow up among 7744 participants aged 20–89 years. A total of 377 deaths were reported in this study. It was observed that TV time and time spent in commuting and combined time spent in these 2 sedentary activates had a strong positive association with increased CVD deaths even after age-adjustment. Compared with those who reported spending less than 4 hours every week sitting in automobiles, an 82% greater risk of CVD mortality was seen in those who reported spending more than 10 hours every week in passive commuting. Similarly, those who spent more than 23 hours per week of

*Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

combined automobile time and TV time had a 64% higher risk of dying from CVD compared to those who spent less than 11 hours every week [20].

To combat all these adverse health-related outcome risks associated with SB, recently a major focus has been directed at making health promotion a priority, including the promotion to reduce the sitting time and to take frequent breaks, in addition to participate in PA to improve the levels of CRF.

## **5. Breaking-up long periods of sedentary behavior and engaging in physical activity**

It is believed that most often serious efforts are required from the people to make even smaller changes in the health behavior to become a part of their lifestyle. With regards to this, interventional protocols that promote healthy behaviors should be easy to follow, simple, recognizable, and not require much energy from a cognitive perspective. Because prolonged sitting is regarded to be highly habitual, the interventional approaches used should be able to instantly elicit a response of breaking and getting up and thus decreasing the prolonged sitting time. Since prolonged sitting is considered to extremely habitual, with little if any conscious planning and processing compared to PA, which requires higher degrees of planning and mental processing. Thus it is easy to express that SB is different from PA based on the above explanation.

Scientific data has provided evidence that SB is highly associated with health risks (e.g. high BP, increased levels of triglycerides, lower DHL-C, arterial stiffness, and increased BMI and WC) regardless of the PA levels [15–17]. This shows that prolonged periods of sitting cannot be compensated by just 30 minutes of MVPA and a shift in the scientific focus has been suggested to include the physiology of sedentary inactivity together with exercise when considering to address the health issues related to SB [8, 31]. If a day is divided into periods of SB, light PA, and MVPA, it can be seen that very little time is spent on light PA and MVPA and a large period is spent on sedentary activates like TV viewing, use of computer and other electronic gadgets and passive commuting. Besides, if a person tries to reduce the SB, that time is mostly spent on doing light PA rather than MVPA. Thus, it makes a lot of sense to focus and target the SB as important health behavior.

Interventional approaches should promote a healthy lifestyle in addition of including the MVPA and simultaneously a major focus should be on reducing and breaking the prolonged sedentary time [43]. The reason for limiting the sitting time is that all sedentary activities evoke a catabolic response which suppresses the skeletal muscle lipoprotein activity [7]. Even though little evidence is available with regards to the thresholds for the prolonged sitting time or when exactly sitting should be interrupted before it can evoke the detrimental health consequences, it is suggested that when short breaks are taken frequently during prolonged sitting, it can help to prevent these detrimental health outcomes [29, 30, 32]. Recently in a systematic review, authors examined the experimental and epidemiological studies and concluded that breaking up prolonged sitting can generate positive effects on metabolic-related health outcomes, even though the type, intensity and frequency of PA were different for participants based on their characteristics, particularly with regards to their habitual PA levels in each study included in the review [44]. By looking at the healthy physiological responses that the body can generate by simply standing up and breaking the prolonged sitting, people with morbidity which are related to lifestyle (SB), may be able to benefit more by taking regular breaks and decreasing the prolonged sitting time [45].

## **5.1 American College of Sports Medicine guidelines on reducing sedentary behavior**

In our current contemporary time, we cannot completely eliminate the time spent in sedentary behaviors, but breaking-up the prolonged sitting using simple activities such as standing or walking can be very helpful at preventing the deleterious health-related outcomes, especially minimizing the higher CVD risk associated with SB. In line with this, the American College of Sports Medicine recommends to adopt an active action plan both at workplace and home to break-up or reduce prolonged periods of sitting, which is summarized in **Table 1** [46].

## **5.2 World Health Organization (WHO 2020) guidelines on sedentary behavior and physical activity**

World Health Organization (WHO 2020) has revised the guidelines on PA and SB for all age groups including people that live with chronic morbidity or disability. It is stated that for all age groups doing some PA is always better than doing no PA at all [2]. If people are physically inactive and living a sedentary life, they should begin with PA that is small in amount and of light intensity, then slowly increasing the intensity, frequency, and time duration over time. The following


*Sit less and move more: Len Kravitz, and Chantal a. Vella (ACSM).*

#### **Table 1.**

*American College of Sports Medicine Information on reducing sedentary behavior.*

*Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

sub-heading will cover the recommendations on PA and SB for children and adolescents, adults, and elderly including those who live with chronic conditions/ disabilities in detail.

#### *5.2.1 WHO 2020 recommendations for children and adolescents aged 5–17 years*

In this population, PA confers benefits when it comes to physical fitness (CRF and muscle strength), cardiometabolic wellness (BP, dyslipidemia, glucose and insulin tolerance), bone health, cognitive functions like academic performance, and executive function, and decreased adiposity. It is suggested that this population should take part in moderate PA of at least 60 minutes every day across the week, with exercises mainly aerobic. Vigorous PA and exercises that target muscles and bones to increase the strength of these tissues should also be included at least 3 days every week. The research evidence suggests that there is a strong association between adverse health-related outcomes and SB, particularly between watching TV or recreational screen time with adverse health consequences in children and adolscents [2]. Therefore, very limited sedentary time should be allowed for this age group.

#### *5.2.2 WHO 2020 recommendations for adults aged 18–64 years including people that have chronic conditions and disability*

In grown-ups, PA confers advantages to all-cause mortality, CVD mortality, incident hypertension, incident type 2 diabetes and measures of adiposity. Recommendations for adults include 150–300 minutes of moderate-intensity PA, aerobic in nature 75–150 minutes of vigorous PA or combination of equivalent volumes of MVPA throughout the week. In addition, adults must also do muscle strengthening exercises at MVPA involving major muscle groups at least 2 or more days every week. Furthermore, evidence on effect of SB on health outcomes provide a strong support that prolonged sedentary time should be limited by adults [2].

### *5.2.3 WHO 2020 recommendations for older adults aged 65 years and above including people that have chronic conditions and disability*

In this population, PA is beneficial in preventing falls and falls-related injuries and declines in bone health and functional ability. It is suggested that older people should follow the same guidelines as recommended for adults. In addition, the elderly should also engage in varied multicomponent PA that emphasizing strengthening exercises and functional training at the moderate-to-high intensity on 3 or even more days weekly. The recommendations on SB apply to this group in the same way as adults [2].

#### **5.3 Australian guidelines on sedentary behavior and physical activity**

Australian guidelines on SB and PA are supported by strong evidence and considers the relationship between PA (e.g. type of PA, intensity, frequency, and duration) and outcome indicators of health, including the risk of chronic diseases and obesity.

The association between SB and outcome indicators of health, including the risk of chronic disease and obesity [47]. Like WHO 2020 guidelines, Australian guidelines on PA and SB are divided based on different age groups.

#### *5.3.1 Recommendations from birth to 5 years*

Most of the waking hours of this group should be playful, engaging them in a variety of activities.

**Infants from birth to 1 year:** PA encouraged for this age group should be done under supervision, mostly floor-based activities of play conducted in safe environment. For infants that are not yet mobile, 30 minutes of tummy time period, which includes reaching, grasping, puling, pressing and crawling during awaking hours throughout the day [47].

**Toddlers aged one to 1-2 years:** For this group, it is recommended to carry out 180 minutes of varieties of PA, which include 60 minutes of energetic play like jumping, kicking, throwing and running during awaking hours throughout the day [47].

**Small children aged 3-5 years:** They should not be restrained in strollers or car seats for more than one hour or allowed to sit for prolonged time. Screen time spent in sedentary tasks (watching TV, playing with electronic gadgets) should not be more than one hour based on twenty four hour time period. When these children are sedentary, parents or caregivers should build a playful relationships with them through routines like singing, reading, storytelling using puzzles etc. [47].

## *5.3.2 Recommendations of young children and young people aged 5–17 years*

This particular population ought to achieve the suggested and recommended low levels of SB and high levels of PA for optimal health benefits [47].

#### **Guidelines on Physical Activity:**


#### **Guidelines on Sedentary Behavior:**


#### *5.3.3 Recommendations for adults aged 18–64 years*

#### **Guidelines on Physical Activity:**


*Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*


## **Guidelines on Sedentary Behavior:**


### *5.3.4 Recommendations for older adults aged 64 years and above*

For this population, being physically active for 30 minutes is achievable. In addition, their health and wellbeing can be improved further if a little increase in the recommended PA is achieved [47].

#### **Guidelines on Physical Activity:**


#### **Guidelines on Sedentary Behavior:**

The guidelines for SB are the same as recommended for adults, which includes minimizing the prolonged sitting time and taking frequent breaks whenever possible during sedentary tasks [47].

#### **6. Conclusion**

SB is a habitual behavior that can be managed effectively when appropriate interventional strategies are employed. If not ponder upon, it can lead to detrimental health consequences. Evidence strongly supports and recommends minimizing the sedentary time and taking regular breaks in between the sedentary tasks, in addition of incorporating the MVPA to decrease the CVD risks and compromising metabolic health. The higher risk of CVD mortality and morbidity and all-cause mortality is independent of PA levels in individuals who engage in longer periods of SB. Therefore, in addition to participating in recommended PA guidelines, equally important is to break-up prolonged sitting and reduce the time spent in sedentary tasks like watching TV, using the computer and other electronic gadgets, and passive commuting, which would lead to improved levels of CRF and better quality of life in all age groups, gender, race, and ethnicities.

## **Acknowledgements**

I would to thank Universiti Tunku Abdul Rahamn for giving me enough time to complete this book chapter, without which it would have not been possible to complete this task.

## **Conflict of interest**

"The author declare no conflict of interest."

## **Notes/thanks/other declarations**

I would also like to thank my beloved wife, Shanilla Shaheen for supporting and encouraging me to write and complete this book chapter.

## **Author details**

Imtiyaz Ali Mir Faculty of Medicine and Health Sciences, Universiti Tunku Abdul Rahman, Bandar, Sunagi Long, Kajang, Selangor, Malaysia

\*Address all correspondence to: imtiyaz2204@yahoo.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Sedentary Behavior, Cardiovascular Risk and Importance of Physical Activity and Breaking-Up… DOI: http://dx.doi.org/10.5772/intechopen.96118*

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## **Chapter 5**

## How to Reduce Sedentary Behavior at All Life Domains

*Olga López Torres, Pablo Lobo, Valeria Baigún and Gabriela F. De Roia*

#### **Abstract**

Lifestyle has changed in the last century increasingly promoting sedentary behaviors. Prolonged sitting time is related to increased all-cause mortality risk. Therefore, scientific research aimed at understanding the effects of sitting on health has increased to find effective interventions that can be carried out in life domains (study, work, transport, and free time). The interaction between physical activity and sitting time plays a key role in the development of strategies to promote physical activity practice and reduce sedentary behavior. Accepting that the modern societies incite to spend long periods seated, the aim seems to find a balance between all the areas during the 24 h of the day. Maintaining sleep time, reducing screen leisure time to 3 h/day, and breaking prolonged sedentary time for 2–3 min every 30 min-1 h of sitting, as well as reaching the physical activity recommendation may help counteract the potential negative effect of too much sitting time. Governments must provide active free time options to promote active leisure time and help reduce screen time. At workplaces, managers and companies should encourage sitting breaks and work standing options, and for the special population such as children or older adults, new strategies must be considered to reduce sitting time.

**Keywords:** sitting time, exercise, older adults, children, work time, leisure time, sedentary breaks

### **1. Introduction**

Lifestyle has changed over the world in the past decades. The industrialization process and technological advances have simplified the physical work of human beings and changed the lifestyle of the last generations. Not that long ago, most of the jobs required physical activity and some energy expenditure. Nowadays the percentage of work sectors demanding high levels of physical activity has reduced drastically. This new reality derives in many people forced to spend at more than 8 h/day sitting and having difficulties to reach the physical activity recommendations [1]. Sedentary lifestyles have become a significant public health issue spreading worldwide, although there is evidence of being linked to a range of chronic health conditions [2]. Extended periods of inactivity can produce metabolic dysfunction and impair blood sugar regulation [3], elevate blood pressure [4], and make it difficult to use fat as a metabolic substrate, as well as increase the risk of early death regardless of physical activity levels [5]. Therefore, it seems crucial to find strategies that can be applied in all life domains to be able to reduce sedentary behavior, as well as

to increase physical activity. Including regular and well-structured sedentary breaks during long sitting periods could help reduce the negative effects of a sedentary lifestyle.

This chapter aimed, firstly, to provide scientific evidence of the need to reduce sedentary behaviors as well as to include regularly sedentary breaks. Secondly, to show some possibilities and examples of how to break sedentarism in daily life. We believe that introducing these practices in workspaces, schools, leisure time, and in the daily activities of older adults might help control the negative effects derived from sedentary lifestyles.

## **2. Sedentary behavior**

#### **2.1 Evolution of lifestyle and the concept of sedentary behavior**

Historically, exercise physiologists have studied sedentary lifestyle as the opposite of physical activity. The terms that have been used for research in this area have been confusing, which makes it difficult to compare clinical trials. Already in the 1950s, Morris et al. [6] concluded that sedentary work increased cardiovascular risk compared to those who worked more physically active. That study, among others, resulted in a strong area of research focused, for over 60 years, on quantifying the level of physical activity necessary to reduce morbidity and mortality [6]. These investigations provided recommendations on physical activity and the implementation of public policies to promote physical activity practice.

Despite the efforts, a high percentage of the population (mostly from countries that suffered rapid urbanization and industrialization) do no reach the physical activity recommendations and the tendency is that this number increases [1] Office works, school, screen games, technology, passive transportation and sedentary leisure time have had a strong impact on reducing the opportunities to perform physical activity at the same time that promote opportunities for sedentary behavior in all the life domains.

For the past two decades, the number of studies focused on sedentary behavior has grown exponentially, and physical activity and sedentary behavior can be considered as an independent research field. The term sedentary behavior comes from Latin "sedere" which means "to sit". But not only the "position" determines what is currently conceived as sedentary behavior. Sedentary behavior is defined as any waking behavior characterized by the expenditure of 1.5 metabolic equivalents of task (MET)s or less of energy while in a sitting, reclining, or lying posture [7]. Sedentary behavior, like physical activity, can be found in all life domains (work, study, transport, and free time). Although research in this field has increased notably in the last decade, there is still confusion in the terminology and the scientific community has not reached a consensus in some terms and concepts yet. Many definitions of sedentary behavior can be found in the literature but some common concepts are repeated, such as low energy expenditure, mostly under 1.5 METs, activities performed in sitting, lying or reclining position and while the person is awake [7]. Besides, some other concepts associated with sedentary behavior have aroused the interest of the scientific community. Sedentary bouts, breaks of sitting, sedentarism, sedentary lifestyle vs. inactivity, among others, are related terms that could help deeply understand this problem.

Sedentary Behavior Concept has suffer an evolution over the years. Although the distinction between sedentarism and physical inactivity (not meeting worldwide recommendations for physical activity) has already been settled [7], it is still common to find some confusion in terms such as sedentary time, sitting time, screen

time and stationary time; which, although in some cases are overlapping concepts, refer to different behaviors [7]. Because they refer to different aspects of behavior (position, movement, effort and the use of digital implements), these traits can be blended in different ways, so that some criteria are met but others are not. For example, one can be seated but doing physical activity (cycloergometer), so it's not a sedentary behavior; one could be stationary, but not sitting (e.g., waiting in line); one may be in sedentary behavior, but not sitting (instead lying down watching TV), which in turn is independent of screen usage (reading a book); among other examples.

## **2.2 Using bed rest models**

Studies on bed rest [8–13] provided useful information on the consequences of inactivity and low energy expenditure for long periods. Thanks to these studies, a lot is known about the effects of prolonged inactivity in metabolism and organ systems. Different studies focused on the effects of bed rest on metabolic function, found peripheral insulin resistance in skeletal muscle and adipose tissue, hepatic insulin resistance and a dyslipidemia [10], as well as a decline in function, muscle mass, and muscle strength [12] and a reduction in cardiorespiratory capacity after one-week bed rest [13]. In regards to the musculoskeletal structure, inactivity produces loss of strength and endurance, contractures, changes in soft tissues, disuse osteoporosis, sarcopenia, and degenerative joint disease [8]. At the cardiovascular level, the consequences can be postural hypotension, cardiac dysfunction, and thrombotic events [13]. Additionally, bed rest can lead to impaired respiratory, renal, gastrointestinal, and nervous system levels [9]. Outside hospitalization or illness, free-living healthy adults rarely spend these amounts of bed rest. Nevertheless, technological and social factors have made prolonged sitting time a common practice in all life domains (work, domestic life, and leisure time).

## **2.3 Quantifying sedentary behavior**

Measuring physical activity and sitting time is complex. Research has been aimed at improving the quality of the data through the objective measurement of sedentary behavior using accelerometry, observing that the self-report measurement underestimates the daily time of sedentary behavior concerning the objective measurement.

Researchers have focused on developing devices to be able to objectively quantify physical activity. In the past decades, many studies using accelerometers have been carried out. A multi-country study (USA, Brazil, UK, Denmark, the Czech Republic, and Hong Kong) using accelerometry found that the average sedentary time per day was 513 min/day, or 8.55 h/day [14]. Sedentary time was estimated to be responsible for 3.8% of all-cause mortality in adults according to a meta-analysis pooling data across 54 countries [15]. The United States Physical Activity Guidelines Advisory Committee (PAGAC) [16] recently comprehensively reviewed the scientific evidence, linking sedentary behavior with specific physical health indicators in adults and older adults, including mortality, cardiovascular disease, type 2 diabetes, cancer, and obesity. Moreover, high levels of sedentary behavior are also negative associated with cognitive function, depression, function and disability, physical activity levels, and health-related quality of life [17]. In contrast, little evidence has demonstrated the relationship between sedentary behavior and musculoskeletal pain, accidents or injuries, fatigue, sleep, or work productivity [18]. Ku et al. [19] published in 2018 a meta-regression analysis involving more than 1 million participants in which the cut-off points of daily sedentary time that were related

to all-cause mortality in adults were established for data measured objectively and self-reported [19]. According to the results of the study, the method of measuring sitting time significantly moderated the association between daily sitting time and mortality risk. The cut-off of daily sitting time in studies with self-report data was 7 h/day in comparison with 9 h/day for those with data measured by devices.

### **2.4 Sedentary behavior VS physical activity**

It is accepted that exercise is an effective strategy for reducing key cardiovascular risks [20]. Nevertheless, it is unclear if the benefits can be modified by a sedentary lifestyle. Therefore, it is important to clearly define different concepts such as physical activity/inactivity or sedentary behavior, as their physiological consequences on health are different. While physical activity/inactivity is referred to whether or not a person reaches the physical activity recommendations, a person is considered as sedentary if he/she spends long periods of the day in sedentary behavior. While for the first one (cut-off points for being physically active) there is enough evidence to determine the recommendations (150 minutes of moderate physical activity or 75 minutes of vigorous physical activity or an equivalent metabolic combination between both, plus 2–3 days/week of resistance training) [21], for the second one (cut-off points for being sedentary) there are still no recommendations, since studies have found inconclusive results.

That means that a person can meet the physical activity guidelines and still be considered sedentary. Sedentary behavior might produce harmful effects on health independently of physical activity level, but when both are combined, the results seem to change (combined joint association). In other words, high levels of sedentary behavior combined with low levels of physical activity increase the risk of death by 46% [18]. On the contrary, some studies have shown that high levels of physical activity can counteract or reduce the risk of death caused by prolonged sedentary behavior [22]. Similar results were obtained in cancer patients, where in the most active patients no relationship was observed between sedentary behavior and cancer mortality, while for those less active the risk of death increased [23].

Using the concepts of sedentary and/or physically active person, we can describe four possible combinations:


**Figure 1** represents graphically these possibilities.

The health implication for possibilities A and D are clear. Classification A has a negative influence on health and is negatively associated with all-cause mortality and D is positively associated with better health markers. What is not fully clear yet, are the implications of classifications B and C. Can one the variables counteract the negative effect of too much of the other one? Or, are the positive effects of one variable suppressed by the other one?

*How to Reduce Sedentary Behavior at All Life Domains DOI: http://dx.doi.org/10.5772/intechopen.97040*


#### **Figure 1.**

*Person's classification according to sedentary behavior and physical activity practice. (A) Sedentary inactive, (B) non-sedentay inactive, (C) sedentary active, (D) non-sedentary active.*

As mentioned before, some studies found that high levels of physical activity might attenuate the increased risk of some illness or death associated with high sitting times [22]. Notwithstanding, there is still some uncertainty in the characteristics of the specific dose–response curves, which makes it difficult to determine specific quantitative public health recommendations [24]. As sedentary lifestyle in western societies does not tend to reduce, new strategies might be the solution. Some degree of sedentary lifestyle might be beneficial for health so that it helps to rest and recover. On the contrary, excessive sitting time may become a risk factor. Scientific evidence has not found an increase in the risk of death from any cause in people with a total sitting time between 4–8 hours/day when compared to those who remain seated for less than 4 hours. Nevertheless, the risk increases by 15% when sitting time rises to 8–11 hours/day, and by 40% with sitting times higher than 11 hours/day [25]. Contrary, some other studies found a dose–response relationship for every 1-hour increase in sitting time in intervals between 0–3, >3–7, and > 7 h/day total sitting and all-cause mortality. This model estimated a 34% higher mortality risk for adults sitting 10 h/day, after taking physical activity into account, although the risk increased staggered [26], similar to other studies that observed statistically significantly higher risk of death with sedentary times of 9.5 h/day or more [23].

This situation has put the focus on the double challenge of increasing levels of physical activity and reducing sedentary behavior. Many countries have developed strategies to promote changes in the population. As an example, the Canadian government created the Canadian 24-Hour Movement Guidelines for Adults (https://csepguidelines.ca/). It recommends that adults between 18–64 years must limit sedentary time to 8 hours/day or less, including no more than 3 hours/day of recreation screen time and breaking long periods of sitting as often as possible.

#### **2.5 Sedentary breaks: effectivity of the different types according to scientific evidence**

As it has been mentioned before, modern lifestyles predispose a high percentage of the population to spend long periods in sedentary behaviors. As too much sitting time is related to different chronic diseases such as type 2 diabetes, obesity, hypertension, and cardiovascular diseases, or some types of cancer, it seems crucial to clearly understand the mechanism and strategies to reduce the negative effects of a sedentary lifestyle. Generalizing, we get up, use the elevator to go to the car, drive to work, take the escalator to go work, spend 8 hours at least working with minimum movement, drive back home, eat, have some hours of recreational time, watch TV and go to bed. Fortunately, different lifestyles and personal situations (occupational situation and leisure-time preferences) as well as inherent individual differences, result in different accumulations of sedentary time. Due to the strong available evidence on the deleterious effects of a sedentary lifestyle on health, it is necessary to better understand the metabolic mechanisms and how it is accumulated. Researchers have observed that reducing or breaking up sedentary time may result in beneficial changes in body composition and acute improvements in markers of cardiometabolic risk.

Sedentary behavior might be considered as a multifactorial concept, where four different aspects influencing it should be taken into account:


It has been proposed that breaks in sedentary time could help counteract the negative effect of prolonged periods of whole-body inactivity. A break in sedentary time can be defined as a period of non-sedentary activity, such as standing or walking in between two sedentary bouts [7]. Experimental studies have demonstrated that interrupting sedentary time with short frequent breaks reduces daily glucose, postprandial glucose, and insulin resistance [3, 26, 27]. In a study carried out by Healy et al. [28] in 2008, the authors found, that interruptions of sedentary behavior were negatively associated with obesity and cardiometabolic health. These results highlighted, already at that time, the fact that not only total sitting matters but also how it is distributed in a period of time. The characteristic of the sedentary breaks in the study from Healy et al. showed that the breaks reported by the participants were shorter than 5 min on average, and they were performed at a light intensity. Results from this study also found lower waist circumference, BMI, triglycerides, and 2-h plasma glucose in the participants with higher sedentary break bouts, independent of total sedentary time or moderate-to-vigorous intensity activity time. Since this pioneering study was published, the scientific community have had an increased interest in analyzing the effects of sedentary breaks, to be able to deeply understand the effects of prolonged sitting on metabolism, as well as to establish clear and specific guidelines of intervention. Different types of sedentary breaks have been studied trying to analyze if shorter bouts of sitting time, are less metabolic disrupting even when the total amount of daily or weekly sitting times are similar.

Brief bouts of light-intensity-activity sedentary breaks could reduce the negative effects of long periods sitting on lower limb vascular function in healthy and overweight/obese adults [29]. Experimental studies [30–32] have seen that combining exercise with breaks in sitting resulted in additional reductions in postprandial insulin-glucose dynamics and triglycerides when comparing exercise and uninterrupted sitting. This effect, although useful in any case, seems to be more effective in those with high basal insulin resistance.

As many studies focused on analyzing the effects of sedentary breaks to counteract the metabolic problems associated with prolonged sitting time have found positive interactions, the question that remains unanswered is not if we should break sitting regularly, what already has a positive answer. The unanswered question is, which is the best structure for a sedentary break?

As it has been mentioned before, the lack of enough specific interventional studies complicates for experts to concrete the most optimal structure for sedentary breaks. A recent study by Wheeler et al. [30] investigated the effects of 3 different sitting strategies in overweight and obese: i) uninterrupted sitting for 8 h, ii) sitting for 1 h, moderate-intensity walking for 30-min and uninterrupted sitting for 6.5 h and iii) sitting for 1 h, moderate-intensity walking for 30 min and sitting for 6.5 h interrupting sitting every 30 min with 3 min of light-intensity walking. They found reductions in postprandial insulin-glucose dynamics and triglycerides by combining exercise with breaks in sitting. This study not only proposes a way to help reach the physical activity recommendation by breaking sedentary time for 30 min/day but also demonstrates that regular sedentary breaks help control the metabolic deleterious effect of prolonged sitting.

A well-controlled meta-analysis conducted by Loh et al. in 2020 [33] found that the use of sitting breaks moderately attenuated post-prandial glucose, insulin, and triacylglycerol. The authors also found that the glycemic attenuation was greater in people with a higher body mass index. An interesting result was that for attenuating glucose levels, a statistically significant small advantage for sitting breaks was found over continuous exercise when exercise matched energy. That could mean that for glucose regulation, it might be more interesting short regular breaks along the day, than one continuous bout of exercise.

The skeletal muscle might also play a key role in glycaemia control, which is even more important in overweight. Bergouignan et al. [34] performed an analysis from randomized clinical trials comparing one or three days uninterrupted sitting with sitting interrupted with light-intensity or moderate-intensity walking every 20-min in the modulation of contraction- and insulin-stimulated glucose uptake pathways in muscle. They found that both sitting break interventions reduced postprandial glucose concentration as well as a transition to modulation of the insulin-signaling pathway and increased capacity for glucose transport. The moderate-intensity intervention resulted in a greater capacity for glycogen synthesis and ATP production. These results might through some light in preventive strategy for metabolic diseases.

Published literature [35] might tend to propose that the best option to reduce the negative effects of sedentary behavior on metabolic functions could be to combine regular activity breaks of several minutes every 30 min of sitting with 30 min of continuous walking whether at the beginning or the end of the long sitting period.

Therefore, breaking sedentary time should be a good way to reduce the negative effects of long periods of sitting, for both metabolic and muscle function. These breaks are even more interesting for patients with initial high blood sugar, insulin resistance, or overweight-obesity. The general recommendation would be to make an active 2–3 min-break every 30 min of sitting time. If the activity made during these breaks is of moderate-high intensity, such as climbing stairs, the metabolic benefits might be greater.

#### **2.6 Sedentary behavior in the workplace. Strategies**

The workplace is considered an important environment for the promotion and protection of health [36]. According to a report from the World Health Organization (WHO) together with the World Economic Forum, 65% of the world's adult population is part of the workforce [37]. In 2007, about 3.1 billion people were part of the economically active population and it was estimated that by 2021 this number would exceed 3.6 billion [38]. Taking into account that this working adult population spends around a third of the day at work, workers´ health must be seen as a priority action.

Encouraging the reduction of sedentary behavior and promoting the practice of physical activity in the workplace is a strategy that helps maintain the health of the working population and affects their close environment. In 2018, the WHO presented the Global Action Plan for Physical Activity [39], with two mean challenges: reducing sedentary behavior by 2030 as well as the percentage of inactive population by 15% to the reported values of 2016. This plan encourages the population to take advantage of the many opportunities that arise in daily living to integrate physical activity, including the workplace (as a fundamental environment to practice physical activity programs as well as its promotion).

The activities where sedentary behavior predominates have increased lately and the workplace is a clear example. The machines have replaced human physical work at the same time that there has been a notable increase in office jobs, where the employee spends most of the working day in front of a computer. Although the negative consequences for cardiometabolic and musculoskeletal health of sedentary behavior have been widely demonstrated and office work represents for many workers a third of their day sitting, few have been made to improve this situation and reduce sitting time at workplaces, with the associated health risk.

The Healthy Work Environment model, proposed by the WHO [38] proposes intervention programs to reduce and break sedentary behavior in the workplace as a health promotion model and protection strategy. This model proposes four scenarios of action or "avenues of influence", which are not isolated, but rather overlap each other:


To successfully establish health promotion programs in the workplace, certain conditions must be considered:


With different adaptations, similar models can be recommended with more or less the same stages.

Experts have suggested different strategies to reduce or interrupt sedentary behavior in the workplace, which could be grouped into the following categories [40].

a.Physical/environmental changes in workplace design

	- Promote the holding of standing or walking meetings.
	- Propose active breaks during working hours (short breaks in which you can do joint mobility exercises, put on a musical theme and dance, or any activity that allows interrupting the sedentary behavior through light physical activity)
	- Offer group physical activity practice.
	- Encourage the use of breaks for short walks.
	- Encourage employees to communicate with their colleagues by approaching their desks rather than by phone or messages.
	- Workshops, training courses and outreach programs on the importance of reducing sedentary behavior. Reporting on the health risks of sedentary behavior and the benefits of practicing physical activity could allow people to evaluate their behavioral choices.
	- Campaigns through various means, such as posters, signage, emails, WhatsApp messages, telephone calls or internal messages to motivate a change in behavior or.
	- Install reminder software every 30 minutes on employees' mobile phones or personal computers, for example, to interrupt the sedentary behavior by standing up, dancing or doing some movements.

#### **2.7 Sedentary behavior in the leisure time. Strategies**

As mentioned so far, human bodies are adapted to maintain a physically active lifestyle. Proof of this is the health consequences of an insufficient level of physical activity. However, it is also true that neurobiologically we are adapted to "optimize" our energy expenditure, avoiding additional efforts when possible; In other words, sedentary behaviors are attractive for human beings, and willing power is required to counteract this attraction and opt for a behavior with higher associated energy expenditure [41]. It has been studied how the energy cost associated with a task affects, not only our decision to choose another more "economic" one, but directly to our perception of the initial task [42] and, therefore, to our future intention to undertake it.

A process as complex as human behavior cannot be reduced to just one component. Emotional/affective factors, as well as built habits, are also related to sedentary behavior and physical activity [43]. However, it is an interesting starting point if we seek an alternative approach to the one traditionally used. The assumption that human behaviors are decided by rational evaluations of the available information are underlying concepts in many current intervention strategies and, therefore, knowing the benefits of regular physical activity and the damages of prolonged sedentary behavior should be enough to solve the problem [44]. Nevertheless, in light of the sustained global pandemic of physical inactivity, it may be necessary to complement and enrich this approach with other perspectives.

Sedentary behaviors in free time are usually classified as screen-time (watching television, videos via streaming platform or physical medium, browsing the internet and social networks by both on a computer, tablet or cell phone and the use of video games) or not screen-time (sitting down to eat, participating in social gatherings, playing board games, recreational, attending cultural events such as cinema, theater, show music, sports competition, religious ceremony, doing artistic activities like writing or drawing or hobbies. The extensive list is testimony to the enormous offer of sedentary activities in free time. Recommendations on physical activity and sedentary behavior limit the amount of time in sedentary behaviors, but particularly those carried out in front of the screen [21].

#### *How to Reduce Sedentary Behavior at All Life Domains DOI: http://dx.doi.org/10.5772/intechopen.97040*

Sedentary activities in front of the screen in free time, in addition to adverse effects on physical health, are related to adverse effects on mental health, mainly in minors [45]. Screen time during childhood is negatively correlated with brain connectivity, compared to time spent reading books, as well as being related to loss of imagery ability [46] or social–emotional functionality [47]. Interestingly, and in contrast to these studies, in the specific case of video games, there is evidence that indicates various cognitive benefits according to the type of game (action, strategy), and even positive socio-emotional impacts [48].

Of the large number of sedentary activities carried out in free time, although the impact on physical health is equivalent, it would be differential over other dimensions of the subject's health. This leads to one of the perspectives mentioned in the literature as a strategy to address sedentary behavior: "harm reduction". Assuming that certain socio-cultural (technological) changes are already part of daily life, priority is given to modifying those behaviors that present a greater health risk: replacing sedentary behaviors in front of the screen with sedentary behaviors without a screen, or by non-sedentary screen activities (for example, walking while using portable devices or replacing sedentary video games with active ones) [49].

Different classifications have been proposed for reducing sedentary behavior in the free time [50]: 1) environmental interventions such as devices that limit the time of television use), and 2) behavioral interventions like education campaigns about the harms of prolonged sedentary behavior; 3) multi-component interventions which include both types mentioned above.

Although studies on this fact do not have homogeneous methodologies, some findings can be pointed out. Studies that focus on the sedentary behavior of children in the home context have found a relationship between the existence of screen devices in the bedroom and greater sedentary behavior (with less reading time). Likewise, both the interventions that use devices that limit the use of television and those on family rules for screen use have been successful in reducing sedentary behavior. Furthermore, it was observed that in those cases in which the parents had more television time, or participated with their children in sedentary activities, the children presented higher levels of sedentary behavior. In some studies, the existence of adequate space or equipment for practicing physical activity at home is related to less sedentary behavior (although it does not present higher levels of physical activity at moderate or vigorous intensities) [51].

In the case of adults and the elderly, studies on free time are scarce and methodological imprecise. The absence of control in the domains makes it difficult to control the changes since the decrease of sedentary time in a domain does not imply its replacement by physical activity since it could simply shift to sedentary behavior in another domain. Those interventions aimed exclusively at reducing sedentary behavior have better results than those that also focused on increasing physical activity [50].

For children and adolescents, as well as for adults and the elderly, there is another alternative intervention strategy, which constitutes itself in an emerging field of research: exergaming, also known as active gaming or effort video game. These video games, unlike the traditional ones, are controlled with body movements (either full body or only certain segments); Thus, instead of being a sedentary activity, at least light-intensity physical activity is achieved (with the potential to become moderate intensity and even vigorous). In the US, it is estimated that 90% of children and adolescents play video games recreationally. In an increasing technophile society, and in which electronic entertainment is already part of our lives, exergaming stands as a strategy to address those to whom other physical activity proposals are not convincing. In addition, the commitment, immersion,

and experience of "flow" that they can generate, make them a great resource for health-related purposes. Sustainability over the years of this type of activity has been investigated, finding greater adherence in women, and similar to that of team sports [52].

Results for studies analyzing experiences in exergaming as part of both school physical education and at-home context show a decrease in sedentary behavior with potential, according to the intensity at which the game is played, increase of moderate-to-vigorous physical activity and good adherence to intervention programs. One of the challenges of exergaming is the "replay value" (once the game becomes monotonous and therefore the motivation to continue playing decreases), which maintain adherence. Multiplayer games (both face-to-face and remotely) show greater adherence. The eventual increase in the number of published games would compensate for this situation, allowing simply to change to a new one [53].

Particularly interesting is the research with older people, which improvements for both institutionalized and community-dwelling subjects, and not only in the physical dimensions but also in the cognitive one [54].

In all these cases, we refer mainly to consoles-home exergaming, but everyday mobile devices with augmented reality technology (Pokémon Go with geo-location system integrated into cell phones) are great opportunities to promote exergaming. Pokémon Go requires active movement of the player around their surroundings to play. This game mechanic has achieved a statistically significant change in the number of steps per day (thus decreasing sedentary behavior), although there is still not enough evidence on long-term adherence.

In the latter case, as in some home exergaming video games, there is no explicit intention in its design to promote health effects or to prescribe a systematic physical activity program. However, they have the potential to have a positive impact on the health and well-being of those who opt for this type of digital entertainment. Sedentary behavior in free time poses a great global challenge that requires, particularly for new generations, imagination and innovative approaches, in tune with contemporary technologies and paradigms.

### **2.8 Sedentary behavior in special populations: children and adolescents and older people. Strategies**

#### *2.8.1 Children and adolescents*

It is well accepted that physical activity is beneficial to maintain and improve health and well-being across life [55]. In infants, toddlers, and preschoolers, high levels of physical activity have been seen to be related to better social and motor development improved metabolic health, and decreased adiposity, while a sedentary lifestyle is related to higher adiposity and poorer psychosocial health and cognitive development [54].

Children (preschoolers and scholars) spend more than 2 h/day of screen time, which is the maximal time recommended for this age group [56], plus eating time, school, passive transportation, homework, etc., which results in more than 8 h/day of sitting at this age. Moreover, studies found that screen time was associated with an increased risk of overweight/obese independent of physical activity [54]. Sex differences were also found. Boys are generally more involved in physical activity than girls, which normally spent more time on domestic tasks and homework. Children living in rural areas tend to use more active transportation than those who live in urban areas. Older children also tend to use more active transportation than the younger ones [57]. Taking into account that sedentary behavior in children is directly associated with classical cardiovascular risk factors like elevated blood

#### *How to Reduce Sedentary Behavior at All Life Domains DOI: http://dx.doi.org/10.5772/intechopen.97040*

glucose levels, insulin resistance, high blood pressure, obesity, and elevated blood lipids [58], strategies that help reduce total daily sitting time in children are crucial.

Nevertheless, although childhood should be a life stage where children should freely play, run and jump as part of their natural development, social rules, obligations, parent's overprotection, new technologies, and urban environments, hinder the practice of physical activity for children with dramatic consequences. A qualitative study performed by Hidding et al. [59] aimed in determining the reasons for children to be sitting from the children or parents perspective, found that children most repeated reason was that they sit because is the norm and they have to and because they can play better that way. Other common answers were: I sit because seated activities are fun, I sit because I'm tired, I want to relax, I want to rest, I sit because of my health, I sit because there is nobody to play with, I sit because there is nothing to do, I sit because I'm not in the mood to do anything, I sit because of the weather. In regards to the answer "I sit because there is nobody to play with", in families with more than one child, seems to be easy for children to perform physical activity [59].

All this information brings the experts 'awareness of the necessity of reconsider children's environments. The CSEP Canadian 24-Hour Movement Guidelines [56] propose an Integration of physical activity (both light and moderate-to-vigorous), sedentary behavior, and sleep as the three principal parts of the day. All three must be right balanced to promote overall health, well-being, and quality of life. These guidelines use "the four S rule":


#### **Figure 2** ilustrates de cited guidelines.

In addition, parents might consider changing indoor activities for outdoor ones, when possible, and including moderate to vigorous physical activity in exchange for light physical activity at some point of the day.

Findings from a recent meta-analysis [60] on the physical activity a sedentary behavior suggest that physical activity interventions can improve adolescents' mental health.

#### *2.8.2 Older adults*

Worldwide, the population is aging, which results in higher economic and social costs, as well as increased numbers of people living with more health problems, as aging increases the risk of suffering from chronic diseases. Therefore, the concept of successful aging has become a priority to guarantee, not only that life expectancy is high, but also that the years lived are of the best quality possible, free or with minimum chronic diseases. Physical activity has been proven to help increase or maintain health throughout life. Due to physical activity tends to reduce with age, older adults must become a risk population. Disability, frailty, dysfunction,

#### **Figure 2.**

*Canadian 24-hour movement guidelines for children and youth (5-17 years): an integration of physical activity, sedentary behavior, and sleep. Taken from CSEP website (https://csepguidelines.ca/).*

or sarcopenia are some of the problems that can affect older adults, which can compromise the independence level [61]. As physical activity decreases in this group, sedentary behavior increases, with fatal consequences. Maintaining physical activity levels and reducing sedentary time, should be a priority for the administrations. In this regard, there is evidence about the negative associations of sedentary behavior with frailty and how this relationship can differ by sitting bout length. Some studies [62] have found that prolonged sedentary bouts and total sedentary time were associated with higher mortality risk in frail individuals but not in robust. These results, including moderate-to-vigorous physical activity, reducing sedentary time in those frail older adults, as well as including sedentary breaks seem like a

#### *How to Reduce Sedentary Behavior at All Life Domains DOI: http://dx.doi.org/10.5772/intechopen.97040*

suitable strategy to prevent dependency and maintain health. As the total hours of a day are always 24, that means that when a person increases the time spent in moderate-to-vigorous physical activity, this person is reducing the time spent in another activity, that could be sitting or light physical activity. If sleeping time remains stable and a person substitutes 30 min/day of light physical activity for moderate-to-vigorous physical activity that includes resistance training, and at the same time changes 1 hour of sitting for light physical activity such as walking, the frailty status could be significantly reduced. Moreover, if this person would include a short sedentary break every 30 min - 1 hour of the total time this person is seated, the benefits would be even higher with only small changes.

Due to older adults are mostly retired, which releases them of office sitting time and have a lot of leisure time, political strategies must center on providing older adults with a safe environment where they can perform light physical activity, such as walking [63]. Pavements and sidewalks in good conditions, green areas, and safe cross-roads might help improve that older adults go more often outside to take a walk. At the same time, organized affordable exercise activities, specifically designed by experts for this population, could make that older adult reach the recommendation for moderate-to-vigorous physical activity and resistance training. Moreover, these activities also promote social interaction, which improve wellbeing and might help reduce depression and anxiety, improving health-related quality of life, as well. These two actions would help to achieve physical activity recommendations at the same time that sedentary time would be reduced. To completely promote health in this group, clinicians, governments, and media should establish campaigns to make older adults understand the importance of breaking sedentary time. Things such as get up in the commercials when they watch TV, walking or standing while they are phoning, or get up to drink some water once each hour might be enough to break sitting time.

## **3. Conclusions**

Lifestyle has dramatically changed in the last century. Industrialization and technology have reduced the physical requirements of many jobs, urbanization has changed population habits, force them to use passive transport instead of active ones, children play with digital devices since they are very young and older adult do not have to go outside because cities, family and environment easily provide all their needs. However, this sedentary lifestyle has disastrous consequences for health. Physical activity is necessary to maintain an optimal physiological function and prolonged sitting time interferes with the proper metabolic regulation. The combination of both, low physical activity levels and prolonged sitting time, maybe even more deleterious. That suggests a double challenge for developed countries; reducing and stopping prolonged sedentary behavior as well as increasing levels of physical activity. Although each of them separately has concrete effects on health, their interaction must be also taken into account. Sedentary behavior appears to be negative for health "per se", as well as low physical activity levels, but how both are combined is what can make the difference. Scientific evidence says that high physical activity levels might help counteract the negative effects of sitting time and that this effect is progressive. That means, that the higher the physical activity intensity, the less negative effects of sitting time. At the same time, it seems that long continuous sitting bouts are more harmful than the same total sitting time but with breaks in between. Eight hours seated without any break might be a lot worse for metabolic regulation than the same 8 h of sitting but with breaks of 2–3 min every 30 min-1 h. With all these ideas in mind, the strategy to reduce sedentary behavior

seems clear: practice enough physical activity, reduce free-time sitting and screen time, promote active transportation, and include sedentary breaks at sedentary jobs. The reason why these strategies are not working is complex and implies a compromise at different levels. First, governments must provide opportunities for affordable exercise practice and physical activity-friendly environments. Secondly, at workplaces, managers, CEOs, and bosses must be aware of the importance of promoting working places where employees have the opportunity of breaking sedentary time, and that it is seen as normal. Third, citizens should make efforts to include active activities in the free time as well as substitute classic videogames for exergaming, where at least, sitting time is exchanged for light physical activity. Last but not least, special populations (children and older adults) should not be forgotten. Parents and schools should reconsider the rules and norms and adapt them, when possible, to others more active versions, not forcing children to spend long periods seated promoting at the same time at least one hour of physical activity per day. Controlling screen time and giving good examples must be another priority for parents. In regards to older adults, societies should allow them to perform easy tasks that increase physical activity, encouraging them to used active transportations to carry them out, at the same time that exercise programs, specifical design for this population, are easily available in every neighborhood.

## **Author details**

Olga López Torres1 \*, Pablo Lobo2 , Valeria Baigún2 and Gabriela F. De Roia2

1 ImFINE Research Group, Health and Human Performance Department, Faculty of Physical Activity and Port Science-INEF, Universidad Politécnica de Madrid, Madrid, Spain

2 Laboratorio de Estudios en Actividad Física, Universidad de Flores, Ciudad Autónoma de Buenos Aires, Argentina

\*Address all correspondence to: olga.lopez@upm.es

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*How to Reduce Sedentary Behavior at All Life Domains DOI: http://dx.doi.org/10.5772/intechopen.97040*

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## **Chapter 6**
