International Journal of

Environmental Research
and Public Health

Article
Breaking up Sedentary Time in Overweight/Obese
Adults on Work Days and Non-Work Days: Results
from a Feasibility Study
Nathan P. De Jong 1 , Isaac Debache 2,3 , Zhaoxing Pan 4 , Mael Garnotel 5,6 , Kate Lyden 7 ,
Cédric Sueur 2,3 , Chantal Simon 6,7 , Daniel H. Bessesen 1,8,† and Audrey Bergouignan 1,2,3, *,†
1 Division of Endocrinology, Metabolism, and Diabetes and Anschutz Health and Wellness Center,
University of Colorado, School of Medicine, Aurora, CO 80045, USA;
[email protected] (N.P.D.J.); [email protected] (D.H.B.)
2 Institut Pluridisciplinaire Hubert Curien, Université de Strasbourg, CNRS 67000 Strasbourg, France;
[email protected] (I.D.); [email protected] (C.S.)
3 UMR 7178 Centre National de la Recherche scientifique (CNRS), 67000 Strasbourg, France
4 Department of Biostatistics and Informatics, Anschutz Medical Campus, University of Colorado,
Aurora, CO 80045, USA; [email protected]
5 CARMEN, CRNH, INSERM U1060/University of Lyon 1/INRA U1235 Lyon, France;
[email protected]
6 Laboratoire de Biochimie CHLS 69310 Pierre Bénite, France; [email protected]
7 KAL Research and Consulting LLC, Denver, CO 80002, USA; [email protected]
8 Denver Health Medical Center, Denver, CO 80204, USA
* Correspondence: [email protected]; Tel.: +33-388-1069-14
† These authors contributed equally to this work.




Received: 31 August 2018; Accepted: 14 November 2018; Published: 16 November 2018


Abstract: Office workers are vulnerable to the adverse health effects of sedentary behavior (i.e., sitting
time). Increasing physical activity and preventing time spent sitting is an occupational health
priority. This randomized crossover design study compared the short-term (3-days) effects of hourly
interruptions of sedentary time with 5-min micrrobouts of activity for 9 hours (MICRO) to a sedentary
control condition (SED) and a duration-matched continuous single bout of physical activity (45-min/d,
ONE) condition on inclinometer-derived sitting-time on work and non-work days in sedentary
overweight/obese adults. Differences in sitting/lying, standing, stepping, number of sit/stand
transitions, time spent in moderate and vigorous activity (MVPA), energy expenditure, self-perceived
vigor and fatigue, and insulin sensitivity were also examined. Twenty-two participants (10M/12F;
31.7 ± 1.3 year old BMI 30.4 ± 0.5 kg/m2 ) completed all conditions. No between-condition effects
were observed in sitting-time and sit/stand transitions. Both interventions increased daily steps,
MVPA and energy expenditure with increases being greater in ONE than MICRO. Feelings of
vigor and fasting insulin sensitivity were also improved. Participants reported less fatigue with
MICRO than SED and ONE. Both interventions increase physical activity and energy expenditure in
occupational and leisure-time contexts. The sustainability of these effects over the long term and on
health outcomes will need to be tested in future studies.

Keywords: sedentary behaviors; sitting; microbouts; physical activity; MVPA; activity energy expenditure;
vigor; fatigue; insulin sensitivity

NCT# NCT02258438

Int. J. Environ. Res. Public Health 2018, 15, 2566; doi:10.3390/ijerph15112566 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2018, 15, 2566 2 of 15

1. Introduction
Sedentary behavior, i.e., sitting time, has been associated with adverse health outcomes including
body mass index, cardio-metabolic outcomes, mental health and premature mortality [1–9] and has
emerged as an important public health concern [10]. In addition to total daily sitting time, prolonged
unbroken sitting time has been negatively associated with cardiometabolic health biomarkers [11,12].
Over the past few decades, advances in technology and computer-based tasks have increased
time spent sitting at the workplace [13]. It has been found that office-based employees spend 66%
of their total work time sitting with 25% of total sitting time in bouts longer than 55 min [14]. These
changes in the workplace have been associated with reduced daily occupational energy expenditure.
Since the 1960s, in the USA and the UK, population levels of occupational physical activity have
declined by more than 30% [15]. Facing this developing public health challenge, the World Health
Organization has recently published new guidelines for employers to promote healthier occupational
environments [16]. Among the four major components of the guidelines, limiting prolonged sitting
and increasing physical activity is one of them. While guidelines exist, they still need to be translated
into practical strategies that can be implemented on a large scale. In this context, there has been
increasing interest in understanding the efficacy of a broad range of interventions targeting sedentary
behavior in the workplace.
A growing number of studies have examined environmental changes in the occupational setting
to reduce sitting time such as active workstations and include sit-to-stand desks, treadmill desks and
seated active workstations utilizing portable pedal machines [17–19]. These interventions have shown
mixed results. While individual sit-to-stand desk interventions have not been shown to decrease
sedentary time [20], interventions with multi-level components targeting the individual but also the
social and built environment showed that stand-up desk options reduce sitting and increase standing
time [21]. However, no effect on stepping time was observed. A personalized consultation with weekly
emails that aimed to reduce prolonged sitting time did not decrease total daily sedentary time but
reduced the occurrence of sedentary bouts of more than 30 min [22,23]. Another study using hourly
computer screen prompts and text messages to break up sitting decreased total time spent sitting and
increased the number of daily steps, but failed at increasing the number of sit-to-stand transitions [10].
Another goal of these interventions is to increase energy expenditure. The implementation of treadmill
desks and seated active workstations can reduce daily sitting time, increase time spent in physical
activity [24,25] and almost triple the energy expenditure of that measured while sitting. For example,
walking at 1.8 km/h can induce an expenditure above 0.41 MJ/h, which could beneficially impact
energy balance if sustained for several hours per day [26,27]. However, long-term adherence to these
interventions (12 months) are poor [24,25], treadmill desks are costly and present a safety hazard.
Therefore, a cost effective, easy to implement intervention that can reduce total time spent sitting,
prevent prolonged sitting bouts as well as increase time spent active and energy expenditure is still
needed. Implementing frequent short bursts of walking could fulfill these requirements.
Such interventions have already been tested in the laboratory setting. Past studies showed beneficial
effects of frequent interruptions of sitting time with short bouts of activity varying in mode, frequency,
duration and intensity on metabolic, cognitive and hemodynamic outcomes [28–40]. Regardless of
adiposity, sex and age frequent interruptions of sedentary actives with walking breaks have been
associated with attenuated postprandial plasma glucose and insulin concentrations in obese and type
2 diabetic adults [31–40]. We have shown that interrupting sedentary behavior with short bursts of
treadmill walking increases self-perceived feelings of energy, vigor and mood and decreases feelings
of fatigue throughout the day in normal weight adults [30]. The effect of such an intervention on the
profile of physical activity and energy expenditure in free-living conditions is unknown.
While the workplace has been identified as a priority setting for addressing sedentary behaviors,
it may be important to target sedentary behaviors in other contexts such as on non-working days.
Non-working days also comprise a large portion of a working adult’s week and have also been
associated with a large amount of time attributed to sedentary activities [41]. Because workers who
Int. J. Environ. Res. Public Health 2018, 15, 2566 3 of 15

spend more time in sedentary pursuits during work hours do not compensate by being more active in
non-working periods [20], there is a need to test interventions that aim at reducing time spent sedentary
both during work days and non-work days outside of the controlled laboratory environment.
Based on the data generated by the past intervention studies conducted in the laboratory setting
and the real-world, we hypothesized that an intervention aimed at breaking up sedentary time with
short bouts of activity could attenuate time spent sitting, increase daily physical activity and energy
expenditure, and positively impact metabolic health and well-being in office workers. The purpose
of this study was to test the feasibility to implement such an intervention over a short period of
time (3-days) in the daily life of overweight sedentary male and female adults during work days
and non-work days. To test whether the effects on time spent sitting, time spent physically active
and energy expenditure were due to the frequent interruptions of sedentary time with short bouts
of activity or to the total time spent active, we used a three arm cross-over randomized design.
Frequent interruptions of sedentary time with short bouts of physical activity were compared to
a duration-matched single continuous bout of physical activity, and a sedentary control condition.
Further, we compared the effect of the interventions on self-perceived vigor and fatigue and an index
of insulin sensitivity. Finally, we assessed how difficult it was for participants to implement these
interventions in their daily life on work days and non-work days.

2. Methods

2.1. Participants
This study was approved by the Colorado Multiple Institutional Review Board (COMIRB) and
was in accordance with the Declaration of Helsinki (COMIRB# 14-0429). Eligible participants were
between 19–45 years old with an occupation that requires sitting time, had a body mass index (BMI)
between 27–33 kg/m2 , were weight stable for at least 3 months, insulin sensitive (fasting plasma insulin
concentration below 25 µIU/mL), and self-reporting > 6 h/day of occupational sitting. All women
enrolled in the study were pre-menopausal and could use birth control medications. Exclusion
criteria included clinically diagnosed diabetes, taking glucose- and/or lipid-lowering medications,
dyslipidemia, smoking, or meeting the American College of Sports Medicine (ACSM) physical activity
recommendations (>150 min/week MVPA). Participants were recruited between October 2014 and
October 2016 from newspaper advertisements, public announcements, and flyers in the Denver and
Aurora areas in Colorado, USA. Participants were randomized to one of three possible trial-condition
orders using balanced blocks separately prepared for male and female participants. The study
statistician (Z.P.) prepared the computer-generated randomization lists and sealed envelopes for
randomization [42].

2.2. Study Design

Eligible volunteers completed three separate 3-day trial phases under free-living conditions.
The study phases were separated by a 28-day wash out period and women were all studied in the
follicular phase of their menstrual cycle. All the study related visits were conducted at the Clinical
and Translational Research Center of University of Colorado (CTRC). The three trial conditions were
administered in random order:
Sedentary (SED): Free-living subjects maintained their usual levels of daily activity during the
three days of measurement and were asked to refrain from structured exercise.
Sedentary + 1 continuous bout of activity (ONE): During the 3-days of measurement, subjects
were asked to perform 45-min of moderate-intensity walking once per day and maintain their usual
sedentary lifestyle the rest of the day.
Sedentary + microbouts of activity (MICRO): During the 3-days of measurement, participants were
asked to perform a 5-min bout of moderate-intensity walking bout each hour for 9 consecutive hours
throughout the day and maintain their usual sedentary lifestyle the rest of the time.
Int. J. Environ. Res. Public Health 2018, 15, 2566 4 of 15

For both interventions, the intensity of the activity was defined during the screening visit. On each
day of measurement, participants were asked to complete a diary log and record the time the participant
went to sleep and woke up from sleep, the time the bouts of physical activity were performed and if it
was a work day or not.

2.3. Screening Visit

Subjects were screened, consented and underwent a review of medical history and physical
examination and a blood draw to verify fasting plasma insulin concentrations for eligibility. Resting
Metabolic Rate (RMR) was measured by indirect calorimetry for 30 min in the fasted state, under
resting conditions and at thermoneutrality. Body composition including fat-free mass (FFM) and fat
mass (FM) was measured by dual energy X-ray absorptiometry (DXA, Hologic Delphi-W, Bedford, MA,
USA). The short version of the International Physical Activity Questionnaire (IPAQ) was completed to
assess habitual physical activity and time spent sitting [43]. Subjects then performed an incremental
exercise test on a treadmill (increments of 0.3 miles/h every 2-min) to determine a walking pace that
was then prescribed for ONE and MICRO conditions. For each exercise level, subjects rated their
perceived effort on a Borg scale from 0 (very light) to 20 (maximal exertion). The aim was to identify
the walking speed that subjects associated with a perceived exertion level of 13 (somewhat hard).
Subjects were instructed to walk at this pace for each bout of activity during the intervention.

2.4. Measurement of Time Spent Sitting/Lying, Standing, Stepping and Daily Steps
Time spent sitting/lying, standing, stepping and daily steps were quantified using an ActivPAL™
triaxial accelerometer/inclinometer (PAL Technologies Ltd., Glasgow, Scotland) during the three days
of measurement in each condition. Participants were instructed to wear the monitor at all times.
The device was worn midline on the anterior aspect of the thigh and wrapped with a nitrile sleeve,
allowing for 24 h measurement. The monitor produces a signal related to thigh inclination and is a
valid and reliable measurement tool for determining posture and motion during activities of daily
living [44]. When the monitor is oriented horizontally, it classifies the activity as sitting/lying. Vertical
positioning of the monitor is classified as standing. Step cadence and number of steps were recorded
by the monitor when a participant was walking.
The ActivPAL™ has been validated for use in adults to distinguish between sitting/lying,
standing, and stepping activities [44–47]. Data event files from the ActivPAL™ were used to quantify
sitting/lying, standing, and stepping time. In these files, the ActivPAL™ records each time an activity
changes and the time that the activity changed. Sitting/lying, standing, and stepping time were
calculated by summing the duration of each event and the number of breaks from sitting time were
quantified as a transition from sitting/lying to either standing or stepping. Sitting bouts lasting
longer than 30-min and 60-min were also used to test the effect of the conditions on the sitting bout
length. A customized R program (www.r-project.org) was used to convert the event data file to
a second-by-second data file to estimate additional metrics of sedentary behaviors and time spent
sitting/lying, standing, stepping. The following metrics of sedentary behaviors were computed over
24 h: total sedentary time (total time spent in sitting/lying events), total breaks in sedentary time
(number of times a sitting/lying event was followed by a standing or stepping event), and time
(minutes/day) in sedentary bouts ≥30 and ≥60-min. The same outcomes were also reported as
percentage of waking time. Because sleep time was removed, we assumed that sitting/lying time
mainly corresponded to sitting time during waking hours. The R package (PAactivPAL) is available
for researchers to generate these metrics [48].

2.5. Measurement of Physical Activity Intensity, Activity Energy Expenditure and Physical Activity Level
Activity energy expenditure (AEE) and time spent in different activity intensities were determined
using the ActiGraph GT3X tri-axial accelerometer (ActiGraph, Pensacola, FL, USA). Participants were
instructed to wear the accelerometer during wake time by attaching it to their right hip directly
Int. J. Environ. Res. Public Health 2018, 15, 2566 5 of 15

above their right knee using an elastic belt that was provided. A sampling rate of 30-Hz was used.
After each of the 3-day study conditions, data were downloaded using the Actilife 6.13 software
provided by the manufacturer and AEE per minute (J/kg/min) was estimated using the ‘Freedson
vector magnitude combination model’ [49,50]. Total energy expenditure (MJ/d) was calculated as
(AEE + RMR)/0.9, where RMR was resting metabolic rate (MJ/d). Physical activity level (PAL)
was calculated as the ratio between TEE over measured RMR. Cut-points of <1.5 and <3 METs and
>3METs (metabolic equivalents) were used for very light intensity activity, light intensity activity and
moderate-to-very vigorous activity, respectively. Minute-data during waking hours were summed
to obtain data per day. Although sedentary behavior has been defined as activities with an energy
expenditure below 1.5 METs while in a sitting, reclining or lying posture [51], activities with METs <1.5
were referred to as very light intensity activity in our study. By only measuring energy expenditure
without recognition of the concomitant posture, we are including activities such as standing that are
not sedentary activities. By choosing the term “very light intensity activity” we are more conservative
and avoiding any misinterpretation.

2.6. Perception of the Challenges Associated with the Conditions, Self-Perceived Vigor and Fatigue
At the end of each intervention or control day participants filled out online 100 mm visual analog
scales (VAS) designed to capture their perception of the study condition [52]. The VAS addressed
the following question “Please indicate on the scale how challenging you found the day.” The anchors for
this question were “Extremely Easy” and “Extremely Challenging.” Immediately after the first survey,
participants then completed an online modified version of the Perception of Mood survey (POMs) to
assess changes in feelings of vigor and fatigue [53]. Only the POMs-Fatigue (POMs-F; n = 7 items)
and the POMs-Vigor (POMs-V; n = 8 items) subscales were used for analysis.

2.7. Plasma Metabolic Outcomes

The morning after each 3-day trial, the participants reported to the CTRC for a fasting blood
collection which was analyzed for glucose and insulin. Whole blood was added to a preservative
(3.6 mg EDTA plus 2.4 mg glutathione in distilled water). Insulin concentrations were measured
using a standard double antibody radioimmunoassay (EMD Millipore, St. Charles, MO, USA). Serum
glucose concentrations were determined using the hexokinase method (Wako Diagnostics, Mountain
View, CA, USA). These analyses were performed on the Beckman Coulter AU480 Chemistry Analyzer
(Brea, CA, USA).

2.8. Statistical Analysis

Based on the diary log information, data were recorded on 43, 47 and 43 work days while in SED,
ONE and MICRO conditions, respectively. Consequently, 23, 19 and 23 study days were non-work
days when participants were in SED, ONE and MICRO conditions, respectively. The analysis of the
working status effect (work day versus non-work day) was a posteriori analysis. This is why the number
of work days and non-work days are unbalanced across the three conditions and the work status.
If there was more than one measure assessed at different days per condition and work status,
the mean value of the repeated measures served as outcome in the model. Linear mixed models
were used to test differences in the two activity monitor outcomes, self-perceived challenge, vigor
and fatigue, with sequence, period, condition (SED, MICRO and ONE), work status (work day vs.
non-work day) and condition-by-work status interaction as fixed effects and subjects as random effect
with a compound symmetry covariance. Contrasts were used, under this model, to test for the between
work status difference under each condition, the between condition differences separately on workdays
and non-work days and the between work status difference with respect to the between condition
difference. No correction for multiple comparisons was applied. Fasting plasma insulin and glucose
concentrations measured on the morning of day 4 were also analyzed using linear mixed model but
work status was not considered. Indeed, within the three days prior to the blood draw, days could have
 Int. J.J. Environ.
Int. Environ. Res.
Res. Public
Public Health
Health 2018,
2018, 15,
15, 2566
x FOR PEER REVIEW 66 of
of 15
15

days could have been randomly spent at work or not, it was therefore impossible to know if the
interaction
been randomlybetween
spent at the condition
work or not, itand
wasthe work impossible
therefore status hadtoany knowinfluence on indexbetween
if the interaction of insulin
the
sensitivity.and
condition Data
theare
workexpressed as mean
status had ± SD, unless
any influence otherwise
on index stated.
of insulin All statistical
sensitivity. Data analyses were
are expressed
as mean ± SD,
performed withunless
SAS 9.4 (SAS Institute,
otherwise stated.Cary, NC, USA).
All statistical analyses were performed with SAS 9.4 (SAS
Institute, Cary, NC, USA).
3. Results
3. Results
3.1. Subjects’ Characteristics and Compliance with the Interventions
3.1. Subjects’ Characteristics and Compliance with the Interventions
Subjects’ characteristics are displayed on Table 1. On average over the 3-days of intervention,
Subjects’ characteristics
participants performed 97.6 ±are displayed
0.0% and 98.4 ±on0.1%Table 1. On
of the averagephysical
prescribed over theactivity
3-days bouts
of intervention,
in MICRO
participants performed 97.6 ± 0.0% and 98.4 ±
and ONE, respectively. High levels of compliance with both interventions was attainedbouts
0.1% of the prescribed physical activity in
despite
MICRO and ONE, respectively. High levels of compliance with both interventions was
reporting that performing the physical activity interventions was more challenging than spending a attained despite
reporting
day beingthat performing
sedentary the physical
(Intervention effect:activity interventions
p = 0.007; was participants
Figure 1). While more challenging than
reported thatspending
MICRO
awas
daychallenging
being sedentary (Intervention effect: p = 0.007; Figure 1). While participants
to perform on work days (p = 0.004 vs. SED), ONE was perceived to be more reported that
MICRO was challenging to perform on work days (p = 0.004 vs. SED), ONE was perceived
challenging to comply with on non-work days compared to both SED (p = 0.05) and MICRO (p = 0.04). to be more
challenging to comply with on non-work days compared to both SED (p = 0.05) and MICRO (p = 0.04).
Table 1. Study participant’s anthropological characteristics and habitual sitting time.
Table 1. Study participant’s anthropological characteristics and habitual sitting time.
Parameters Males Females All
Parameters
n Males 10 Females12 All 22
Age (year)
n 1031.5 ± 7.4 1232.0 ± 6.1 2231.8 ± 6.6
BMI
Age(kg/m
(year)2) 31.5 ± 28.8
7.4± 2.9 32.0 ±31.7
6.1 ± 1.8 31.8 ± 30.5
6.6± 2.7
BMI (kg) 2 )
FM(kg/m ± 2.9
28.824.6 ± 4.3 *** 31.7 ±36.0
1.8 ± 4.7 30.5 ± 2.7± 7.3
30.9
FM (kg)
FFM 24.6 ± 9.9 *** 36.0 ±49.9
4.3±***
63.1 ± 7.3± 10.1
4.7 ± 5.0 30.9 56.0
FFM (kg)
FM (%) 63.1 ± 2.4 *** 49.9 ±41.8
9.9±***
28.1 5.0 ± 2.4 56.0 ±35.6
10.1± 7.4
FM (%)
Self-reported sitting time (h/d) 28.1 ± 2.4 ***
9.0 ± 3.2 41.8 ± 2.4
10.6 ± 1.1 35.6 ± 7.4± 4.1
9.5
Self-reported sitting time (h/d) 9.0 ± 3.2 10.6 ± 1.1 9.5 ± 4.1
Data are presented as mean ± SD. *** p < 0.0001 vs. Female. n, number of subjects; BMI, body mass
Data are presented as mean ± SD. *** p < 0.0001 vs. Female. n, number of subjects; BMI, body mass index;
index; FFM, fat-free mass; FM, fat mass; Self-reported sitting time was estimated from the IPAQ,
FFM, fat-free mass; FM, fat mass; Self-reported sitting time was estimated from the IPAQ, international physical
international
activity physical activity questionnaire.
questionnaire.

Figure 1.1.Visual
Figure Visualanalog scale
analog representing
scale the perception
representing of the challenges
the perception associatedassociated
of the challenges with the conditions.
with the
At
conditions. At the end of each intervention or control day participants filled out online 100 mm scales
the end of each intervention or control day participants filled out online 100 mm visual analog visual
(VAS)
analogdesigned to capture
scales (VAS) theirtoperception
designed of the
capture their study condition.
perception Thecondition.
of the study VAS addressed the addressed
The VAS following
question
the following indicate on
“Pleasequestion the scale
“Please how challenging
indicate on the scaleyou found
how the day.”you
challenging Thefound
anchors
the for this
day.” question
The anchorswere
for
“Extremely Easy”
this question were “Extremely Challenging.”
and “Extremely SED, indicates
Easy” and “Extremely the sedentary
Challenging.” SED,condition;
indicatesONE, indicates
the sedentary
the one-bout
condition; intervention;
ONE, MICRO,
indicates the indicates
one-bout the microbouts
intervention; MICRO, intervention. * p < 0.05, **intervention.
indicates the microbouts p < 0.01 vs.
sedentary control.
* p < 0.05, ** p < 0.01 vs. sedentary control.

3.2. Effect of the Physical Activity Interventions on Time Spent Sitting/Lying, Standing and Stepping
Time spent sitting/lying, standing and stepping over 24 h is reported in Table 2. One ActivPAL™
was lost and two were defective, we are therefore reporting data obtained in 19 subjects. Both MICRO
Int. J. Environ. Res. Public Health 2018, 15, 2566 7 of 15

3.2. Effect of the Physical Activity Interventions on Time Spent Sitting/Lying, Standing and Stepping
Time spent sitting/lying, standing and stepping over 24 h is reported in Table 2. One ActivPAL™
was lost and two were defective, we are therefore reporting data obtained in 19 subjects. Both MICRO
(11. 4 ± 4.7 vs. 9.2 ± 3.4%, p = 0.009) and ONE (13.9 ± 3.5% vs. 9.2 ± 3.4%, p < 0.0001) increased
the percentage of waking time spent stepping compared to SED on work days but not on non-work
days. This resulted in 0.4 ± 0.1 h more spent stepping in ONE than in MICRO (p = 0.01). As a result,
the number of daily steps increased from 7125 ± 2554 to 12,257 ± 3145 in ONE (p < 0.0001) and
10,036 ± 4262 in MICRO (p = 0.0002) on work days; participants took more steps when performing
ONE than MICRO (p = 0.005). Both ONE (+2967 ± 456, p = 0.005) and MICRO (+2841 ± 552, p = 0.02)
led to a greater number of daily steps compared to SED on non-working days. However, time spent
sitting and standing, the average duration of the sedentary bouts and the number of transitions from
the sitting to standing position (index of breaking up prolonged sitting) were not significantly different
across conditions and days (p > 0.05 for all). Surprisingly, the sitting bouts of more than 30 min
tended to occur more often in MICRO than in both SED (p = 0.057) and ONE (p = 0.051) when in
leisure contexts.

Table 2. Time spent sitting/lying, standing and stepping over 24hr and as percent of wake time.

Physical Activity
SED ONE MICRO
Outcomes
Non-work day Work Non-work day Work Non-work day Work
Sitting/lying (h/d) 9.8 ± 2.0 10.6 ± 2.3 9.6 ± 1.9 10.2 ± 2.4 9.6 ± 2.5 10.5 ± 2.2
Standing (h/d) 3.5 ± 1.8 3.4 ± 1.8 3.0 ± 1.8 3.4 ± 1.5 3.6 ± 2.1 3.2 ± 1.9
Stepping (h/d) 1.4 ± 0.5 1.4 ± 0.5 1.7 ± 0.4 2.1 ± 0.5 *** 1.7 ± 0.4 1.7 ± 0.7 **δ
Sitting (% waking time) 66.6 ± 14.2 68.4 ± 13.5 67.2 ± 12.7 64.5 ± 10.4 64.0 ± 15.3 67.8 ± 14.1
Standing (% waking time) 23.9 ± 12.3 22.3 ± 11.6 20.7 ± 11.9 21.4 ±8.8 24.0 ± 14.5 20.7 ± 12.6
Stepping (% waking time) 9.4 ± 3.6 9.2 ±3.4 11.9 ± 2.4 13.9 ± 3.5 *** 11.9 ± 2.9 11.4 ± 4.7 **δ
Sit-to-stand transitions (#) 48.8 ± 15.1 47.2 ± 17.7 42.5 ± 13.6 50.1 ± 22.3 46.1 ± 12.4 50.7 ± 21.3
Sitting bouts > 30-min (#) 5.6 ± 1.7 6.2 ± 2.2 5.5 ± 1.7 6.1 ± 1.7 6.7 ± 2.7 *δ 7.4 ± 2.7
Sitting bouts > 60-min (#) 3.1 ± 1.4 3.1 ± 1.5 2.6 ± 1.1 3.1 ± 1.6 2.3 ± 1.6 2.8 ± 2.0
Step count (#) 6409 ± 2843 7125 ± 2554 9376 ± 2387 ** 12,257 ± 3149 *** 9250 ± 2291 * 10,036 ± 4262 **δδ
Data are presented as the mean ± SD. * p < 0.05, ** p < 0.01, *** p < 0.0001 compared to SED control within the same
location. δ p < 0.05, δδ p < 0.01 different from ONE within same location. Sitting/lying (h/d), number of hours per
day spent siting; Standing (h/d), number of hours per day spent standing; Stepping (h/d), number of hours per day
spent standing; Sitting (% waking time), percent of waking hours spent sitting; Standing (% waking time), percent
of waking hours spent sitting; Stepping (% waking time), percent of waking hours spent stepping; Sitting bouts
>30-min, number of sitting bouts lasting at least 30 min; Sitting bouts >60-min, number of sitting bouts lasting at
least 60 min; Sit-to-stand transitions, number of times a participant rose from a seated position; Step Count (#), is
the number of steps taken per day.

3.3. Effect of the Physical Activity Interventions on Time Spent in Very-Light, Light, Moderate and Vigorous
Intensity Physical Activity
Time spent in very-light, light, MVPA during waking hours is shown in Figure 2. One ActiGraph
GT3X was lost; data are reported for 21 subjects.
On work days, waking time spent in very light intensity activities tended to be lower in ONE
compared to SED (12.5 ± 1.3 vs. 13.5 ± 1.1 h/d, p = 0.055), but not different between MICRO and SED
or ONE. Light intensity activities were not different across conditions (p > 0.05 for all). On non-work
days, MICRO significantly reduced time spent in light intensity activities compared to SED (1.5 ± 0.5
vs. 1.9 ± 0.8 h/d, p = 0.040), but was associated with more time spent in very light intensity activities
than ONE (13.7 ± 0.5 vs. 11.5 ± 0.5 h/d, p = 0.002). Both MICRO (work day: +23.4 ± 6.6 min, non-work
day: +21.6 ± 8.4 min) and ONE (work day: +40.2 ± 6.6, non-work day: +36.0 ± 9.0 min) significantly
increased time spent in MVPA compared to SED on both non-work and work days (p < 0.01 for all).
On work days, MVPA was even greater in ONE than in MICRO (p = 0.02).
 number of steps taken per day.

3.3. Effect of the Physical Activity Interventions on Time Spent in Very-Light, Light, Moderate and Vigorous
Intensity Physical Activity
Time spent
Int. J. Environ. in very-light,
Res. Public light,
Health 2018, 15, 2566MVPA during waking hours is shown in Figure 2. One ActiGraph
8 of 15
GT3X was lost; data are reported for 21 subjects.

Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 8 of 15

intensity physical activity; MVPA, moderate-to-very vigorous intensity physical activity; SED,
sedentary condition; ONE, one-bout intervention; MICRO, microbouts intervention. * p < 0.05, ** p <
0.01, *** p < 0.0001 vs. sedentary control condition.

On work days, waking time spent in very light intensity activities tended to be lower in ONE
compared to SED (12.5 ± 1.3 vs. 13.5 ± 1.1 h/d, p = 0.055), but not different between MICRO and SED
or ONE. Light intensity activities were not different across conditions (p > 0.05 for all). On non-work
days, MICRO significantly reduced time spent in light intensity activities compared to SED (1.5 ± 0.5
Figure 2. Waking time per day performing very light, light and moderate-to-vigorous intensity physical
vs. 1.9 ± 0.8 h/d, p = 0.040), but
Figure Accelerometry
2. Waking timedata
was associated with
percollected
day performing
more time
very light, light
spent in very light intensity
and accelerometer
moderate-to-vigorous
activities
intensity
activity. from ActiGraph GT3X tri-axial are displayed by
than ONE (13.7
physical(work± 0.5
activity.vs. 11.5 ± 0.5
Accelerometryh/d, p = 0.002). Both MICRO (work day: +23.4 ± 6.6 min, non-work
location or non-work day) anddata collected
by physical from intensity.
activity ActiGraph GT3Xvery
V. light, tri-axial accelerometer
light intensity are
physical
day: +21.6 ± 8.4by
displayed min) and (work
location ONE or(work day: +40.2
non-work day) ± 6.6,
and by non-work
physical day: intensity.
activity +36.0 ± 9.0V. min) very
light, significantly
light
activity; MVPA, moderate-to-very vigorous intensity physical activity; SED, sedentary condition; ONE,
increased time spent in MVPA compared to SED on both non-work and work days (p < 0.01 for all).
one-bout intervention; MICRO, microbouts intervention. * p < 0.05, ** p < 0.01, *** p < 0.0001 vs.
On work days, MVPA was even greater in ONE than in MICRO (p = 0.02).
sedentary control condition.

3.4. Effect of the Physical Activity Interventions on 24 h Activity Energy Expenditure

Expenditure and
and Physical
Physical Activity
Activity
Level Level
Changes in MVPA induced by the physical activity interventions translated into parallel changes
Both MICRO
in AEE (Figure 3). Both MICRO and
and ONE
ONE significantly
significantly increased AEE compared to SED on both work
and non-work days (p < 0.05 for all). Physical
Physical activity
activity level
level (PAL)
(PAL) was significantly lower in SED
non-work days
compared to ONE on non-work days (SED: 1.46 ±±0.04,
(SED: 1.46 0.04,ONE: 1.62± ±
ONE:1.62 p =p 0.004)
0.04,
0.04, = 0.004)
andand compared
compared to
to both
both ONE ONE andand MICRO
MICRO on work
on work days
days (SED:
(SED: 1.431.43 ± 0.03,
± 0.03, ONE:ONE:
1.65 ±1.65 ±p0.03,
0.03, p < MICRO:
< 0.001, 0.001, MICRO:
1.55 ±
0.03,±
1.55 p =0.03, p = PAL
0.003). 0.003).
wasPAL was further
further higher higher
in ONEinthan
ONE inthan
MICROin MICRO
on work ondays
work(pdays (p = 0.008).
= 0.008).

Figure 3.
Figure Activity energy
3. Activity energy expenditure.
expenditure. TheThe activity
activity energy
energy expenditure
expenditure (MJ/d) estimated from
(MJ/d) estimated from
ActiGraph GT3X tri-axial accelerometer is displayed by location (work or non-work
ActiGraph GT3X tri-axial accelerometer is displayed by location (work or non-work day). SED, day). SED,
condition; ONE, one-bout intervention; MICRO, microbouts intervention. * p
sedentary condition; ONE, one-bout intervention; MICRO, microbouts intervention. * p < 0.05, **0.05,
sedentary < p<
** p <***
0.01, 0.01,
p <*** p < 0.0001
0.0001 vs. sedentary
vs. sedentary controlcontrol condition.
condition.
3.5. Effect of the Physical Activity Interventions on Self-Perceived Vigor and Fatigue
3.5. Effect of the Physical Activity Interventions on Self-Perceived Vigor and Fatigue
No significant differences in self-perceived vigor were noted across conditions on non-work days
(p > 0.05 significant
No differences
for all, Figure in self-perceived
4). On working vigor were
days, participants noted aacross
reported conditions
greater on non-work
level of self-perceived
days (p
vigor > 0.05
at the endfor all, day
of the Figure 4). On
in both working
MICRO days,
(386.7 participants
± 27.9, reported
p = 0.01) and a greater
ONE (403.4 level
± 28.1, p =of0.002)
self-
perceived vigor at the end of the day in both MICRO (386.7 ± 27.9, p = 0.01) and ONE (403.4 ± 28.1, p
= 0.002) compared to SED (314.1 ± 28.0). They further reported feeling less fatigue on work days after
a day performing MICRO than after a day performing ONE (−119.7 ± 52.5, p = 0.03). On non-work
days, they tended to feel less fatigue on MICRO compared to both SED (-128.9 ± 65.6, p = 0.054) and
ONE (−124.5 ± 67.3, p = 0.069).
Int. J. Environ. Res. Public Health 2018, 15, 2566 9 of 15

compared to SED (314.1 ± 28.0). They further reported feeling less fatigue on work days after a day
performing MICRO than after a day performing ONE (−119.7 ± 52.5, p = 0.03). On non-work days,
they tended to feel less fatigue on MICRO compared to both SED (-128.9 ± 65.6, p = 0.054) and ONE
Int. J. Environ. Res. Public Health 2018, 15, x FOR PEER REVIEW 9 of 15
(−124.5 ± 67.3, p = 0.069).

Figure 4. Self-perceived fatigue and vigor. At the end of each study day participants rated their
Figure 4. Self-perceived fatigue and vigor. At the end of each study day participants rated their self-
self-perceived feeling of fatigue and vigor (arbitrary unit). SED, sedentary condition; ONE, one-bout
perceived feeling
intervention; MICRO,of fatigue and intervention.
microbouts vigor (arbitrary
* p <unit).
0.05, SED,
** p < sedentary condition;
0.01 vs. sedentary ONE,
control one-bout
condition.
intervention; MICRO, microbouts intervention. * p < 0.05, ** p < 0.01 vs. sedentary control condition.
3.6. Effect of the Physical Activity Interventions on Index of Insulin Sensitivity
3.6. Effect of the Physical Activity Interventions on Index of Insulin Sensitivity
On the morning of day 4, fasting insulin and glucose concentrations were measured (Table 3).
MICRO On and ONE significantly
the morning of day 4, decreased fasting
fasting insulin andinsulin concentration
glucose by 37.3%
concentrations (p = 0.03) and
were measured 43.6%
(Table 3).
(p = 0.02) respectively compared to SED. Fasting glucose concentrations remained unchanged.
MICRO and ONE significantly decreased fasting insulin concentration by 37.3% (p = 0.03) and 43.6% As a
result, insulin:glucose
(p = 0.02) respectivelyratio, an index
compared of insulin
to SED. sensitivity,
Fasting glucose was reduced by remained
concentrations both MICRO (p = 0.03)As
unchanged. anda
ONE
result,(pinsulin:glucose
= 0.02) compared to SED,
ratio, suggesting
an index an sensitivity,
of insulin improvement wasinreduced
insulin sensitivity.
by both MICRONo differences
(p = 0.03)
were observed
and ONE (p =between the two active
0.02) compared conditions.
to SED, suggesting an improvement in insulin sensitivity. No
differences were observed between the two active conditions.
Table 3. Fasting plasma glucose and insulin concentrations.

Table 3. Fasting plasma

Parameters SEDglucose and insulin
ONEconcentrations.
MICRO
FastingParameters
glucose (mg/dL) 90.1 ±
SED7.3 88.4 ±ONE7.7 ± 10.6
88.7MICRO
Fasting
Fasting insulin
glucose(uI/mL)
(mg/dL) 10.8 ± 8.9
90.1 ± 7.3 ± 3.0
6.1 88.4 *
± 7.7 ± 6.1
6.788.7 *
± 10.6
I/G (uI/mL)
Fasting insulin ± 0.101
0.12110.8 ± 8.9 ± 0.341
0.0696.1 ± 3.0 ** ± 0.063
0.0756.7 ± 6.1 **
I/Gas the mean ± SD. * p0.121
Data are presented < 0.05± compared
0.101 to0.069
SED control.
± 0.341I/G,
* insulin/glucose
0.075 ± 0.063ratio.
*
Data are presented as the mean ± SD. * p < 0.05 compared to SED control. I/G, insulin/glucose ratio.
4. Discussion
4. Discussion
In this randomized feasibility study, we showed that sedentary, physically inactive, overweight/obese
In thiswere
individuals randomized feasibility
able to implement study,
physical we showed
activity that consisting
interventions sedentary, physically
either inactive,
of frequent bouts
overweight/obese individuals were able to implement physical activity interventions consisting
either of frequent bouts of activity or one continuous bout, the latter being more commonly
promulgated by public health promotion initiatives and healthcare providers. Overall these two
physical activity interventions had similar effects. Both interventions increased daily steps, MVPA,
AEE and PAL on both working and non-working days compared to the sedentary control. These
Int. J. Environ. Res. Public Health 2018, 15, 2566 10 of 15

of activity or one continuous bout, the latter being more commonly promulgated by public health
promotion initiatives and healthcare providers. Overall these two physical activity interventions had
similar effects. Both interventions increased daily steps, MVPA, AEE and PAL on both working and
non-working days compared to the sedentary control. These increases were more pronounced with a
daily single bout of physical activity as compared to microbouts. The greater physical activity and
energy expenditure were further associated with higher self-perceived feelings of vigor at the end
of the day and improved fasting insulin sensitivity. Microbouts of activity were also associated with
lower feelings of fatigue at the end of the day both on work days and non-work days. Neither of the
interventions decreased time spent sitting or standing, the number of breaks from the sitting position
and the average duration of a sitting bout.
Because office employees are vulnerable to the adverse health effects of prolonged sitting,
an increasing number of interventions have targeted the work environment [54]. Strategies that
promote body movements, such as passive pedaling or treadmill desks have been shown to increase
physical activity and energy expenditure and to some extent reduce time spent sitting [18–20,25–27].
However, they are relatively expensive, can be a safety hazard and may be impractical to implement
on a large scale. Therefore, we proposed that an intervention involving frequent short bouts of brisk
walking could be an inexpensive, safe, easy to implement physical activity promotion intervention.
Contrary to our hypothesis, microbouts of activity spread out across the day did not reduce the number
or duration of sitting bouts and did not increase the number of transitions from the sitting position
to standing or stepping. This may be because asking individuals to break-up prolonged sitting nine
times a day, every hour for nine consecutive hours to perform 5-min of walking is not a sufficient
stimulus. In support of this interpretation, a recent study used hourly computer screen prompts or text
messages to break up sitting. Sitting time was broken up with 7 min of walking to accumulate 30–60
min of walking per day. Additionally, there was an additional 6000 step count goal. This intervention
was 7 days measured in overweight/obese and resulted in a decrease in total sitting time by 1.85 h/d
on average [10]. Despite the frequency of activity being more frequent (every 30–60 min), this study
also failed to show an increase in the number of sedentary breaks (sit-to-stand transitions) [10]. In our
study, the number of sitting bouts longer than 30-min was even greater when participants were asked
to perform microbouts of activity compared to single bouts on non-work days. This suggests that
people tend to stay seated until they have to stand up and be active. Therefore, future studies may
need to test specific interventions that primarily target breaks from sitting in addition to sitting time,
daily steps or bouts of physical activity.
The American College of Sports Medicine, the American Heart Association and the American
Diabetes Association recommend that adults perform at least 150–300 min/wk (21.4–42.8 min/day)
of MVPA to maintain and promote cardiovascular health and insulin sensitivity [55]. Implementing
frequent short bouts of 5-min brisk walking across the day in our study led to a significant
22.5–min/day increase in MVPA on average. In addition, the microbouts intervention produced
an increase in AEE of 0.54 MJ/d (129 kcal/d) on non-working days and 0.78 MJ/d (187 kcal/d)
on work days. It has been proposed that a very small energy gap—the difference between energy
intake and energy expenditure—plays a role in weight gain [56]. A difference of 100 kcal/day at
the population level could theoretically prevent weight gain in 90% of the U.S. adult population.
Consequently, the increase in AEE along with the suppressive effect on appetite previously reported
with microbouts of activity (at least in normal-weight individuals) [27,30] may help mitigate weight
gain. Implementing microbouts of activity at work could be a viable strategy, among other strategies,
to slow down weight gain. In addition, large prospective cohort studies of diverse populations have
shown that an AEE of approximately 4.18 MJ/wk (1000 kcal/wk) is associated with lower rates of
cardiovascular disease and premature mortality [55]. It would therefore be important to study the effect
of this intervention over the long-term and verify whether a 1000 kcal/wk energy expenditure could
be reached. Finally, our feasibility study showed that three days of microbouts of activity performed
in daily life improves insulin sensitivity, which adds to the increasing body of data collected in the
Int. J. Environ. Res. Public Health 2018, 15, 2566 11 of 15

laboratory settings on the beneficial effect of frequent interruptions of prolonged sitting on insulin
action [31–40,57]. This is the first study to show that an intervention using small bouts of activity
promotes overweight-obese sedentary adults to comply with the current physical activity guidelines, at
least in the short term. As a result, this strategy may have positive effects on body weight control and
cardiometabolic health. However, we need to acknowledge that the single bout intervention we tested
in the same subjects induced greater increases in MVPA (40 min/work day) and AEE 1.41 MJ/work
day (+337 kcal/work day). The subjects thus attained a PAL of 1.65 that is characteristic of people
who are moderately active. Future studies are needed to test the long-term effects of the microbouts
of activity versus single bout of activity on the daily pattern of physical activity and energy balance
regulation (appetite, energy intake, energy expenditure).
The long-term goal will be to test this type of intervention in the public on a large scale.
The modern occupational environment promotes increased sedentary time [58], and has therefore
been identified as an ideal environment to target sedentary behaviors. This is even more important
because adults who spend more time sedentary at work do not compensate by being more active
during non-working periods [59]. Interestingly, we showed that the beneficial effects of the microbouts
intervention on physical activity and self-perceived fatigue were observed on both work and non-work
days. This means that if implemented in occupational contexts this intervention, if sustained on
weekends, could also increase physical activity on non-work days. A limitation is that instead of
shifting time from very light to MVPA intensity activities as observed with the single bout of activity,
the microbouts of activity increased MVPA in detriment of light intensity activity on non-work days.
Another potential issue for future implementation of such intervention is the fact that participants
reported the microbouts of activity to be more challenging to perform at work. But in our study,
participants were the only employees performing these activities at their workplace. If the environment
was designed to support breaking up sitting, participants may find this approach less challenging. It is
well known that socio-ecological approaches acting on both the micro environment (individual) and
macro environment (socio-professional environment, office layout, alternative work stations, active
vs. sitting meetings, etc.) are key when aiming to implement new interventions that change behavior
for a sustained period of time. Developing strategies to self-motivate individuals in adopting this
new behavior is also crucial [60]. The fact that our overweight/obese participants perceived less
fatigue at the end of a workday performing the microbouts than a single continuous bout of activity,
as we previously reported in normal weight individuals, could be used to encourage employers to
incorporate microbouts of activity into the daily routines of their office employees [30]. Additionally,
strategies aiming to reduce time spent sitting have not been shown to affect productivity or cognitive
functions [28–30]. Most likely, a combination of the two interventions to target both occupational and
non-work time may be the best approach. It could also provide individuals with different tools to
choose from according to their mood that day at the office or outside the office.
Several limitations need to be acknowledged. The main limitation is that the study was conducted
over 3-days and so conclusions about whether the weekly level of recommended MVPA could be
reached and sustained for longer time periods cannot be made. The comparison between work days
and non-work days was not a priori powered and led to an unbalanced number of days spent in the
two different settings. Because participant’s knew their physical activity was being tracked by two
physical activity monitors there could have been an effect of increased activity [61]. Indeed Clemes et
al. showed that wearing activity monitors for three days induces a spike in physical activity levels
that regresses back to the mean after 7-days [61]. However, other studies have shown no evidence of
reactivity to physical activity monitors [62,63]. In addition, the cross-over design may have limited
the reactivity effect to the monitors. Another strength was that the pattern of physical activities was
assessed using two complementary activity monitors, one specifically designed to detect changes in
sitting and the other one designed to determine time spent in activities of different intensities and the
associated energy expenditure. Finally, this feasibility study testing a novel lifestyle intervention to
Int. J. Environ. Res. Public Health 2018, 15, 2566 12 of 15

prevent sedentary behavior was conducted in overweight/obese, sedentary, physically inactive adults,
which represent a high-risk group for metabolic diseases.

5. Conclusions
This feasibility study showed in overweight/obese physically inactive sedentary adults that
regardless of the terms of the intervention, promoting physical activity led to an increase in physical
activity and energy expenditure, and improved insulin sensitivity and vigor. However, none reduced
total daily sitting time or the length of sitting bouts. This suggests that more efforts are needed
in the workplace to increase physical activity along with a concomitant reduction in the number
and duration of sitting bouts. It may be that frequent prompts to rise from sitting in combination
with encouragements for either microbouts or single bouts of activity may represent the best overall
strategy. This will need to be tested as part of a multicomponent intervention at the organizational,
environmental and individual levels. Therefore, the overall public health message should communicate
that any increase in physical activity can be beneficial when performed consistently over time.

Author Contributions: A.B. and D.H.B. designed the study, collected, analyzed and interpreted data, and drafted
the manuscript. N.P.D.J. collected, analyzed and interpreted data, and drafted the manuscript. I.D., M.G., K.L., C.S.
(Cédric Sueur), C.S. (Chantal Simon) analyzed and interpreted data and drafted the manuscript. Z.P. performed
statistical analysis and drafted the manuscript. All authors gave final approval of the manuscript to be published
and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and resolved.
Funding: This work was supported by the National Institutes of Health grant numbers K99DK100465 (A.B.) and
UL1 TR001082 (A.B.), NORC 5P30DK048520 (A.B., D.H.B.), CTRC UL1TR002535 (A.B., D.H.B.), 5P30DK048520
(Z.P.). This publication was also supported by Grant Number T42OH009229-10 (A.B.) from CDC NIOSH Mountain
and Plains Education and Research Center. C.S. (Cédric Sueur) and I.D. are funded by a grant from the French
national Research Agency (ANR-15-CE36-0005) and by the Grand Est Region (France). The contents of this
publication are solely the responsibility of the authors and do not necessarily represent the official views of the
funding sources.
Acknowledgments: The authors thank study volunteers for their time and participation. They are also very
thankful for the University of Colorado Hospital CTRC staff.
Conflicts of Interest: The authors declare no conflict of interest. The funding sponsors had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, and in the
decision to publish the results.

References
1. Owen, N.; Healy, G.N.; Matthews, C.E.; Dunstan, D.W. Too Much Sitting: The Population-Health Science of
Sedentary Behavior. Exerc. Sport Sci. Rev. 2010, 38, 105–113. [CrossRef] [PubMed]
2. Bauman, A.E.; Chau, J.Y.; Ding, D.; Bennie, J. Too Much Sitting and Cardio-Metabolic Risk: An Update of
Epidemiological Evidence. Curr. Cardiovasc. Risk Rep. 2013, 7, 293–298. [CrossRef]
3. Thorp, A.A.; Owen, N.; Neuhaus, M.; Dunstan, D.W. Sedentary behaviors and subsequent health outcomes
in adults a systematic review of longitudinal studies, 1996–2011. Am. J. Prev. Med. 2011, 41, 207–215.
[CrossRef] [PubMed]
4. Wilmot, E.G.; Edwardson, C.L.; Achana, F.A.; Davies, M.J.; Gorely, T.; Gray, L.J.; Khunti, K.; Yates, T.;
Biddle, S.J. Sedentary time in adults and the association with diabetes, cardiovascular disease and death:
Systematic review and meta-analysis. Diabetologia 2012, 55, 2895–2905. [CrossRef] [PubMed]
5. Edwardson, C.L.; Gorely, T.; Davies, M.J.; Gray, L.J.; Khunti, K.; Wilmot, E.G.; Yates, T.; Biddle, S.J. Association
of sedentary behaviour with metabolic syndrome: A meta-analysis. PLoS ONE 2012, 7, e34916. [CrossRef]
[PubMed]
6. de Rezende, L.F.; Rodrigues Lopes, M.; Rey-Lopez, J.P.; Matsudo, V.K.; Luiz Odo, C. Sedentary behavior and
health outcomes: An overview of systematic reviews. PLoS ONE 2014, 9, e105620. [CrossRef] [PubMed]
7. Suchert, V.; Hanewinkel, R.; Isensee, B. Sedentary behavior and indicators of mental health in school-aged
children and adolescents: A systematic review. Prev. Med. 2015, 76, 48–57. [CrossRef] [PubMed]
Int. J. Environ. Res. Public Health 2018, 15, 2566 13 of 15

8. van Uffelen, J.G.; van Gellecum, Y.R.; Burton, N.W.; Peeters, G.; Heesch, K.C.; Brown, W.J. Sitting-time,
physical activity, and depressive symptoms in mid-aged women. Am. J. Prev. Med. 2013, 45, 276–281.
[CrossRef] [PubMed]
9. Rynders, C.A.; Blanc, S.; DeJong, N.; Bessesen, D.H.; Bergouignan, A. Sedentary behaviour is a key
determinant of metabolic inflexibility. J. Physiol. 2017, 596, 1319–1330. [CrossRef] [PubMed]
10. Judice, P.B.; Hamilton, M.T.; Sardinha, L.B.; Silva, A.M. Randomized controlled pilot of an intervention to
reduce and break-up overweight/obese adults’ overall sitting-time. Trials 2015, 16, 490. [CrossRef] [PubMed]
11. Healy, G.N.; Dunstan, D.W.; Salmon, J.; Cerin, E.; Shaw, J.E.; Zimmet, P.Z.; Owen, N. Breaks in sedentary
time: Beneficial associations with metabolic risk. Diabetes Care 2008, 31, 661–666. [CrossRef] [PubMed]
12. Healy, G.N.; Matthews, C.E.; Dunstan, D.W.; Winkler, E.A.; Owen, N. Sedentary time and cardio-metabolic
biomarkers in US adults: NHANES 2003-06. Eur. Heart J. 2011, 32, 590–597. [CrossRef] [PubMed]
13. McCrady, S.K.; Levine, J.A. Sedentariness at Work: How Much Do We Really Sit? Obesity 2009, 17, 2103–2105.
[CrossRef] [PubMed]
14. Ryan, C.G.; Dall, P.M.; Granat, M.H.; Grant, P.M. Sitting patterns at work: Objective measurement of
adherence to current recommendations. Ergonomics 2011, 54, 531–538. [CrossRef]
15. Church, T.S.; Thomas, D.M.; Tudor-Locke, C.; Katzmarzyk, P.T.; Earnest, C.P.; Rodarte, R.Q.; Martin, C.K.;
Blair, S.N.; Bouchard, C. Trends over 5 decades in U.S. occupation-related physical activity and their
associations with obesity. PLoS ONE 2011, 6, e19657. [CrossRef] [PubMed]
16. Physical Activity Strategy for the WHO European Region. Available online: http://www.euro.
who.int/__data/assets/pdf_file/0010/282961/65wd09e_PhysicalActivityStrategy_150474.pdf (accessed
on 30 August 2018).
17. Alkhajah, T.A.; Reeves, M.M.; Eakin, E.G.; Winkler, E.A.H.; Owen, N.; Healy, G.N. Sit–Stand Workstations:
A Pilot Intervention to Reduce Office Sitting Time. Am. J. Prev. Med. 2012, 43, 298–303. [CrossRef] [PubMed]
18. Carr, L.J.; Walaska, K.A.; Marcus, B.H. Feasibility of a portable pedal exercise machine for reducing sedentary
time in the workplace. Br. J. Sports Med. 2012, 46, 430–435. [CrossRef] [PubMed]
19. Jones, R.A.; Hinkley, T.; Okely, A.D.; Salmon, J. Tracking physical activity and sedentary behavior in
childhood: A systematic review. Am. J. Prev. Med. 2013, 44, 651–658. [CrossRef] [PubMed]
20. Gilson, N.D.; Suppini, A.; Ryde, G.C.; Brown, H.E.; Brown, W.J. Does the use of standing ‘hot’ desks change
sedentary work time in an open plan office? Prev. Med. 2012, 54, 65–67. [CrossRef] [PubMed]
21. Healy, G.N.; Eakin, E.G.; Owen, N.; Lamontagne, A.D.; Moodie, M.; Winkler, E.A.; Fjeldsoe, B.S.; Wiesner, G.;
Willenberg, L.; Dunstan, D.W. A Cluster Randomized Controlled Trial to Reduce Office Workers’ Sitting
Time: Effect on Activity Outcomes. Med. Sci. Sports Exerc. 2016, 48, 1787–1797. [CrossRef] [PubMed]
22. Hutchinson, J.; Headley, S.; Matthews, T.; Spicer, G.; Dempsey, K.; Wooley, S.; Janssen, X. Changes in Sitting
Time and Sitting Fragmentation after a Workplace Sedentary Behaviour Intervention. Int. J. Environ. Res.
Public Health 2018, 15, 1148. [CrossRef] [PubMed]
23. Evans, R.E.; Fawole, H.O.; Sheriff, S.A.; Dall, P.M.; Grant, P.M.; Ryan, C.G. Point-of-choice prompts to reduce
sitting time at work: A randomized trial. Am. J. Prev. Med. 2012, 43, 293–297. [CrossRef] [PubMed]
24. Carr, L.J.; Karvinen, K.; Peavler, M.; Smith, R.; Cangelosi, K. Multicomponent intervention to reduce daily
sedentary time: A randomised controlled trial. BMJ Open 2013, 3, e003261. [CrossRef] [PubMed]
25. Koepp, G.A.; Manohar, C.U.; McCrady-Spitzer, S.K.; Ben-Ner, A.; Hamann, D.J.; Runge, C.F.; Levine, J.A.
Treadmill desks: A 1-year prospective trial. Obesity 2013, 21, 705–711. [CrossRef] [PubMed]
26. Tudor-Locke, C.; Schuna, J.M., Jr.; Frensham, L.J.; Proenca, M. Changing the way we work: Elevating energy
expenditure with workstation alternatives. Int. J. Obes. 2014, 38, 755–765. [CrossRef] [PubMed]
27. Levine, J.A.; Miller, J.M. The energy expenditure of using a “walk-and-work” desk for office workers with
obesity. Br. J. Sports Med. 2007, 41, 558. [CrossRef] [PubMed]
28. Wennberg, P.; Boraxbekk, C.-J.; Wheeler, M.; Howard, B.; Dempsey, P.C.; Lambert, G.; Eikelis, N.; Larsen, R.;
Sethi, P.; Occleston, J.; et al. Acute effects of breaking up prolonged sitting on fatigue and cognition: A pilot
study. BMJ Open 2016, 6, e009630. [CrossRef] [PubMed]
29. Thorp, A.A.; Kingwell, B.A.; Owen, N.; Dunstan, D.W. Breaking up workplace sitting time with intermittent
standing bouts improves fatigue and musculoskeletal discomfort in overweight/obese office workers.
Occup. Environ. Med. 2014, 71, 765–771. [CrossRef] [PubMed]
30. Bergouignan, A.; Legget, K.T.; De Jong, N.; Kealey, E.; Nikolovski, J.; Groppel, J.L.; Jordan, C.; O’Day, R.;
Hill, J.O.; Bessesen, D.H. Effect of frequent interruptions of prolonged sitting on self-perceived levels of
Int. J. Environ. Res. Public Health 2018, 15, 2566 14 of 15

energy, mood, food cravings and cognitive function. Int. J. Behav. Nutr. Phys. Act. 2016, 13, 113. [CrossRef]
[PubMed]
31. Dunstan, D.W.; Kingwell, B.A.; Larsen, R.; Healy, G.N.; Cerin, E.; Hamilton, M.T.; Shaw, J.E.; Bertovic, D.A.;
Zimmet, P.Z.; Salmon, J.; et al. Breaking Up Prolonged Sitting Reduces Postprandial Glucose and Insulin
Responses. Diabetes Care 2012, 35, 976–983. [CrossRef] [PubMed]
32. Peddie, M.C.; Bone, J.L.; Rehrer, N.J.; Skeaff, C.M.; Gray, A.R.; Perry, T.L. Breaking prolonged sitting reduces
postprandial glycemia in healthy, normal-weight adults: A randomized crossover trial. Am. J. Clin. Nutr.
2013, 98, 358–366. [CrossRef] [PubMed]
33. van Dijk, J.W.; Venema, M.; van Mechelen, W.; Stehouwer, C.D.; Hartgens, F.; van Loon, L.J. Effect of
moderate-intensity exercise versus activities of daily living on 24-hour blood glucose homeostasis in male
patients with type 2 diabetes. Diabetes Care 2013, 36, 3448–3453. [CrossRef] [PubMed]
34. Blankenship, J.M.; Granados, K.; Braun, B. Effects of subtracting sitting versus adding exercise on glycemic
control and variability in sedentary office workers. Appl. Physiol. Nutr. Metab. 2014, 39, 1286–1293. [CrossRef]
[PubMed]
35. Buckley, J.P.; Mellor, D.D.; Morris, M.; Joseph, F. Standing-based office work shows encouraging signs of
attenuating post-prandial glycaemic excursion. Occup. Environ. Med. 2014, 71, 109–111. [CrossRef] [PubMed]
36. Holmstrup, M.; Fairchild, T.; Keslacy, S.; Weinstock, R.; Kanaley, J. Multiple short bouts of exercise over 12-h
period reduce glucose excursions more than an energy-matched single bout of exercise. Metab. Clin. Exp.
2014, 63, 510–519. [CrossRef] [PubMed]
37. Bailey, D.P.; Locke, C.D. Breaking up prolonged sitting with light-intensity walking improves postprandial
glycemia, but breaking up sitting with standing does not. J. Sci. Med. Sport 2015, 18, 294–298. [CrossRef]
[PubMed]
38. Larsen, R.N.; Kingwell, B.A.; Robinson, C.; Hammond, L.; Cerin, E.; Shaw, J.E.; Healy, G.N.; Hamilton, M.T.;
Owen, N.; Dunstan, D.W. Breaking up of prolonged sitting over three days sustains, but does not enhance,
lowering of postprandial plasma glucose and insulin in overweight and obese adults. Clin. Sci. 2015, 129,
117–127. [CrossRef] [PubMed]
39. Dempsey, P.C.; Blankenship, J.M.; Larsen, R.N.; Sacre, J.W.; Sethi, P.; Straznicky, N.E.; Cohen, N.D.; Cerin, E.;
Lambert, G.W.; Owen, N.; et al. Interrupting prolonged sitting in type 2 diabetes: Nocturnal persistence of
improved glycaemic control. Diabetologia 2017, 60, 499–507. [CrossRef] [PubMed]
40. Dempsey, P.C.; Larsen, R.N.; Sethi, P.; Sacre, J.W.; Straznicky, N.E.; Cohen, N.D.; Cerin, E.; Lambert, G.W.;
Owen, N.; Kingwell, B.A.; et al. Benefits for Type 2 Diabetes of Interrupting Prolonged Sitting With Brief
Bouts of Light Walking or Simple Resistance Activities. Diabetes Care 2016, 39, 964–972. [CrossRef] [PubMed]
41. Hadgraft, N.T.; Lynch, B.M.; Clark, B.K.; Healy, G.N.; Owen, N.; Dunstan, D.W. Excessive sitting at work
and at home: Correlates of occupational sitting and TV viewing time in working adults. BMC Public Health
2015, 15, 899. [CrossRef] [PubMed]
42. Kim, J.; Shin, W. How to Do Random Allocation (Randomization). Clin. Orthop. Surg. 2014, 6, 103–109.
[CrossRef] [PubMed]
43. Booth, M. Assessment of physical activity: An international perspective. Res. Q. Exerc. Sport 2000, 71,
114–120. [CrossRef] [PubMed]
44. Grant, P.M.; Ryan, C.G.; Tigbe, W.W.; Granat, M.H. The validation of a novel activity monitor in the
measurement of posture and motion during everyday activities. Br. J. Sports Med. 2006, 40, 992–997.
[CrossRef] [PubMed]
45. Godfrey, A.; Culhane, K.M.; Lyons, G.M. Comparison of the performance of the activPAL Professional
physical activity logger to a discrete accelerometer-based activity monitor. Med. Eng. Phys. 2007, 29, 930–934.
[CrossRef] [PubMed]
46. Kozey-Keadle, S.; Libertine, A.; Lyden, K.; Staudenmayer, J.; Freedson, P.S. Validation of wearable monitors
for assessing sedentary behavior. Med. Sci. Sports Exerc. 2011, 43, 1561–1567. [CrossRef] [PubMed]
47. Ryan, C.G.; Grant, P.M.; Tigbe, W.W.; Granat, M.H. The validity and reliability of a novel activity monitor as
a measure of walking. Br. J. Sports Med. 2006, 40, 779–784. [CrossRef] [PubMed]
48. Zhang, Y.; Li, H.; Keadle, S.; Matthews, C.E.; Carroll, R. PAactivPAL: Summarize Daily Physical Activity
from ‘activPAL’ Accelerometer Data. Available online: https://rdrr.io/cran/PAactivPAL/ (accessed on
31 August 2018).
Int. J. Environ. Res. Public Health 2018, 15, 2566 15 of 15

49. Actigraph Support Center. What Is the Difference among the Energy Expenditure Algorithms? Available
online: https://actigraph.desk.com/customer/en/portal/articles/2515835-what-is-the-difference-among-
the-energy-expenditure-algorithms- (accessed on 5 May 2018).
50. Sasaki, J.E.; John, D.; Freedson, P.S. Validation and comparison of ActiGraph activity monitors. J. Sci.
Med. Sport 2011, 14, 411–416. [CrossRef] [PubMed]
51. Tremblay, M.S.; Aubert, S.; Barnes, J.D.; Saunders, T.J.; Carson, V.; Latimer-Cheung, A.E.; Chastin, S.F.M.;
Altenburg, T.M.; Chinapaw, M.J.M.; Altenburg, T.M.; et al. Sedentary Behavior Research Network
(SBRN)—Terminology Consensus Project process and outcome. Int. J. Behav. Nutr. Phys. Act. 2017,
14, 75. [CrossRef] [PubMed]
52. Reips, U.D.; Funke, F. Interval-level measurement with visual analogue scales in Internet-based research:
VAS Generator. Behav. Res. Methods 2008, 40, 699–704. [CrossRef] [PubMed]
53. McNair, D.M.; Lorr, M.; Droppleman, L.F. Manual Profile of Mood States; Educational & Industrial Testing
Service: San Diego, CA, USA, 1971.
54. Parry, S.; Straker, L. The contribution of office work to sedentary behaviour associated risk. BMC Public Health
2013, 13, 296. [CrossRef] [PubMed]
55. Haskell, W.L.; Lee, I.M.; Pate, R.R.; Powell, K.E.; Blair, S.N.; Franklin, B.A.; Macera, C.A.; Heath, G.W.;
Thompson, P.D.; Bauman, A. Physical activity and public health: Updated recommendation for adults from
the American College of Sports Medicine and the American Heart Association. Med. Sci. Sports Exerc. 2007,
39, 1423–1434. [CrossRef] [PubMed]
56. Hill, J.O. Understanding and addressing the epidemic of obesity: An energy balance perspective. Endocr. Rev.
2006, 27, 750–761. [CrossRef] [PubMed]
57. Bergouignan, A.; Latouche, C.; Heywood, S.; Grace, M.S.; Reddy-Luthmoodoo, M.; Natoli, A.K.; Owen, N.;
Dunstan, D.W.; Kingwell, B.A. Frequent interruptions of sedentary time modulates contraction- and
insulin-stimulated glucose uptake pathways in muscle: Ancillary analysis from randomized clinical trials.
Sci. Rep. 2016, 6, 32044. [CrossRef] [PubMed]
58. Black, A.E. Physical activity levels from a meta-analysis of doubly labeled water studies for validating energy
intake as measured by dietary assessment. Nutr. Rev. 1996, 54, 170–174. [CrossRef] [PubMed]
59. Clemes, S.A.; O’Connell, S.E.; Edwardson, C.L. Office workers’ objectively measured sedentary behavior and
physical activity during and outside working hours. J. Occup. Environ. Med. 2014, 56, 298–303. [CrossRef]
[PubMed]
60. Bessesen, D.; Bergouignan, A. Behavior Change Strategies for Increasing Exercise and Decreasing Sedentary
Behaviors in Diabetes. In Diabetes and Exercise: From Pathophysiology to Clinical Implementation; Reusch, J.E.B.,
Regensteiner, J.G., Stewart, K.J., Veves, A., Eds.; Springer International Publishing: Cham, Switzerland, 2018;
pp. 201–219.
61. Clemes, S.A.; Parker, R.A. Increasing our understanding of reactivity to pedometers in adults. Med. Sci.
Sports Exerc. 2009, 41, 674–680. [CrossRef] [PubMed]
62. Behrens, T.K.; Dinger, M.K. Motion sensor reactivity in physically active young adults. Res. Q. Exerc. Sport
2007, 78, 1–8. [CrossRef] [PubMed]
63. Davis, R.E.; Loprinzi, P.D. Examination of Accelerometer Reactivity among a Population Sample of Children,
Adolescents, and Adults. J. Phys. Act. Health 2016, 13, 1325–1332. [CrossRef] [PubMed]

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).