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  • Review Article
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Sit less and move more for cardiovascular health: emerging insights and opportunities

Nature Reviews Cardiology volume 18, pages 637–648 (2021)Cite this article

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Abstract

Sedentary behaviour — put simply, too much sitting, as a distinct concept from too little exercise — is a novel determinant of cardiovascular risk. This definition provides a perspective that is complementary to the well-understood detrimental effects of physical inactivity. Sitting occupies the majority of the daily waking hours in most adults and has become even more pervasive owing to the COVID-19 pandemic. The potential for a broad cardiovascular health benefit exists through an integrated approach that involves ‘sitting less and moving more’. In this Review, we first consider observational and experimental evidence on the adverse effects of prolonged, uninterrupted sitting and the evidence identifying the possible mechanisms underlying the associated risk. We summarize the results of randomized controlled trials demonstrating the feasibility of changing sedentary behaviour. We also highlight evidence on the deleterious synergies between sedentary behaviour and physical inactivity as the underpinnings of our case for addressing them jointly in mitigating cardiovascular risk. This integrated approach should not only reduce the specific risks of too much sitting but also have a positive effect on the total amount of physical activity, with the potential to more broadly benefit the health of individuals living with or at risk of developing cardiovascular disease.

Key points

  • Sedentary behaviour — that is, too much sitting, as a distinct concept from too little exercise — has been shown through observational and experimental findings to adversely affect cardiovascular health.

  • Observational evidence shows that sitting occupies the majority of adults’ waking hours and excessive sitting contributes to cardiovascular risk, particularly among individuals who do not meet the current physical activity recommendations.

  • Prolonged, uninterrupted sitting detrimentally affects several biological processes related to cardiovascular risk; high levels of sitting displace total physically active time, negating the cardiovascular benefits of skeletal muscle activity.

  • New evidence suggests the potential for broad cardiovascular health benefits through reducing and interrupting sitting time through practical and acceptable approaches involving ‘sitting less and moving more’.

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Fig. 1: Daily activities that involve sitting.
Fig. 2: Single-day activity data generated from the activPAL device.
Fig. 3: Potential mechanisms for the sitting-induced risk of cardiovascular disease.
Fig. 4: The SIT-ACT risk matrix.
Fig. 5: The ‘sitting less and moving more’ strategy.

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Acknowledgements

D.W.D. and N.O. thank the National Health and Medical Research Council, the Heart Foundation of Australia, and the Victorian Government Operational Infrastructure programme for ongoing support of their sedentary behaviour research programme. We are extremely grateful for the insights and guidance provided by P. Katzmarzyk (Pennington Biomedical Research Center, Baton Rouge, LA, USA) in the development of the SIT-ACT all-cause mortality matrix. Thanks to D. Kaye (Baker Heart & Diabetes Institute, Australia) for stimulating some key ideas and perspectives that have been incorporated into the Review. Thanks also to E. Winkler (University of Queensland, Australia) for providing assistance with the preparation of the figures relating to the device-based measured sitting and physical activity time from the Australian Diabetes, Obesity and Lifestyle Study (AusDiab).

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Authors and Affiliations

  1. Physical Activity Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia

    David W. Dunstan

  2. Behaviour, Environment and Cognition Research Program, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, Victoria, Australia

    David W. Dunstan

  3. Faculty of Health Sciences (Kinesiology), University of Ontario Institute of Technology, Oshawa, Ontario, Canada

    Shilpa Dogra

  4. School of Science, Technology and Health, York St John University, York, UK

    Sophie E. Carter

  5. Behavioural Epidemiology Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia

    Neville Owen

  6. Centre for Urban Transitions, Swinburne University, Melbourne, Victoria, Australia

    Neville Owen

Authors
  1. David W. Dunstan
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  2. Shilpa Dogra
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  3. Sophie E. Carter
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  4. Neville Owen
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Contributions

All the authors researched the data for the article, provided substantial contributions to discussions of its content, wrote the article, and undertook review and/or editing of the manuscript before submission.

Corresponding author

Correspondence to David W. Dunstan.

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Competing interests

The authors declare no competing interests.

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Nature Reviews Cardiology thanks U. Wisløff and the other, anonymous, reviewer(s) for their contribution to the peer review of this work.

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Glossary

Sedentary behaviours

Specific categories of sedentary behaviour, the most common include sitting during television viewing, video game playing and computer use (collectively termed ‘screen time’), sitting in automobiles and sitting while reading.

Sitting

A position in which an individual’s weight is supported by the buttocks rather than the feet and in which the back is upright.

Physical activity

Any bodily movement produced by skeletal muscles that results in energy expenditure.

Exercise

A component of physical activity; refers to activity that is planned, structured and repetitive for the purpose of improving or maintaining one or more components of physical fitness.

Physical inactivity

A level of weekly physical activity that is insufficient to meet present physical activity and health guidelines.

Physical activity guidelines

Recommendations from authoritative health-care bodies for practitioners and the public, specifying the type, amount and intensities of physical activity from which worthwhile health benefits should accrue.

Metabolic equivalent of task

(MET). Unit corresponding to multiples of the resting metabolic rate in humans (3.5 ml O2 per kg/min).

Lying

Being in a horizontal position on a supporting surface.

Reclining

A body position between sitting and lying.

Device-based measurement

Measures of physical activity based on hip-worn, wrist-worn or thigh-worn devices from which minute-by-minute measures of bodily acceleration and posture can be captured across a whole day.

Vigorous-intensity physical activity

Physical activities of >6 metabolic equivalent of tasks.

Total physical activity

Sum of time spent in physical activity of light, moderate and vigorous intensity.

Light-intensity physical activity

Physical activities of 1.5 to <3.0 metabolic equivalent of tasks.

Sedentary behaviour

Any waking behaviour characterized by an energy expenditure of <1.5 metabolic equivalent of tasks, while in a sitting, reclining or lying posture.

Self-reported measures

The type of exposure assessment that has been most typically used in epidemiological studies on physical activity and health outcomes, often using 1-week recall via a self-completion survey or interview.

Total sedentary time

Time spent in sedentary behaviour that can be inferred from minimal measured movement based on an accelerometer reading; for example, the total time accumulated below a defined threshold.

Moderate-intensity physical activity

Physical activities of 3 to <6 metabolic equivalent of tasks.

Interruptions to sedentary time

Transition from sitting to standing or moving so that prolonged periods of sitting time are regularly interrupted, with observational and experimental evidence suggesting health benefits from doing so.

Total sitting time

Time in which a specific measure of sitting can be derived from a thigh-worn monitor device (for example, the activPAL device), which uses accelerometer-derived information about both thigh position and acceleration to determine body posture (that is, sitting, lying or upright).

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Dunstan, D.W., Dogra, S., Carter, S.E. et al. Sit less and move more for cardiovascular health: emerging insights and opportunities. Nat Rev Cardiol 18, 637–648 (2021). https://doi.org/10.1038/s41569-021-00547-y

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