Sedentary lifestyles: a review of the updated evidence on potential health risks (2023)

1. Epidemiology

Approximately 31% of the world's population aged ≥15 years engage in insufficient physical activity, and it is known to contribute to the deaths of approximately 3.2 million people each year.1]. In South Korea, rates of physical activity are declining among adults ≥19 years, regardless of the type of activity, including aerobic exercise, walking, and muscle training. Thus, in 2017, the rates of aerobics, walking, and muscle training in the adult Korean population were 48.5%, 39.0%, and 21.6%, respectively, and the majority of the Korean population was physically inactive.2]. Along with physical inactivity, a sedentary lifestyle is also a serious problem and a significant number of people practice it for long periods of time. For example, Americans spend 55% of their waking hours (7.7 hours a day) on sedentary behavior, while Europeans spend 40% of their free time (2.7 hours a day) watching TV. [3]. Similar patterns were seen in Koreans who reported sitting for prolonged periods. According to the 2018 Korea Health Statistics, Korean adults aged ≥19 years spend 8.3 hours of sedentary time. Only 8.9% of the adult population spend less than 4 hours sedentary, while 20.6% of adults spend more than 12 hours sedentary.4].

2. Causes of physical inactivity and lack of exercise

It is speculated that the low participation in physical activity is influenced by several factors. Some environmental factors include traffic congestion, air pollution, lack of parks or pedestrian paths, and lack of sports or recreational facilities.1]. Television, video viewing, and cell phone use are positively correlated with an increasingly sedentary lifestyle.5]. Due to this sociocultural context, it is projected that sedentary behaviors will continue to increase.

A sedentary lifestyle has a great impact on the general health of the world population. Many people around the world lead a sedentary lifestyle and the prevalence of relevant non-communicable diseases is increasing. It is well known that little physical activity, that is, lack of exercise, has a negative effect on health. Physical inactivity is the fourth main risk factor for global mortality, representing 6% of global mortality.6]. Despite the fact that sedentary behaviors pose comparable health risks and contribute to the prevalence of various diseases, most physical activity-related training in clinical practice focuses on improving physical activity levels rather than reducing them. sedentary behaviors. In addition to understanding and educating patients about the health implications of a sedentary lifestyle, healthcare professionals from various sectors, including physicians, need to reflect on its political implications. This study examined the health effects of a sedentary lifestyle and related lifestyle improvements that need to be made to promote healthy living.

1. The concept of sedentary lifestyle

Sedentary behavior is defined as any waking behavior, such as sitting or bending over, with an energy expenditure of 1.5 metabolic equivalents (METs) or less.7]. Proposed by the Sedentary Behavior Research Network in 2012, this definition is currently the most widely accepted definition of sedentary behavior. Some examples of sedentary behaviors include watching TV, playing video games, using computers, sitting at school or work, and sitting during travel (illustration 1) [8]. According to the 2011 Compendium of Physical Activities, the MET is defined as the ratio between the work output and the standard resting output (RMR) of 1 kcal/(kg/h). A MET is the RMR, or cost of energy, for a person at rest. When quantitatively ranked by intensity, physical activities can be divided into 1.0–1.5 METs (sedentary behavior), 1.6–2.9 METs (light intensity), 3–5.9 (moderate intensity) and ≥6 METs (vigorous intensity) (Figure 2) [9].

A sedentary lifestyle increases all-cause mortality and the risk of cardiovascular disease (CVD), diabetes mellitus (DM), hypertension (AHT), and cancer (breast, colon, epithelial colon, endometrial, and ovarian). This is consistently documented in the literature [3,10,11]. There is no disagreement that prolonged total times of sedentary behavior are associated with poor disease outcomes. However, patterns of sedentary time may differ even within the same total time, and not much is known about the particular patterns of prolonged sedentary time that pose the greatest health risks (eg, continuous sedentary behavior without interruption or behavior intermittent sedentary). To behave) [12]. One study reported that even when total sedentary time was the same, short bouts of sedentary activity and intermittent physical activity may have health-related benefits. Total sedentary time and moderate to vigorous physical activity (MVPA) have been reported to be negatively correlated with waist circumference (standardized β, -0.16; 95% confidence interval [CI], -0. 31 to -0.02, P = 0.026), body mass index (β, -0.19; 95% CI, -0.35 to -0.02, P = 0.026), triglyceride levels (β, - 0.18, 95% CI, -0.34 to -0.02, P = 0.029) and the 2-hour postprandial index plasma glucose level (β, -0.18, 95% CI, - 0.34 to -0.02, P = 0.025) decreased with increasing number of breaks in sedentary time from [13]. In addition, systolic and diastolic blood pressure values ​​decreased by 2 to 3 mm Hg when sedentary time was interrupted with light- or moderate-intensity physical activity, while sedentary time was interrupted with light physical activity (LIPA) or simple muscle training. in patients with diabetes (88% of the population had hypertension) decreased systolic pressure between 14 and 16 mm Hg and diastolic pressure between 8 and 10 mm Hg [14].

2. Physiological characteristics

The exact mechanisms of the various adverse effects of a sedentary lifestyle on the human body are currently unknown. However, several hypotheses have been proposed for the general understanding of the effects of sedentary behavior on the human body, which are described below.

A sedentary lifestyle is associated with metabolic disorders such as elevated plasma triglycerides and high-density lipoprotein (HDL) cholesterol, and reduced insulin sensitivity.15,sixteen]. Lipoprotein lipase (LPL) is a protein that interacts at the cellular level, and low concentration of LPL is known to reduce plasma HDL cholesterol levels while affecting the prevalence of severe hypertension, diabetes-induced dyslipidemia, metabolic disorders related to age and metabolic diseases. disorders - Syndrome and diseases of the coronary arteries. Additionally, physical inactivity decreases LPL activity. Furthermore, physical inactivity inhibits LPL activity in skeletal muscle and rapidly signals impaired lipid metabolism. In an experiment based on a mouse model, the reduction in LPL activity in light-walking mice was only about 10% of the LPL activity in newly caged mice [17]. The fact that LPL muscle activity is highly sensitive to physical inactivity and low-intensity contractile muscle activity may serve as evidence to support the theory that sedentary behavior is a risk factor for various metabolic disorders.18].

Physical inactivity reduces bone mineral density [19]. In a study of healthy adult men and women, 12 weeks of bed rest reduced mineral density of the lumbar spine, femoral neck, and greater trochanter by 1-4% [19]. The balance between bone resorption and bone deposition mediates the relationship between sedentary behavior and reduced bone mineral density. According to some studies, bed rest increases bone resorption markers and does not affect bone formation markers.20-22].

Some studies have provided limited evidence that sedentary behavior has a negative impact on vascular health. A study in healthy women reported that 56 days of bed rest reduced endothelium-dependent vasodilation, increasing damage to endothelial cells. Such changes in vascular function were prevented by aerobic exercise and muscle training.23].

1. Lack of exercise, mortality and morbidity (cardiovascular disease and other causes)

A sedentary lifestyle is strongly associated with cardiovascular disease, DM, cancer, and premature mortality. Total daily sedentary time and television viewing time were correlated with increased risk of all-cause mortality.24]. In a study that looked at mortality rates in people with more than 10 hours and less than 5 hours of sitting time per day, sitting time was significantly correlated with all-cause mortality (odds ratio [OR], 1.16 95% CI, 1.04-1.29, p<0.05) [25]. In a study examining the association between television viewing and all-cause mortality, individuals who watched television ≥ 6 hours per day had a two-fold increased risk of all-cause mortality compared with those who watched television for ≥ 6 hours per day. they watched less television. (hazard ratio [HR], 1.98; 95% CI, 1.25–3.15) [26] While those who watched television ≥4 hours per day had a 1.5-fold increased risk of all-cause mortality compared with those who watched television <2 hours per day (HR, 1.48; 95% CI, 1. 19–1.83) [27].

Sedentary time (sedentary time, television or screen time, leisure time sitting during the day) is independent of all-cause mortality, CVD incidence or mortality, incidence or mortality of certain cancers (breast, colon, colon, endometrial and epithelial). ovarian cancer) associated cancer) and type 2 DM. In particular, the adverse effect of sedentary time was more pronounced in those who were inactive than in those who were physically active. The relative risk (RR) of all-cause mortality was 30% higher with high physical activity (HR 1.16; 95% CI 0.84-1.59) than with low physical activity (HR 1.46; 95% CI 0.84-1.59). 95% 1.22-1.75) [28].

2. Lack of exercise and metabolic diseases

3. Lack of exercise and cancer risk

Sedentary behavior is also closely related to the prevalence of cancer. According to a study that examined the association between sedentary behavior and cancer prevalence, the group with the most sedentary time was 13% more likely to develop cancer than the group with the least sedentary time.28], and another study reported that sedentary time increases overall cancer risk by 20% [36].

Prolonged sitting increases the risk of colorectal, endometrial, ovarian, and prostate cancers and has been reported to increase cancer mortality, especially in women.37]. There was a significant correlation between cancer mortality and the incidence of epithelial cancer of the breast, colon, endometrium, and ovary.28]. Increased total sitting time was positively correlated with colon cancer (RR, 1.24; 95% CI, 1.03-1.50) and endometrial cancer (RR, 1.32; 95% CI , 1.08 -1.61) [36]. In addition, TV viewing time was also positively correlated with colon cancer (RR, 1.54; 95% CI, 1.19-1.98) and endometrial cancer (RR, 1.66; 95% CI, 1.21-2.28) [36]. Sedentary occupational time was positively correlated only with colorectal cancer (RR, 1.24; 95% CI, 1.09-1.41) [36].

Sedentary behavior leads to metabolic dysfunctions such as hyperglycemia, hyperinsulinemia, insulin resistance, impaired insulin-like growth factor axis, and changes in circulating levels of sex hormones. Altered blood levels of sex hormones may be associated with hormone-related cancers, such as breast and endometrial cancer.38]. In addition, sedentary behavior induces chronic low-grade systemic inflammation, and sedentary time is associated with inflammation-related markers, such as C-reactive protein (β, 0.18 ± 0.06; P = 0.002), interleukin 6 (β, 0.24 ± 0.06; P < 0.001), leptin (β, 0.15 ± 0.04; P < 0.001) and the leptin:adiponectin ratio (β, 0.21 ± 0.05; P < 0.001)39]. Chronic inflammation can trigger cancer growth [40]. Obesity may also mediate the relationship between physical inactivity and cancer, and obesity is a risk factor for several types of cancer.8].

4. Sedentary lifestyle and osteoporosis

Sedentary lifestyle is known to have a negative association with bone mineral density of the entire femur and all subregions of the hip, regardless of AFMV, and bone mineral density (g/cm2) of the entire femur had a significant negative correlation. with sedentary time (β, -0.16; 95% CI, -0.24 to -0.08) in adult women [41]. Bone mineral density was correlated with duration rather than frequency of sedentary behavior. In men, sedentary behavior was not significantly correlated with hip and spine bone mineral density.41].

5. Sedentary lifestyle and musculoskeletal disorders

Prolonged sedentary time was correlated with chronic knee pain. In an analysis of the correlation between chronic knee pain and total daily sedentary time (<5, 5–7, 8–10, >10 hours), the results indicated that the incidence of chronic knee pain was higher in those with prolonged sedentary time (P for trend = 0.02) [42]. Notably, sedentary time >10 hours per day was significantly correlated with chronic knee pain (adjusted OR, 1.28; 95% CI, 1.02-1.61; p = 0.03) [42]. People who exercised more had less chronic knee pain (adjusted OR, 0.78; 95% CI, 0.67-0.91; P=0.00), but women with more than 10 hours of exercise time sedentary while practicing, those who were more physically active were more likely to have chronic knee pain (adjusted OR, 1.19; 95% CI, 1.02-1.39; p=0.03). The study recommends that people reduce their sedentary times to less than 10 hours a day [42].

6. Lack of exercise and other diseases

1. Different effects on health of a sedentary lifestyle and physical activity

Previous studies have observed that prolonged sedentary lifestyles, regardless of physical activity, lead to poor health outcomes. A sedentary lifestyle was independently correlated with mortality and was not offset by physical activity.10]. Time spent in front of a screen was positively correlated with the presence of metabolic syndrome, regardless of physical activity level (OR, 3.30; 95% CI, 2.04-5.34) [50].

2. The mitigating effect of physical activity on a sedentary lifestyle

Some recent studies have reported that increased physical activity can offset the adverse effects of sedentary behavior. In particular, the compensation effect was more pronounced in individuals with low levels of physical activity.

A meta-analysis reported that mortality was not increased in people with high levels of moderate-intensity physical activity (60-75 minutes of moderate-intensity physical activity per day), even when they spent more than 8 hours per day sedentary. There was no difference in mortality between more active individuals (>35.5 MET-h/week) with <4 hours of sedentary time per day and equally active individuals (>35.5 MET-h/week) with >8 hours of sedentary time per day (HR, 1.04; 95% CI, 0.99-1.10). However, television viewing for > 3 hours per day increased mortality independent of physical activity, and those who watched television ≥ 5 hours per day had significantly higher mortality (HR, 1.16; 95% CI, 1.05 -1.28) [51].

In one study, sitting time showed a dose-response relationship with all-cause mortality and CVD mortality risk in the least active group (<150 MVPA min/week) [51]. In contrast, the group with at least 8 hours of sedentary lifestyle per day had higher mortality than the group with less than 4 hours of sedentary lifestyle per day (HR 1.52; 95% CI 1.13-2.03). However, the group that met the core criterion of MVPA (150-299 MVPA min/week) or that did more physical activity did not show a consistent trend in the relationship between increased sitting time and cardiovascular disease and mortality from all causes.

Likewise, one study showed that sedentary time greater than 9 hours per day in the low physical activity group (<600 METs-min/week) was significantly associated with increased CVD risk (OR, 1.29; 95% CI). , 1.04–1.62). ). In the more physically active group, sedentary time was not significantly associated with CVD risk.52].

In other words, while prolonged sedentary time increases mortality in people with low levels of physical activity, adequate physical activity appears to offset the effects of prolonged sedentary time on mortality.53].

One study examined the correlation between all-cause mortality and metabolic equivalent hours (USMh = MET/h [session time] - MET/h [MVPA time]) in sitting decompensated metabolic behavior, calculated by subtracting METs for MET MVPA for physical activity. inactivity has been behaving all day. hUSM was independently associated with all-cause mortality when it was greater than 7 MET/h and with television viewing when it was greater than 3 MET/h. The mean increase in hUSM mortality was 1% (RR, 1.01; 95% CI, 1.00-1.02; P = 0.01) and the mean increase in hUSM mortality for the television was 7% (RR, 1.07; 95% CI). , 1.04–1.10; p<0.001). In other words, both physical activity and sedentary time should be assessed and, therefore, the hUSM has proven to be a more practical index for assessing sedentary behavior.54].

In those with less daily activity (≤17 min/d MVPA), replacing 30 minutes of daily sitting time with light physical activity reduced the risk of mortality by 14% (HR, 0.86; 95% CI, 0.81 -0.89), and MVPA replacement reduced the risk of mortality by 45% (HR: 0.55; 95% CI: 0.47-0.62). However, in those with higher daily activity (MVPA > 38 min/d), replacing sedentary time with LIPA or MVPA was not associated with a reduced risk of mortality.55].

Replacing a sedentary lifestyle with physical activity also has an impact on cancer-related mortality. A recently published study showed that sedentary behavior was independently associated with cancer mortality risk, with longer periods of sedentary activity leading to increased cancer mortality risk. In this study, those in the upper third of the sedentary group had a significantly higher risk of cancer mortality than those in the lower third (adjusted HR, 1.52; 95% CI, 1.01-2.27) [56]. However, replacing 30 minutes of sedentary time with LIPA reduced cancer mortality by 8% (HR, 0.92; 95% CI, 0.86-0.97), and replacing it with AFMV reduced it by 31%. (HR, 0.69; 95% CI, 0.48). -0.97) [56].

1. Recommendations in the United States

Although the 2018 Advisory Committee found that sedentary behavior was highly correlated with cardiovascular and all-cause mortality in adults, the evidence was insufficient to provide advice on recommended daily sedentary time and duration of physical activity. It was not possible to determine the recommended daily sedentary time and frequency of physical activity for adults or adolescents because the risks associated with sedentary behavior are related to the amount of MVPA.

Inactive individuals who do not engage in Moderate Physical Activity (MPA) are recommended to reduce their sedentary lifestyle and replace their sedentary lifestyle with LIPA. However, LIPA by itself is not enough to provide health benefits; They will be able to reduce their health risk by gradually increasing their physical activity to MPA or higher. Inactive individuals who do not engage in adequate physical activity and who do not meet the criteria of 150-300 MPA minutes per week may gain health benefits from slightly increasing their MPA and even greater health benefits from reducing their sedentary behavior. Active people who get enough physical activity (150-300 MPA minutes per week) would benefit most from reducing their sedentary behavior. It is recommended that very active individuals who do more than 300 minutes of MPA per week maintain or improve their level of physical activity by participating in a variety of activities.57].

2. Recommendations in Australia

The Australian Government Department of Health has provided age-specific recommendations for physical activity and sedentary behaviour. According to Australia's Physical Activity and Sedentary Behavior Guidelines, people are advised to minimize their sedentary times, including sitting during work, commutes and breaks, and to avoid sitting for prolonged periods both as possible.58]. It is recommended that infants and children under 5 years of age are not restrained in a pram, pushchair or high chair for more than 1 hour at a time. When adopting a sedentary behavior, they are advised to spend time reading books, singing, solving puzzles, and talking with their caregivers, rather than watching TV or DVDs (digital video disc), playing computer games, or other video games [59]. For children ages 5-17, sedentary screen time should be limited to 2 hours a day and they are encouraged to engage in positive social interactions and experiences. People over the age of 65 are advised to be as active as possible every day [60]. The recommended amount of physical activity for adults is 150 to 300 minutes of MPA or 75 to 150 minutes of vigorous physical activity or the equivalent of MVPA per week.

3. Recommendations in Korea

The physical activity guidelines for the Korean population, published by the Department of Health Promotion of the Ministry of Health and Welfare in October 2013, recommend that people limit their sedentary leisure time (for example, computer, smartphone, and television). to 2 hours a day and perform low-level physical activity. It is recommended that children and adolescents develop a generally active lifestyle, including physical education, physical education, walking, and bicycling at home and at school. When older adults and people with chronic conditions cannot perform the recommended physical activities, these groups are recommended to perform physical activity within their situation.61].

CONFLICT OF INTERESTS

No potential conflicts of interest relevant to this article were reported.

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