https://doi.org/10.4082/kjfm.20.

0165 • Korean J Fam Med 2020;41:365-373

Review Article

Sedentary Lifestyle: Overview of

eISSN: 2092-6715

Updated Evidence of Potential Health

Risks
Jung Ha Park1, Ji Hyun Moon1,2, Hyeon Ju Kim1,2, Mi Hee Kong1,2, Yun Hwan Oh1,2,*
1
Department of Family Medicine, Jeju National University Hospital, Jeju, Korea
2
Department of Family Medicine, Jeju National University School of Medicine, Jeju, Korea

One-third of the global population aged 15 years and older engages in insufficient physical activities, which affects
health. However, the health risks posed by sedentary behaviors are not well known. The mean daily duration of
sedentary behavior is 8.3 hours among the Korean population and 7.7 hours among the American adult popula-
tion. Sedentary lifestyles are spreading worldwide because of a lack of available spaces for exercise, increased occu-
pational sedentary behaviors such as office work, and the increased penetration of television and video devices.
Consequently, the associated health problems are on the rise. A sedentary lifestyle affects the human body through
various mechanisms. Sedentary behaviors reduce lipoprotein lipase activity, muscle glucose, protein transporter
activities, impair lipid metabolism, and diminish carbohydrate metabolism. Furthermore, it decreases cardiac out-
put and systemic blood flow while activating the sympathetic nervous system, ultimately reducing insulin sensitivi-
ty and vascular function. It also alters the insulin-like growth factor axis and the circulation levels of sex hormones,
which elevates the incidence of hormone-related cancers. Increased sedentary time impairs the gravitostat, the
body’s weight homeostat, and weight gain, adiposity, and elevated chronic inflammation caused by sedentary be-
havior are risk factors for cancer. Sedentary behaviors have wide-ranging adverse impacts on the human body in-
cluding increased all-cause mortality, cardiovascular disease mortality, cancer risk, and risks of metabolic disor-
ders such as diabetes mellitus, hypertension, and dyslipidemia; musculoskeletal disorders such as arthralgia and
osteoporosis; depression; and, cognitive impairment. Therefore, reducing sedentary behaviors and increasing
physical activity are both important to promote public health.

Keywords: Sedentary Behavior; All-Cause Mortality; Cancer; Metabolic Disease; Physical Activity; Exercise

Received: July 15, 2020, Accepted: August 4, 2020

*Corresponding Author: Yun Hwan Oh https://orcid.org/0000-0002-1627-7528
Tel: +82-64-717-8650, Fax: +82-64-757-8276, E-mail: [email protected]

Copyright © 2020 The Korean Academy of Family Medicine

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0)
which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
366  
www.kjfm.or.kr Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks

INTRODUCTION rise on the basis of this socio-cultural background.

Sedentary lifestyles have a major impact on the overall health of the
1. Epidemiology global population. Many people worldwide engage in sedentary life-
Approximately 31% of the global population aged ≥15 years engages in styles, and the prevalence of relevant non-communicable diseases is
insufficient physical activity, and it is known to contribute to the death on the rise. It is well known that insufficient physical activity, that is,
of approximately 3.2 million people every year.1) In South Korea, the physical inactivity, has a detrimental effect on health. Physical inactivi-
physical activity rate is on the decline among adults aged ≥19 years, ir- ty is the fourth leading risk factor for global mortality, accounting for
respective of the type of activity, including aerobic exercise, walking, 6% of global mortality.6) Despite the fact that sedentary behavior poses
and muscle training. Therefore, in 2017, the rates of aerobic exercise, a comparable risk to health and contributes to the prevalence of vari-
walking, and muscle training in the Korean adult population were ous diseases, most physical activity-related education in clinical prac-
48.5%, 39.0%, and 21.6%, respectively, with the majority of the Korean tice is focused on improving the physical activity levels, with less em-
2)
population engaging in physical inactivity. In addition to physical in- phasis on lowering the sedentary behavior. In addition to understand-
activity, sedentary behavior is also a serious problem, and a substantial ing and informing patients about the health impact of a sedentary life-
number of people engage in it for prolonged periods. For instance, style, healthcare providers of various fields, including clinicians,
Americans spend 55% of their waking time (7.7 hours a day) engaged should reflect upon its significance in policies. This study examined
in sedentary behaviors whereas Europeans spend 40% of their leisure the effects of a sedentary lifestyle on health and the lifestyle-related
time (2.7 hours a day) watching television.3) Similar patterns have been improvements to be made to promote healthy living.
observed in Koreans, who have been reported to demonstrate long
sedentary times. According to Korea Health Statistics of 2018, adults in OVERVIEW OF SEDENTARY LIFESTYLE
Korea aged ≥19 years engage in 8.3 hours of sedentary time. Only 8.9%
of the adult population engaged in <4 hours of sedentary time whereas 1. The Concept of a Sedentary Lifestyle
20.6% of the adults were involved in >12 hours of sedentary time.4) Sedentary behavior is defined as any waking behavior such as sitting
or leaning with an energy expenditure of 1.5 metabolic equivalent task
2. Causes of Physical Inactivity and Sedentary Lifestyles (MET) or less.7) This definition, proposed by the Sedentary Behavior
A poor participation in physical activity is speculated to be influenced Research Network in 2012, is currently the most widely used definition
by multiple factors. Some environmental factors include traffic con- of sedentary behavior. Some examples of sedentary behavior include
gestion, air pollution, shortage of parks or pedestrian walkways, and a television viewing, playing video games, using a computer, sitting at
1)
lack of sports or leisure facilities. Television viewing, video viewing, school or work, and sitting while commuting (Figure 1).8) According to
and cell phone usage are positively correlated with an increasingly the 2011 Compendium of Physical Activities, MET is defined as the ra-
sedentary lifestyle.5) Sedentary behaviors are projected to continue to tio of work metabolic rate to the standard resting metabolic rate (RMR)

A B

Figure 1. Examples of sedentary behavior. (A)

C D Playing a video game. (B) Watching television.
(C) Using a computer. (D) Reading a book.

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of 1 kcal/(kg/h). One MET is the RMR or energy cost for a person at scribed below.
rest. When classified quantitatively based on their intensities, physical Sedentary lifestyles are associated with metabolic dysfunctions,
activities can be classified into 1.0–1.5 METs (sedentary behavior), 1.6– such as elevated plasma triglycerides and high-density lipoprotein
2.9 METs (light intensity), 3–5.9 (moderate intensity), and ≥6 METs (HDL) cholesterol and reduced insulin sensitivity.15,16) Lipoprotein li-
9)
(vigorous intensity) (Figure 2). pase (LPL) is a protein that interacts at the cellular level, and a low LPL
A sedentary lifestyle increases all-cause mortality and the risks for concentration is known to decrease the plasma HDL cholesterol level,
cardiovascular diseases (CVD), diabetes mellitus (DM), hypertension while affecting the prevalence of severe HTN, diabetes-induced dys-
(HTN), and cancers (breast, colon, colorectal, endometrial, and epi- lipidemia, metabolic disorders caused by aging, metabolic syndrome,
thelial ovarian cancer). This has been consistently documented in the and coronary artery diseases. Moreover, LPL activity is diminished by
literature.3,10,11) There is no disagreement on the fact that prolonged to- physical inactivity. Additionally, physical inactivity inhibits LPL activity
tal sedentary behavior times are associated with poor disease out- in skeletal muscles and rapidly signals for impaired lipid metabolism.
comes. However, the patterns of sedentary time may differ even within In an experiment based on a rat model, the reduction of LPL activity in
the same total amount of time, and not much is known about the par- rats that engaged in light walking was only about 10% of the LPL activi-
ticular patterns of prolonged sedentary time that pose more significant ty in rats that were only placed in their cages.17) The fact that muscle
health hazards (for example, continuous sedentary behavior without a LPL activity is highly sensitive to physical inactivity and low-intensity
12)
break or intermittent sedentary behavior). One study reported that muscular contractile activity can serve as evidence supporting the the-
even if the total sedentary time was equal, having short sedentary ory that sedentary behavior is a risk factor for various metabolic disor-
bouts and engaging in physical activities intermittently can have rela- ders.18)
tive health benefits. The total sedentary time and moderate-to-vigor- Physical inactivity reduces bone mineral density.19) In a study on
ous physical activity (MVPA) have been reported to be negatively cor- healthy adult men and women, 12 weeks of bed rest decreased the
related, where the waist circumference (standardized β, -0.16; 95% mineral density of the lumbar spine, femoral neck, and greater tro-
confidence interval [CI], -0.31 to -0.02; P=0.026), body mass index (β, chanter by 1%–4%.19) The balance between bone resorption and bone
-0.19; 95% CI, -0.35 to -0.02; P=0.026), triglyceride level (β, -0.18; 95% deposition mediates the relationship between sedentary behavior and
CI, -0.34 to -0.02; P=0.029), and 2-hour postprandial plasma glucose the reduction of bone mineral density. According to some studies, bed
level (β, -0.18; 95% CI, -0.34 to -0.02; P=0.025) decreased with increas- rest elevates bone resorption markers and does not influence bone
ing the number of breaks in the sedentary time.13) Furthermore, when formation markers.20-22)
the sedentary time was interrupted with light- or moderate-intensity Some studies have provided limited evidence that sedentary behav-
physical activity, the systolic and diastolic blood pressures dropped by ior has a negative impact on vascular health. A study on healthy wom-
2–3 mm Hg whereas interrupting the sedentary time with light-inten- en reported that 56 days of head-down bed rest decreased the endo-
sity physical activity (LIPA) or simple muscle training in patients with thelium-dependent vasodilation while increasing the endothelial cell
diabetes (88% of the population had HTN) decreased the systolic pres- damage. Such alterations in vascular function were prevented through
14)
sure by 14–16 mm Hg and the diastolic pressure by 8–10 mm Hg. aerobic exercise and muscle training.23)

2. Physiological Features SEDENTARY LIFESTYLES AND HEALTH RISKS

The exact mechanisms of the various adverse effects of sedentary be-
havior on the human body are currently unknown. However, several 1. Sedentary Lifestyles, Mortality, and Morbidity
hypotheses have been proposed for the overall understanding of the (Cardiovascular Diseases and Other Causes)
impact of sedentary behavior on the human body, which are de- A sedentary lifestyle is strongly associated with CVD, DM, cancer, and
premature mortality. The total daily sedentary time and television
viewing time were correlated with an increased all-cause mortality
risk.24) In a study analyzing the mortality rates of people with >10 hours
and <5 hours of sitting times a day, the 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 that examined the correlation between the
television viewing time and all-cause mortality, the people who
watched television for ≥6 hours a day had a two-fold higher all-cause
mortality risk compared to the people who watched television for <2
hours a day (hazard ratio [HR], 1.98; 95% CI, 1.25–3.15)26) whereas the
A B
people who watched television for ≥4 hours a day had a 1.5 times
Figure 2. Examples of moderate to vigorous physical activity. (A) Riding a bicycle. (B) higher all-cause mortality risk compared to the people who watched
Running. TV for <2 hours a day (HR, 1.48; 95% CI, 1.19–1.83).27)

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www.kjfm.or.kr Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks

Sedentary time (sitting time, television or screen viewing time, lei- 3) Dyslipidemia
sure time while sitting in a day) is independently associated with all- Sedentary behaviors induce metabolic dysfunction characterized by
cause mortality, CVD incidence or mortality, incidence or mortality of elevated blood triglyceride levels, reduced HDL-cholesterol levels, and
certain cancers (breast, colon, colorectal, endometrial, and epithelial diminished insulin sensitivity.17) A study reported that sedentary be-
ovarian cancer), and type 2 DM. In particular, the adverse effect of haviors increased the rate of newly diagnosed dyslipidemias in women
sedentary time was more evident among people who engaged in little (OR, 1.17; 95% CI, 1.00–1.36) and increased the risk for dyslipidemia in
physical activity compared to those who engaged in frequent physical both men and women (men: OR, 1.21; 95% CI, 1.02–1.44) (women:
activity. The relative risk (RR) for all-cause mortality was 30% higher OR, 1.24; 95% CI, 1.04–1.48).31) In contrast, MVPA was negatively asso-
with high physical activity (HR, 1.16; 95% CI, 0.84–1.59) compared to ciated with blood triglyceride levels (β, -0.18; 95% CI, -0.36 to -0.01;
that with low physical activity (HR, 1.46; 95% CI, 1.22–1.75).28) P=0.038).32)

2. Sedentary Lifestyles and Metabolic Diseases 4) Obesity

Sedentary time is known to have significant correlations with waist cir-
1) Diabetes mellitus cumference and clustered metabolic risk scores independent of
The fact that the prevalence of type 2 DM increases with increasing MVPA. The waist circumference increased by 3.1 cm with a 10% in-
sedentary time has been consistently documented in various studies crease in the sedentary time.32) Obese patients tend to move less;
28)
(HR, 1.91; 95% CI, 1.64–2.22). therefore, increasing the activity levels can be utilized as a strategy in
In an assessment of DM risk considering both sedentary time and obesity treatment.33) While this is a widely known fact, the underlying
physical activity, the DM risk increased with the increasing daily sed- mechanism remains unknown. A study in 2020 reported that the rea-
entary time (HR, 1.13; 95% CI, 1.04–1.22; P<0.001), and the effect was son for weight gain is a prolonged sedentary time.34) According to a
not offset by the level of physical activity (HR, 1.11; 95% CI, 1.01–1.19; Swedish study that compared an experimental group which wore a
P<0.001). The risk for CVD also increased with the increasing daily heavy 11-kg vest for 8 hours a day and the control group which wore a
sedentary time (HR, 1.29; 95% CI, 1.27–1.30; P<0.001), and although light 1-kg vest for 8 hours a day, the experimental group had a weight
the physical activity level slightly offset this effect, sedentary time still loss of 1.6 kg whereas the control group lost 0.3 kg three weeks later. An
significantly increased the risk (HR, 1.11; 95% CI, 1.01–1.19; P<0.001). animal study shed light on an energy balance system known as the
This shows that the level of physical activity does not influence the im- “gravitostat” that maintains a consistent body weight.35) This regulation
pact of prolonged sedentary time on the risk for CVD and DM. occurs partially due to an influence on appetite where the system re-
A few biological mechanisms can explain the impact of the total quires a personal weighing machine for the proper functioning of this
daily sedentary time on CVD and DM risk. Prolonged sitting is known regulation. This Swedish study found that humans also feature a simi-
to affect the content and activity of muscle glucose transporter pro- lar built-in scale. An individual’s scale measures lower values with pro-
teins. An animal study observed that prolonged muscle inactivity re- longed sitting, which explains why sitting is associated with obesity
duces the LPL activity, which regulates blood lipid concentration and and poor health. A heavy vest can increase the score on this, thereby
carbohydrate metabolism through cellular pathways that differ from inducing weight loss.34)
the normal motor response; however, additional verification is re-
quired by human studies.29) 3. Sedentary Lifestyles and Cancer Risk
Sedentary behavior is also closely related to the prevalence of cancer.
2) Hypertension According to a study that investigated the correlation between seden-
A sedentary lifestyle affects blood pressure through various mecha- tary behavior and cancer prevalence, the cancer risk was 13% higher in
nisms, and subsequently changes the blood pressure by altering the the group with the longest sedentary time compared to that with the
cardiac output and total peripheral vascular resistance. A prolonged shortest sedentary time,28) and another study reported that sedentary
sedentary time reduces the metabolic demands and systemic blood time increased the overall cancer risk by 20%.36)
flow, and by stimulating the sympathetic nervous system, it decreases Prolonged sitting increases colorectal, endometrial, ovarian, and
insulin sensitivity and vascular function while increasing the oxidative prostate cancer risks, and it has been reported to increase cancer mor-
stress and promoting the low-grade inflammatory cascade.14) A study tality particularly in women.37) There was a significant correlation be-
reported a direct association between sedentary behavior and a high tween cancer mortality and the incidences of breast, colorectal, endo-
risk of HTN (HR, 1.48; 95% CI, 1.01–2.18; P for trend=0.03). Among metrial, and epithelial ovarian cancers.28) An increased total sitting
sedentary behaviors, non-interactive sedentary behaviors (watching time was positively correlated with colon cancer (RR, 1.24; 95% CI,
television, sleeping) have been reported to further escalate the risk for 1.03–1.50) and endometrial cancer (RR, 1.32; 95% CI, 1.08–1.61).36) Ad-
HTN compared to interactive sedentary behaviors (driving, using a ditionally, television viewing time was also positively correlated with
computer).30) colon cancer (RR, 1.54; 95% CI, 1.19–1.98) and endometrial cancer
(RR, 1.66; 95% CI, 1.21–2.28).36) Occupational sitting time was positive-

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ly correlated with only colon cancer (RR, 1.24; 95% CI, 1.09–1.41).36) (RR, 0.99; 95% CI, 0.79–1.23)43) but was positively correlated with de-
Sedentary behavior leads to metabolic dysfunctions such as hyper- pression risk in another study (RR, 1.22; 95% CI, 1.10–1.34),44) and thus
glycemia, hyperinsulinemia, insulin resistance, perturbation of insu- its correlation with depression remains controversial. The mechanism
lin-like growth factor axis, and changes in the circulation levels of sex underlying the correlation between sedentary behavior and depres-
hormones. Altered circulation levels of sex hormones can be linked to sion may involve the following: sedentary behaviors may increase the
hormone-related cancers such as breast and endometrial cancers.38) risk for depression by blocking direct communication and lowering
Additionally, sedentary behavior induces low-grade chronic systemic social interactions, or by reducing the available time to engage in
inflammation, and sedentary time is associated with inflammation-re- physical activities that help to prevent and treat depression.43)
lated markers such as C-reactive protein (β, 0.18±0.06; P=0.002), inter-
leukin 6 (β, 0.24±0.06; P<0.001), leptin (β, 0.15±0.04; P<0.001), and the 2) Cognitive function
leptin: adiponectin ratio (β, 0.21±0.05; P<0.001).39) Chronic inflamma- The relationship between sedentary behavior and cognitive function
40)
tion can trigger cancer growth. Adiposity can also mediate the rela- is uncertain. A systematic review found marked alterations of cogni-
tionship between sedentary behavior and cancer, and obesity is a risk tion (improved in two studies45,46) and impaired in two studies47,48)) in
8)
factor for several cancers. some studies but no changes in cognitive function in some studies.49)
However, the only long-term study included in that systematic review
4. Sedentary Lifestyles and Osteoporosis suggested that a less-sedentary lifestyle and less sedentary work have
Sedentary behavior is known to show a negative association with the benefits related to cognitive function.46) It is believed that replacing the
bone mineral density of the total femur and all hip sub-regions irre- sedentary time with physical activity can help improve the cognitive
spective of MVPA, and the bone mineral density (g/cm2) of the total function. In a randomized clinical trial that analyzed the cognitive
femur had a marked negative correlation with the sedentary time (β, changes after 30 minutes of sedentary behavior with other activities for
-0.16; 95% CI, -0.24 to -0.08) in adult women.41) Bone mineral density 6 months in older adults with little physical activity, replacing the sed-
was correlated with the duration and not the frequency of sedentary entary time with MVPA and sleep significantly improved cognitive
behavior. In men, sedentary behavior was not markedly correlated functions, and replacing it with LIPA did not lead to statistically signifi-
41)
with the bone mineral density of the hip and spine. cant changes.46)

5. Sedentary Lifestyles and Musculoskeletal Diseases SEDENTARY LIFESTYLES AND PHYSICAL ACTIVITY
A prolonged sedentary time was correlated with chronic knee pain. In
an analysis of the correlation between chronic knee pain and the total 1. Discrepant Health Effects of Sedentary Lifestyle and
daily sedentary time (<5, 5–7, 8–10, >10 hours), the results claimed that Physical Activity
the incidence of chronic knee pain was higher in individuals with lon- Past studies have observed that a prolonged sedentary lifestyle leads to
ger sedentary times (P for trend=0.02).42) In particular, a sedentary time poor health outcomes irrespective of physical activity. A sedentary life-
>10 hours a day was markedly correlated with chronic knee pain (ad- style was independently correlated with mortality and was not com-
justed OR, 1.28; 95% CI, 1.02–1.61; P=0.03).42) People who engaged in pensated for by physical activity.10) The time spent in front of a screen
greater physical activity had less chronic knee pain (adjusted OR, 0.78; was positively correlated with the presence of metabolic syndrome, in-
95% CI, 0.67–0.91; P=0.00), but women with >10 hours of sedentary dependent of the level of physical activity (OR, 3.30; 95% CI, 2.04–
time while engaging in greater physical activity were highly likely to 5.34).50)
experience chronic knee pain (adjusted OR, 1.19; 95% CI, 1.02–1.39;
P=0.03). The study recommends individuals to shorten their sedentary 2. The Attenuative Effect of Physical Activity on Sedentary
times to <10 hours a day.42) Lifestyles
A few recent studies have reported that increasing physical activity can
6. Sedentary Lifestyles and Other Diseases offset the adverse impacts of sedentary behavior. In particular, the off-
set effect was more evident in people with little physical activity.
1) Depression A meta-analysis reported that mortality was not elevated in the peo-
Mentally passive sedentary behaviors such as television viewing (RR, ple engaging in high levels of moderate-intensity physical activity (60–
1.18; 95% CI, 1.07–1.30), sitting, listening to music, and talking while 75 minutes of moderate-intensity physical activity a day) even when
sitting were positively correlated with depression risks (RR, 1.17; 95% they had >8 hours of sedentary time a day. There was no difference in
CI, 1.08–1.27). In contrast, mentally active sedentary behaviors such as mortality between the most active people (>35.5 MET-h/wk) with <4
reading books or newspapers, driving, attending a meeting, or knitting hours of sedentary time a day and equally active people (>35.5 MET-
or sewing were not markedly correlated with depression risk (RR, 0.98; h/wk) with >8 hours of sedentary time a day (HR, 1.04; 95% CI, 0.99–
95% CI, 0.83–1.15).43) Using a computer, which is a mentally active sed- 1.10). However, television viewing for >3 hours a day increased the
entary behavior, was not correlated with depression risk in one study mortality regardless of physical activity, and the people who watched

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www.kjfm.or.kr Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks

television for ≥5 hours a day showed markedly high mortalities (HR, CLINICAL PEARLS FOR SEDENTARY INDIVIDUALS
1.16; 95% CI, 1.05–1.28).51)
In one study, sitting time showed a dose-response with all-cause While the various countries have their own guidelines for physical ac-
mortality and CVD mortality risk in the least active group (<150 MVPA tivity and sedentary behavior, overall, the recommendations are simi-
min/wk).51) In contrast, the group with at least 8 hours of sedentary lar.
time a day showed a higher mortality than the group with less than 4
hours of sedentary time a day (HR, 1.52; 95% CI, 1.13–2.03). However, 1. Recommendations in the United States
the group who met the essential MVPA criterion (150–299 MVPA min/ Although the 2018 Advisory Committee revealed that sedentary be-
wk) or engaged in more physical activity did not show a consistent havior is strongly correlated with all-cause and CVD mortalities in
trend in the relationship between increased sitting time and CVD and adults, the evidence was insufficient to offer advice on the recom-
all-cause mortalities. mended daily sedentary time and duration of physical activity. It could
Similarly, a study showed that a sedentary time of over 9 hours per not determine the recommended daily sedentary time and frequency
day in the low physical activity group (<600 METs-min/wk) had a sig- of physical activity for adults or adolescents because the risks associat-
nificant association with an increased CVD risk (OR, 1.29; 95% CI, ed with sedentary behavior are related to the amount of MVPA.
1.04–1.62). In the group with more physical activity, sedentary time It is advisable for inactive people not engaging in moderate physical
52)
was not significantly associated with CVD risk. activity (MPA) to lower their sedentary behavior and replace their sed-
In other words, while increased sedentary time increases the mor- entary behavior with LIPA. However, LIPA alone is insufficient to ob-
tality among people who engage in little physical activity, adequate tain health benefits; they will be able to reduce their health risk by
physical activity seems to offset the impact of increased sedentary time gradually increasing their physical activities to MPA or beyond. Inac-
53)
on mortality. tive people who engage in insufficient physical activity that does not
A study analyzed the correlation between all-cause mortality and meet the criterion of 150–300 minutes of MPA per week would be able
net uncompensated sedentary behavior metabolic equivalent hours to obtain health benefits by increasing their MPA slightly and reap
(USMh=MET/h [sedentary time]–MET/h [MVPA time]), which was even greater health benefits by reducing their sedentary behaviors. Ac-
computed by subtracting METs for MVPA from METs for sedentary tive people who engage in sufficient physical activity (150–300 minutes
behavior throughout a day. USMh was independently associated with of MPA per week) would gain more benefits by lowering their seden-
all-cause mortality when it was greater than 7 MET/h, and for televi- tary behaviors. Highly active people who engage in more than 300
sion viewing, when it was greater than 3 MET/h. The mean increase in minutes of MPA per week are recommended to maintain or improve
mortality per USMh was 1% (RR, 1.01; 95% CI, 1.00–1.02; P=0.01), and their levels of physical activity by participating in a variety of activi-
the mean increase in mortality per USMh for TV watching was 7% (RR, ties.57)
1.07; 95% CI, 1.04–1.10; P<0.001). In other words, physical activity as
well as sedentary time should be assessed, and therefore, USMh was 2. Recommendations in Australia
revealed to be a more practical index for assessing sedentary behav- The Australian Government Department of Health presented age-spe-
ior.54) cific recommendations for physical activity and sedentary behavior.
In the people with the least daily activity (≤17 min/d MVPA), replac- According to the Australian physical activity-sedentary behavior
ing 30 minutes of the sitting time each day with light physical activity guidelines, individuals are recommended to minimize their sitting
reduced the mortality risk by 14% (HR, 0.86; 95% CI, 0.81–0.89), and times, including sitting during work, commuting, and breaks, and to
replacing it with MVPA reduced the mortality risk by 45% (HR, 0.55; avoid sitting for prolonged periods as much as possible.58) Infants and
95% CI, 0.47–0.62). However, in the people with the highest daily activ- children aged less than 5 years are advised to not be bound in a stroller,
ity (MVPA >38 min/d), replacing the sitting time with LIPA or MVPA car seat, or high chair for more than 1 hour at a time. While they en-
55)
was not linked with a reduced mortality risk. gage in sedentary behaviors, they are recommended to spend time
Replacing the sedentary behavior with physical activity also has an reading books, singing, solving puzzles, and talking with their caregiv-
impact on cancer-related mortality. A recently published study ers as compared to watching television or a DVD (digital video disc),
showed that sedentary behavior was independently associated with playing on the computer, or playing other video games.59) For children
cancer mortality risk, where a higher sedentary time led to a greater between the ages of 5 and 17, the sedentary recreational screen time
cancer mortality risk. In this study, the individuals in the top 1/3 of the should be limited to 2 hours a day, and they are advised to engage in
sedentary group showed a substantially higher cancer mortality risk positive social interactions and experiences. Older adults aged 65
than those in the bottom 1/3 (adjusted HR, 1.52; 95% CI, 1.01–2.27).56) years and more are advised to remain active as much as possible every
However, replacing 30 minutes of sedentary time with LIPA reduced day.60) The recommended amount of physical activity for adults is 150–
the cancer mortality by 8% (HR, 0.92; 95% CI, 0.86–0.97) and replacing 300 minutes of MPA or 75–150 minutes of vigorous physical activity or
it with MVPA reduced it by 31% (HR, 0.69; 95% CI, 0.48–0.97).56) an equivalent MVPA per week.

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Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks www.kjfm.or.kr  371

3. Recommendations in Korea ORCID

The guidelines for physical activity for the Korean population pub-
lished by the Department of Health Promotion at the Ministry of Jung Ha Park: https://orcid.org/0000-0002-1269-333X
Health and Welfare in October 2013 recommend that people limit Ji Hyun Moon: https://orcid.org/0000-0001-6788-7521
their sedentary leisure time (e.g., computer, smartphone, and televi- Hyeon Ju Kim: https://orcid.org/0000-0002-9103-3275
sion) to 2 hours a day and engage in a low level of physical activity. Mi Hee Kong: https://orcid.org/0000-0003-1464-8812
Children and adolescents are recommended to develop an active life- Yun Hwan Oh: https://orcid.org/0000-0002-1627-7528
style overall, including sports, physical education, walking, and cycling
at home and school. If older adults and people with chronic diseases REFERENCES
are unable to engage in the recommended physical activities, these
groups of people are advised to engage in physical activities to the ex- 1. World Health Organization. Physical inactivity: a global public health
tents permitted by their situations.61) problem [Internet]. Geneva: World Health Organization; 2020 [cited
2020 Jun 15]. Available from: https://www.who.int/dietphysicalactivity/
CONCLUSION factsheet_inactivity/en/.
2. Korea Centers for Disease Control and Prevention. Trends in percent-
Since the beginning of the coronavirus pandemic, social distancing age of physical activity, among Korean adults aged ≥19 years, 2007-
has become important, and engaging in physical activity in the post- 2017 [Internet]. Cheongju: Korea Centers for Disease Control and Pre-
vention; 2019 [cited 2020 Jun 15]. Available from: https://www.cdc.go.
corona era is difficult. Therefore, a study of the problems of sedentary
kr/board.es?mid=a20602010000&bid=0034&list_no=364483&act=view.
lifestyle is considered more valuable at this point.
3. Patterson R, McNamara E, Tainio M, de Sa TH, Smith AD, Sharp SJ, et
A sedentary lifestyle has an array of adverse health effects, including
al. Sedentary behaviour and risk of all-cause, cardiovascular and can-
elevated all-cause mortality, CVD mortality, cancer risk, risks for meta-
cer mortality, and incident type 2 diabetes: a systematic review and
bolic diseases such as DM, HTN, dyslipidemia, and musculoskeletal dose response meta-analysis. Eur J Epidemiol 2018;33:811-29.
diseases such as knee pain and osteoporosis. 4. Statistics Korea. Korea health statistics 2018: Korea National Health
It is indisputable that the negative health impacts intensify with in- and Nutrition Examination Survey (KNHANES VII-3). Daejeon: Statis-
creases in the total daily sedentary times. For this reason, it is impor- tics Korea; 2018.
tant to reduce the sedentary time as much as possible. 5. Fennell C, Barkley JE, Lepp A. The relationship between cell phone
The findings of studies determining the worst type of sedentary be- use, physical activity, and sedentary behavior in adults aged 18-80.
havior varied across studies. Studies observed better health outcomes Comput Human Behav 2019;90:53-9.
with a short sedentary bout with intermittent physical activity, with 6. World Health Organization. Global recommendations on physical ac-
tivity for health. Geneva: World Health Organization; 2010.
light physical activity or simple muscle training, intermittent interrup-
7. Sedentary Behaviour Research Network. SBRN Terminology Consen-
tions of sedentary behavior during work, and rest with physical activity.
sus Project: 2017-2020 [Internet]. Ottawa: Sedentary Behaviour Re-
Health outcomes also vary depending on the type of sedentary be-
search Network; 2020 [cited 2020 Nov 6]. Available from: https://www.
havior and watching television led to the worst outcomes. This may be
sedentarybehaviour.org/sbrn-terminology-consensus-project/.
attributable to the fact that television watching is a passive sedentary 8. Jochem C, Wallmann-Sperlich B, Leitzmann MF. The influence of sed-
behavior and that people often consume snacks while watching televi- entary behavior on cancer risk: epidemiologic evidence and potential
sion. Therefore, among the various types of sedentary behaviors, indi- molecular mechanisms. Curr Nutr Rep 2019;8:167-74.
viduals should refrain from watching television as much as possible, 9. Ainsworth BE, Haskell WL, Herrmann SD, Meckes N, Bassett DR Jr,
and snacking should be minimized while watching television. Tudor-Locke C, et al. 2011 Compendium of physical activities: a sec-
Even if the total daily sedentary time cannot be reduced for un- ond update of codes and MET values. Med Sci Sports Exerc 2011;43:
avoidable reasons, it is advisable to engage in sufficient exercise equiv- 1575-81.
alent to or more than 150–300 minutes of MPA per week, as studies 10. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and
found that physical activity could offset the adverse effects of sedentary mortality from all causes, cardiovascular disease, and cancer. Med Sci
Sports Exerc 2009;41:998-1005.
behavior. If sufficient exercise cannot be performed, individuals
11. Dunstan DW, Barr EL, Healy GN, Salmon J, Shaw JE, Balkau B, et al.
should at least perform light physical activity, as opposed to not engag-
Television viewing time and mortality: the Australian Diabetes, Obesi-
ing in physical activity at all as health benefits can be obtained even
ty and Lifestyle Study (AusDiab). Circulation 2010;121:384-91.
with light physical activity, albeit insufficient; they should further try to
12. Diaz KM, Duran AT, Colabianchi N, Judd SE, Howard VJ, Hooker SP.
increase their physical activity levels as their situations permit. Potential effects on mortality of replacing sedentary time with short
sedentary bouts or physical activity: a national cohort study. Am J Epi-
CONFLICT OF INTEREST demiol 2019;188:537-44.
13. Healy GN, Dunstan DW, Salmon J, Cerin E, Shaw JE, Zimmet PZ, et al.
No potential conflict of interest relevant to this article was reported. Breaks in sedentary time: beneficial associations with metabolic risk.

https://doi.org/10.4082/kjfm.20.0165
372  
www.kjfm.or.kr Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks

Diabetes Care 2008;31:661-6. of cardiovascular disease and diabetes: a systematic review and meta-
14. Dempsey PC, Larsen RN, Dunstan DW, Owen N, Kingwell BA. Sitting analysis. Am J Prev Med 2019;57:408-16.
less and moving more: implications for hypertension. Hypertension 30. Beunza JJ, Martinez-Gonzalez MA, Ebrahim S, Bes-Rastrollo M, Nunez
2018;72:1037-46. J, Martinez JA, et al. Sedentary behaviors and the risk of incident hy-
15. Yanagibori R, Kondo K, Suzuki Y, Kawakubo K, Iwamoto T, Itakura H, pertension: the SUN Cohort. Am J Hypertens 2007;20:1156-62.
et al. Effect of 20 days’ bed rest on the reverse cholesterol transport 31. Zhou J, Zhou Q, Wang DP, Zhang T, Wang HJ, Song Y, et al. Associa-
system in healthy young subjects. J Intern Med 1998;243:307-12. tions of sedentary behavior and physical activity with dyslipidemia.
16. Hamburg NM, McMackin CJ, Huang AL, Shenouda SM, Widlansky Beijing Da Xue Xue Bao Yi Xue Ban 2017;49:418-23.
ME, Schulz E, et al. Physical inactivity rapidly induces insulin resis- 32. Healy GN, Wijndaele K, Dunstan DW, Shaw JE, Salmon J, Zimmet PZ,
tance and microvascular dysfunction in healthy volunteers. Arterio- et al. Objectively measured sedentary time, physical activity, and met-
scler Thromb Vasc Biol 2007;27:2650-6. abolic risk: the Australian Diabetes, Obesity and Lifestyle Study (Aus-
17. Hamilton MT, Hamilton DG, Zderic TW. Role of low energy expendi- Diab). Diabetes Care 2008;31:369-71.
ture and sitting in obesity, metabolic syndrome, type 2 diabetes, and 33. Levine JA, Lanningham-Foster LM, McCrady SK, Krizan AC, Olson
cardiovascular disease. Diabetes 2007;56:2655-67. LR, Kane PH, et al. Interindividual variation in posture allocation: pos-
18. Bey L, Hamilton MT. Suppression of skeletal muscle lipoprotein lipase sible role in human obesity. Science 2005;307:584-6.
activity during physical inactivity: a molecular reason to maintain dai- 34. Ohlsson C, Gidestrand E, Bellman J, Larsson C, Palsdottir V, Hagg D, et
ly low-intensity activity. J Physiol 2003;551:673-82. al. Increased weight loading reduces body weight and body fat in
19. Zerwekh JE, Ruml LA, Gottschalk F, Pak CY. The effects of twelve obese subjects: a proof of concept randomized clinical trial. EClini-
weeks of bed rest on bone histology, biochemical markers of bone calMedicine 2020;22:100338.
turnover, and calcium homeostasis in eleven normal subjects. J Bone 35. Lund J. Weighing the evidence for a body mass-regulating gravitostat.
Miner Res 1998;13:1594-601. Proc Natl Acad Sci U S A 2018;115:E1334.
20. Kim H, Iwasaki K, Miyake T, Shiozawa T, Nozaki S, Yajima K. Changes 36. Schmid D, Leitzmann MF. Television viewing and time spent seden-
in bone turnover markers during 14-day 6 degrees head-down bed tary in relation to cancer risk: a meta-analysis. J Natl Cancer Inst
rest. J Bone Miner Metab 2003;21:311-5. 2014;106:dju098.
21. Smith SM, Davis-Street JE, Fesperman JV, Calkins DS, Bawa M, Macias 37. Lynch BM. Sedentary behavior and cancer: a systematic review of the
BR, et al. Evaluation of treadmill exercise in a lower body negative literature and proposed biological mechanisms. Cancer Epidemiol
pressure chamber as a countermeasure for weightlessness-induced Biomarkers Prev 2010;19:2691-709.
bone loss: a bed rest study with identical twins. J Bone Miner Res 2003; 38. Tworoger SS, Missmer SA, Eliassen AH, Barbieri RL, Dowsett M, Han-
18:2223-30. kinson SE. Physical activity and inactivity in relation to sex hormone,
22. Zwart SR, Hargens AR, Lee SM, Macias BR, Watenpaugh DE, Tse K, et prolactin, and insulin-like growth factor concentrations in premeno-
al. Lower body negative pressure treadmill exercise as a countermea- pausal women: exercise and premenopausal hormones. Cancer
sure for bed rest-induced bone loss in female identical twins. Bone Causes Control 2007;18:743-52.
2007;40:529-37. 39. Henson J, Yates T, Edwardson CL, Khunti K, Talbot D, Gray LJ, et al.
23. Demiot C, Dignat-George F, Fortrat JO, Sabatier F, Gharib C, Larina I, Sedentary time and markers of chronic low-grade inflammation in a
et al. WISE 2005: chronic bed rest impairs microcirculatory endotheli- high risk population. PLoS One 2013;8:e78350.
um in women. Am J Physiol Heart Circ Physiol 2007;293:H3159-64. 40. Murata M. Inflammation and cancer. Environ Health Prev Med 2018;
24. Katzmarzyk PT, Powell KE, Jakicic JM, Troiano RP, Piercy K, Tennant B, 23:50.
et al. Sedentary behavior and health: update from the 2018 Physical 41. Chastin SF, Mandrichenko O, Helbostadt JL, Skelton DA. Associations
Activity Guidelines Advisory Committee. Med Sci Sports Exerc between objectively-measured sedentary behaviour and physical ac-
2019;51:1227-41. tivity with bone mineral density in adults and older adults, the
25. Rillamas-Sun E, LaMonte MJ, Evenson KR, Thomson CA, Beresford NHANES study. Bone 2014;64:254-62.
SA, Coday MC, et al. The influence of physical activity and sedentary 42. Lee SH, Son C, Yeo S, Ha IH. Cross-sectional analysis of self-reported
behavior on living to age 85 years without disease and disability in sedentary behaviors and chronic knee pain among South Korean
older women. J Gerontol A Biol Sci Med Sci 2018;73:1525-31. adults over 50 years of age in KNHANES 2013-2015. BMC Public
26. Hamer M, Yates T, Demakakos P. Television viewing and risk of mor- Health 2019;19:1375.
tality: exploring the biological plausibility. Atherosclerosis 2017;263: 43. Huang Y, Li L, Gan Y, Wang C, Jiang H, Cao S, et al. Sedentary behav-
151-5. iors and risk of depression: a meta-analysis of prospective studies.
27. Imran TF, Ommerborn M, Clark C, Correa A, Dubbert P, Gaziano JM, Transl Psychiatry 2020;10:26.
et al. Television viewing time, physical activity, and mortality among 44. Zhai L, Zhang Y, Zhang D. Sedentary behaviour and the risk of depres-
African Americans. Prev Chronic Dis 2018;15:E10. sion: a meta-analysis. Br J Sports Med 2015;49:705-9.
28. Biswas A, Oh PI, Faulkner GE, Bajaj RR, Silver MA, Mitchell MS, et al. 45. Mullane SL, Buman MP, Zeigler ZS, Crespo NC, Gaesser GA. Acute ef-
Sedentary time and its association with risk for disease incidence, fects on cognitive performance following bouts of standing and light-
mortality, and hospitalization in adults: a systematic review and meta- intensity physical activity in a simulated workplace environment. J Sci
analysis. Ann Intern Med 2015;162:123-32. Med Sport 2017;20:489-93.
29. Bailey DP, Hewson DJ, Champion RB, Sayegh SM. Sitting time and risk 46. Fanning J, Porter G, Awick EA, Ehlers DK, Roberts SA, Cooke G, et al.

https://doi.org/10.4082/kjfm.20.0165
Jung Ha Park, et al. • Sedentary Lifestyle: Overview of Updated Evidence of Potential Health Risks www.kjfm.or.kr  373

Replacing sedentary time with sleep, light, or moderate-to-vigorous Sedentary behavior, physical activity, and all-cause mortality: dose-re-
physical activity: effects on self-regulation and executive functioning. J sponse and intensity weighted time-use meta-analysis. J Am Med Dir
Behav Med 2017;40:332-42. Assoc 2019;20:1206-12.
47. Ohlinger CM, Horn TS, Berg WP, Cox RH. The effect of active worksta- 55. Rees-Punia E, Evans EM, Schmidt MD, Gay JL, Matthews CE, Gapstur
tion use on measures of cognition, attention, and motor skill. J Phys SM, et al. Mortality risk reductions for replacing sedentary time with
Act Health 2011;8:119-25. physical activities. Am J Prev Med 2019;56:736-41.
48. John D, Bassett D, Thompson D, Fairbrother J, Baldwin D. Effect of us- 56. Gilchrist SC, Howard VJ, Akinyemiju T, Judd SE, Cushman M, Hooker
ing a treadmill workstation on performance of simulated office work SP, et al. Association of sedentary behavior with cancer mortality in
tasks. J Phys Act Health 2009;6:617-24. middle-aged and older US adults. JAMA Oncol 2020;6:1210-7.
49. Magnon V, Vallet GT, Auxiette C. Sedentary behavior at work and cog- 57. U.S. Department of Health and Human Services. Physical activity
nitive functioning: a systematic review. Front Public Health 2018;6: guidelines for Americans. 2nd ed. Washington (DC): U.S. Department
239. of Health and Human Services; 2018.
50. Bertrais S, Beyeme-Ondoua JP, Czernichow S, Galan P, Hercberg S, 58. Brown WJ, Bauman AE, Bull FC, Burton NW. Development of evi-
Oppert JM. Sedentary behaviors, physical activity, and metabolic syn- dence-based physical activity recommendations for adults (18-64
drome in middle-aged French subjects. Obes Res 2005;13:936-44. years): report prepared for the Australian Government Department of
51. Ekelund U, Steene-Johannessen J, Brown WJ, Fagerland MW, Owen N, Health. Canberra: Commonwealth of Australia; 2012.
Powell KE, et al. Does physical activity attenuate, or even eliminate, 59. Department of Health, Australian Government. Australian 24-hour
the detrimental association of sitting time with mortality?: a harmon- movement guidelines for the early years (birth to 5 years): an integra-
ised meta-analysis of data from more than 1 million men and women. tion of physical activity, sedentary behaviour, and sleep [Internet].
Lancet 2016;388:1302-10. Canberra: Commonwealth of Australia; 2019 [cited 2020 Jun 15]. Avail-
52. Lee Y, Son JS, Eum YH, Kang OL. Association of sedentary time and able from: https://www1.health.gov.au/internet/main/publishing.
physical activity with the 10-year risk of cardiovascular disease: Korea nsf/Content/ti-0-5years.
National Health and Nutrition Examination Survey 2014-2017. Korean 60. Commonwealth of Australia; Repatriation Commission. Choose
J Fam Med 2020 Feb 3 [Epub]. https://doi.org/10.4082/kjfm.19.0089. health: be active: a physical activity guide for older Australians. Can-
53. Stamatakis E, Gale J, Bauman A, Ekelund U, Hamer M, Ding D. Sitting berra: Commonwealth of Australia and the Repatriation Commission;
time, physical activity, and risk of mortality in adults. J Am Coll Cardiol 2005.
2019;73:2062-72. 61. Ministry of Health and Welfare. The Physical Activity Guide for Kore-
54. Xu C, Furuya-Kanamori L, Liu Y, Faerch K, Aadahl M, Seguin RA, et al. ans. Sejong: Ministry of Health and Welfare; 2013.

https://doi.org/10.4082/kjfm.20.0165