11/18/2013 Outline State of knowledge (evidence base) Sedentary - - PDF document

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Is Sitting the new smoking?

Professor David Dunstan

Head – Physical Activity ARC Future Fellow Baker IDI Heart & Diabetes Institute Melbourne, Australia Adjunct Professor - UWA David.Dunstan@bakeridi.edu.au

Outline

• State of knowledge (evidence base)

– Sedentary behaviour (too much sitting) as a unique public health problem – paradigm shift

• Current & future research directions towards

building the evidence-base in relation to sitting

– Controlled laboratory studies

• Prof Neville Owen, Dr Alicia Thorp, Prof Bronwyn Kingwell, Dr

Robyn Larsen, Dr Brigid Lynch, Beth Howard: Baker IDI Heart and Diabetes Institute

• Dr Genevieve Healy, Prof Elizabeth Eakin, Dr Elisabeth Winkler,

Dr Paul Gardiner, Dr Bronwyn Clark: The University of Queensland

• Professor Jo Salmon: Deakin University
• Australian Research Council
• Victorian Health Promotion Foundation

Acknowledgements Baker IDI Heart and Diabetes Institute

Dr Genevieve Healy Prof Elizabeth Eakin Prof Neville Owen Beth Howard Dr Alicia Thorp Dr Brigid Lynch Prof Jo Salmon Owen N, Healy GN, Matthews CE, Dunstan DW. Exerc Sports Sci Rev 2010 Volume 38: 105-113 Commentary: Medical Hazards of Prolonged Sitting Page: 101-102

Population Health – Through a Sedentary Behaviour Lens

The problem of “Too much sitting”

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Blair SN, et al. Am J Clinic Nutri. 2004;79:913S−920S.

1960 1970 1990 2000 2010

Sallis JF, et al. Am J Prev Med. 2005;28:93S−95S.

From Occupations to Exercise to Active Living

Exercise Physical Activity Active Living Sedentary Behaviour

Dunstan DW, et al.Diabetes Care. 2004;27:2603−2609.

Occupational Activity

Morris, et al. Lancet. 1953;265:1053-7.

1950 1980

Australian Bureau of Statistics. National Health Survey 2004–05.

Current Public Health Problem – The “Flat Line Issue” The Sobering Reality

NHANES 2005-2006

Source: Tucker et al. (2011) Am J Prev Med: 40: 454-461

Meet The Rare & Potentially Extinct Creature

Modern Society: Minimising Daily Muscular Activity!

Then Now

Transport Domestic Work Too much sitting: a unique health problem – right under our noses?

Our technologically advanced, ‘sitting orientated’ society

Sleep 11pm Awake 7 am

   

Work on computer 4 hrs Transport to work 45 mins Lunch 30 mins Evening meal 30 mins Breakfast 15 mins Work on computer 3.5 hrs Transport From work 45 mins Watch TV 4 hrs Sitting Opportunities 15.5 hrs

Exercise – 30 min

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What Is Sedentary Behaviour?

Any waking behaviour characterized by an energy expenditure ≤1.5 METs while in a sitting or reclining posture

Sedentary Behaviour Research Network (SBRN) 2012

Device-Based Measurement of Movement and Posture

Accelerometer Inclinometer The ‘market dominator’ from whose output (counts of less than 100

pm) we infer ‘sedentary’

time From whose output we can derive posture-based indices

• f ‘sitting’ time

Device-measured sitting time

The Population ‘Reality’ Pie Chart

You Can Be ‘Active’, But Mostly Sit

The ‘Active’ Couch Potato

Mean mod-to-vigorous time = 31 mins/day % Waking hours spent in Sedentary = 71% Time (minutes) Morning Night Sedentary Light Moderate/vigorous Activity Intensity Energy Expenditure Very Low Very High

Time to re-think the physical activity paradigm

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The ‘Breaks In Sedentary Time’ Hypothesis

• ‘Breaking-up’ sedentary time (frequent transitions from sitting to

standing) has beneficial associations with health outcomes (independent of sedentary time)

Healy GN, Dunstan DW et al. Diabetes Care 2008; 31: 661-666 “Prolonger” “Breaker”

Sedentary CPM < 100 Not sedentary CPM 100+

Prolonged Sitting - Not a New Concern

“...those who sit at their work and are therefore called 'chair workers,' such as cobblers and tailors, suffer from their own particular diseases ... [T]hese workers ... suffer from general ill-health and an excessive accumulation of unwholesome humors caused by their sedentary life” “All sedentary workers ... suffer from the itch, are a bad colour, and in poor condition ... for when the body is not kept moving the blood becomes tainted, its waste matter lodges in the skin, and the condition of the whole body deteriorates”. (1700) Bernadino Rammazzini 1633-1714 De Morbis Artificum Diatriba “Disease of Workers”

Causality

EXPERIMENTAL EVIDENCE PLAUSABILITY & COHERENCE BIOLOGICAL GRADIENT TEMPORAL RELATIONSHIP STRENGTH OF ASSOCIATION/ CONSISTENCY

SITTING

Source: Bradford-Hill A. 1965 Proc of Royal Soc Med 58: 295-300 STRENGTH OF ASSOCIATION/ CONSISTENCY

SITTING

Causality

Source: Bradford-Hill A. 1965 Proc of Royal Soc Med 58: 295-300

Sedentary (sitting) Behaviours & All-Cause Mortality – Meta Analysis

Source: Wilmot E.G et al. Diabetologia 2012; 55: 2895-2905

49% ↑ RR

TEMPORAL RELATIONSHIP STRENGTH OF ASSOCIATION/ CONSISTENCY

SITTING

Causality

Source: Bradford-Hill A. 1965 Proc of Royal Soc Med 58: 295-300

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Sedentary Behaviour and Health Outcomes

Associations reported from prospective studies: 1996-2011

Thorp et al. Am J Prev Med 2011

+ve association mediated by BMI / one gender no association

Obesity risk/incidence: Weight gain: Diabetes: Cancer: Cardiovascular disease: Mortality (all-cause & CVD):

Every hour of TV from age 25 reduces your life expectancy by 22 minutes

Veerman et al 2011 Br J Sp Med

TV Viewing and Reduced Life Expectancy

Source: Veerman L et al. British J Sports Med 2011

Prolonged Sitting

Then Now

?

Sun Exposure

BIOLOGICAL GRADIENT TEMPORAL RELATIONSHIP STRENGTH OF ASSOCIATION/ CONSISTENCY

SITTING

Causality

Source: Bradford-Hill A. 1965 Proc of Royal Soc Med 58: 295-300

Sitting Time and All-Cause Mortality Risk in 222,497 Australian Adults

Hidde P van Der Ploeg, Tien Chey, Rosemary J Korda, Emily Banks, Adrian Bauman Arch Intern Med. 2012; 172 (6) : 494-500

Adjusted for: age, sex, education, marital status, urban/rural residence, physical activity, BMI, smoking

Causality

EXPERIMENTAL EVIDENCE PLAUSABILITY & COHERENCE BIOLOGICAL GRADIENT TEMPORAL RELATIONSHIP STRENGTH OF ASSOCIATION/ CONSISTENCY

Sedentary Behaviour

Source: Bradford-Hill A. 1965 Proc of Royal Soc Med 58: 295-300

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Sitting Induces Muscular Inactivity

The ‘Circulatory’ Perils of Too Much Sitting

• Limited mobility = Less demand on circulatory

system → reduced blood flow

• Insufficient blood flow

» Pooling of blood in the lower limbs » Swollen or numb legs and eventually varicose veins » Accelerates muscle fatigue » Reduces the efficiency of the body’s regulatory processes

Dunstan et al. (2012) Diabetes Care 35: 976-983 2012

AIM: To examine the acute effects of postprandial glucose and insulin levels of uninterrupted sitting compared with sitting interrupted by brief bouts of light- or moderate-intensity walking

CONDITION 1: A single bout of prolonged sitting

Standardised mixed meal: ~75g CHO and ~50g Fat Blood sample: glucose, insulin, triglycerides, FFA’s Muscle and adipose tissue biopsy (optional)

• 2 -1 0 1

2 3 4 5 hrs

ACTIVPAL PROFILE EXPERIMENTAL SET UP CONDITIONS 2 & 3: Sitting + light/moderate-intensity activity bouts

Light-intensity walking (2mins): Treadmill Speed = 3.2 km/hr Moderate-intensity walking (2mins): Treadmill Speed = 5.8-6.4 km/hr

• 2 -1 0 1

2 3 4 5 hrs

ACTIVPAL PROFILE EXPERIMENTAL SET UP

Results: Glucose

> 24% 

Dunstan DW et al. (2012) Diabetes Care 35: 976-983 2012

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Exposure beyond one day Length of breaks – short vs. long-term Type of breaks – ambulation vs. standing Frequency of breaks – high vs. low Moderating factors

• Age
• Sex
• Ethnicity
• Adiposity levels
• Disease presence
• Fitness Levels –Regular Exerciser
• ??????

? ? ? ? ? ? ? ? ? ? ? Other mechanisms

• inflammatory?
• haemostasis?
• endothelial?
• autonomic?

NHMRC Centre of Research Excellence (2014-2018)

Sitting Time and Chronic Disease Prevention – Measurement, Mechanisms and Interventions

Owen, Salmon, Trost, Dunstan, Eakin, Healy, Kingwell, Lambert, Timperio

Workplace Health Promotion & Chronic Disease: Looking Through a Workplace Sitting Lens

Organisational Policy & Culture Workplace Physical Environment Individuals

DUTY OF CARE “A person conducting a business or undertaking must ensure so far as is reasonably practicable the provision and maintenance of a work environment without risks to health and safety” Model Work Health and Safety Bill 23/06/2011

Epidemiology  Experimental laboratory  Interventions Translational research

Program of research investigating benefits from reducing sitting time in the workplace

The Stand Up Australia Program of Research

A National collaboration between the Baker IDI Heart & Diabetes Institute University of Queensland, University of Melbourne, Deakin University Government & Non-Government Partner Organizations

Australia

Thorp AA et al. Int J Behav Nutr Phys Act 2012; 26: 128

Activity distribution (%) Proportion of prolonged (≥30 mins) sedentary time (%)

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Can Workplace Sitting Be Reduced? Intervention Development Frameworks

Sitting

Policy Context Physical Environment Interpersonal Intrapersonal

Ecological Model

• f sedentary behavior change

WHO Healthy Workplace Model

Multiple influences Participatory approach Strong evaluation framework

Multi-Component Intervention

• Organisational (workshops, manager emails)
• Environmental (height-adjustable workstation)
• Individual (individual consultation, telephone

support)

Stand Up Comcare

Feasibility study

Stand Up Victoria

Cluster-RCT

SUA - Organizational Strategies

• 1. Senior management consultation (~30-45mins)
• Background & rationale
• Identification of relevant OHS policies & organizational

structures, team champions & any additional resources

• 2. Representatives consultation workshop (~2-

4hrs)

• Participatory approach: reps from various levels
• Identification of organizational-appropriate strategies to

support key message “Stand Up, Sit Less, Move More”

• Manager emails, champion for change

Stand Up Australia

SUA Organizational Strategies

• 3. Staff information & brainstorming (~30-45mins)
• Background & intervention details to all staff
• Build on strategies identified in (2)
• Summary email & electronic info book post-session

Stand Up Australia

Stand Up Comcare

Aim: to assess the short term feasibility and efficacy of a multicomponent intervention to reduce workplace sitting

DESIGN: Intervention: Multicomponent (n=18) Control: Assessment only (n=18) PARTICIPANTS: Comcare staff 2 ASSESSMENTS: Baseline, 4 weeks

Healy et al., Prev Med, July 2013

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Phase 1 1-2 weeks Phase 2: 4 -weeks Intervention: Baseline Unit reps consult Group consult Work- station install Individual consult (Day 1-3) Call 1 (wk 2) Call 2 (wk 3) Call 3 (wk4) Assessment 2 (end of Ix) Control: Baseline Assessment 2

OHS, management, general staff

• Role
• Brainstorm

Study Timeline Unit Representatives’ Input

• “laps” around office - defined circuit
• introduction of more standing into meetings (initiated by

Chairperson from the outset)

• use printers further away
• ergonomically sound exercises at scheduled times
• wireless headsets for conference calls (to enable standing)
• breaks compliance software
• use the stairs (reduced access during intervention period)
• “no bins” policy – no personal bins
• timed walking routes in vicinity of building

Phase 1 1-2 weeks Phase 2: 4 weeks (Comcare) 12 weeks (SUV) Intervention: Baseline Unit reps consult Group consult Work- station install Individual consult (Day 1-3) Call 1 Call 2 Call 3 Assessment 2 (end of Ix) Control: Baseline Assessment 2

OHS, management, general staff

• Role
• Brainstorm

All Ix participants

• Information
• Refinement
• Group feedback

Face-to-Face

• Instruction
• Feedback
• Goal setting
• Tracking

Support bhr change

Study Timeline Management Emails Environmental Change

Height adjustable workstation: WorkFit S: Ergotron

Product kindly donated by Ergotron

Individual Strategies

• One face-to-face coaching session (~30mins)
• Delivered by MI trained health coach
• Individual feedback reviewed in relation to key messages
• Specific goals for each key message developed &

documented (workstation tracker)

• Email summary post session

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Example Individual Feedback

24% 56% 11% 9%

Focus on reducing prolonged, unbroken sitting ≥30 minutes

Sitting Standing Stepping

Identifying Strategies Documenting Goals: Workstation Tracker Individual Strategies

• One face-to-face coaching session (~30mins)
• Delivered by MI trained health coach
• Individual feedback reviewed in relation to key messages
• Specific goals for each key message developed &

documented (workstation tracker)

• Email summary post session
• Four support telephone calls (~10mins each)
• Delivered by health coach
• Staggered intervals (e.g. 1, 3, 6, 10 weeks post coaching)
• General check-in & identification of barriers, problem

solving, potential adjustment of goals

• Phone call 3: strategies outside workplace

Favourite Behaviour Change Strategies

Stand Up

• Set a timer (e.g. outlook)
• Stand up when someone enters the office / phone rings
• Stand up when someone else does

Sit Less

• Determine certain ‘standing times’, i.e. morning; after lunch
• Standing meetings

Move More

• Use the stairs instead of the lift
• Walking laps
• More active lunch breaks (e.g. walking around the block)
• Fill water bottle / pick up printing more often
• iMails

Results: at the workplace (%)

*Based on an 8h workday Control (n=18) Intervention (n=18) Baseline Follow-up

Sitting Standing Stepping Healy et al., Preventive Medicine, 2013

21,7 43,4 24,4 10,5 24,3 43,1 22,6 10,0 26,3 40,8 21,9 11 12,7 29,3 47,5 10,5

Sitting ≥30m

Workplace sitting reduced by >2 hrs

(range -262 to -29mins)

No significant impacts on health or productivity

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Comcare: Since the Research Study…

• Sedentary work practices toolkit
• http://www.comcare.gov.au/safety__and__prevention/your_working_environment/sedentary_wo

rk_practices_toolkit

• Installing workstations for all employees

Stand Up Victoria

CIs: David Dunstan, Genevieve Healy, Neville Owen, Elizabeth Eakin, Anthony LaMontagne, Marj Moodie

• 3-year cluster-randomised controlled trial

– 320 participants (160 per group) – 14 worksites from one organisation

• 3 months of intervention, 9 months of follow-up
• Cost-effectiveness analysis

Stand Up  Sit Less  Move More

Progress to date......

• n= 228 participants from 14 sites (7 x Ix; 7 x Control)
• 4 sites fully completed 12 months
• last site will be initiated mid-Nov 2013
• Retention rate: 93% at 3 months; 70% at 12 months

Results to date: baseline characteristics

• n= 213 participants from 13 sites (7 x Ix; 6 x Control)
• Worked on average 8.5 hours/day; 4.3 days/week

Table 1. Self Reported Demographics and Health History n % Gender Male 63 30 Female 150 70 Ethnicity Caucasian 169 79 Asian 37 17 Other 7 4 Highest Level of Education Some High School 18 8 Completed High School 54 25 TAFE or trade certificate 60 28 University 81 38 Currently Smoking 39 18 History of Diabetes 22 10 History of Dyslipidaemia 53 25 Mean SD BMI (kg/m2) Females 28.0 6.5 Males 28.3 5.1 Fat % Females 36.5 8.6 Males 25.9 7.1 Waist (cm) Females 91.0 15.0 Males 98.5 12.8 Waist/Hip ratio Females 0.84 0.54 Males 0.93 0.07 Table 2. Anthropometrics

Results: baseline sitting, standing and stepping times

36% 43% 14% 7%

At the workplace*......

79%

31% 34% 24% 11%

All waking hours*......

65%

*n=198

http://www.heartfoundation.org.au/Healthy_Living/Physical_Activity/Pages/default.aspx

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Tips For Sitting Less Tips – At Work

• Stand and take a break from your computer every 30 minutes
• Take breaks in sitting time in long meetings
• Stand to greet a visitor to your workspace
• Use the stairs
• Stand during phone calls
• Walk to your colleagues desk instead of phoning or emailing
• Drink more water - going to the water cooler and toilet will break up sitting
• Move your bin away from your desk so you have to get up to use it
• Use a height-adjustable desk so you can work standing or sitting
• Have standing or walking meetings
• Use headsets or the speaker phone during teleconferences so you can

stand

• Eat your lunch away from your desk
• Stand at the back of the room during presentations

Tips For Sitting Less – At Work

NC = No cost $ = Cost NC NC NC NC $? NC NC NC $ NC $? NC NC

Summing Up & Take Home Messages

• Even in physically active adults, concurrent reductions in

the amount of time spent sitting is likely to confer health benefits

• More experimental evidence and intervention studies (to

provide the relevant dose-response data) are needed to inform specific guidelines for the general populations

• Advice: “Create opportunities to limit sitting time and

break up prolonged periods of sitting through frequent transitions from sitting to standing/ambulating throughout the day”

‘Life is like riding a bicycle. To keep your balance, you must keep moving’

Albert Einstein

Thank You for Listening

Contact Details Prof David Dunstan

Head – Physical Activity Baker IDI Heart & Diabetes Institute Melbourne, Australia Email: David.Dunstan@bakeridi.edu.au Web: www.bakeridi.edu.au/research/physical_activity/