Recommendations and interventions to decrease physical inactivity at work

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Dianne Commissaris, Marjolein Douwes, TNO


Introduction

Many contemporary work tasks, e.g. at an office workplace, are characterised by physical inactivity and by long periods of uninterrupted sitting. These characteristics increase the risk of several health problems, among others obesity, cardiovascular disorders, diabetes, cancer, musculoskeletal disorders of lower back, neck and shoulders, and lower limb problems. Noteworthy is that the health risks associated with the sedentary character of work cannot be fully compensated by physical exercise in leisure time. Recommendations and various interventions to prevent physical inactivity and diminish sedentary time at the workplace have been developed. This article describes the health risks, recommendations and some of the interventions.

Health risks of physical inactivity and sedentary work

Occupations and activities with physical inactivity are, for instance, office workers, drivers, teachers, researchers, laboratory workers and process and security surveillance. As early as the 1950s, the first evidence for the harmful effects of physical inactivity was delivered by Morris and co-workers [1] who found that bus drivers had a higher risk of coronary heart diseases than bus conductors. Since then, many studies have shown associations and causal relations between physical inactivity and increased risks for cardiovascular disorders, type II diabetes, obesity, cancer (colon and breast), high blood pressure, musculoskeletal complaints and psychological disorders (depression and anxiety) [2]; [3]. Physical inactivity in both work and leisure time is estimated to be responsible for about one-third of the annual deaths due to coronary heart disease, colon cancer and diabetes in the USA [4].

Worldwide, the World Health Organisation (WHO)[3] estimates that each year 1.9 million people die a premature death because of an inactive lifestyle. If everyone would meet the general guidelines on physical activity, the annual number of premature deaths worldwide could diminish with 20-30%, which are about 400,000 to 600,000 persons [2]The physiological links between physical inactivity and the health risks mentioned above is complex and multi factorial. Physical activity was found to: improve high-density lipoprotein (HDL) cholesterol and serum triglyceride levels and reduce blood pressure (reducing the risk of cardiovascular disorders); enhance fibrinolysis and platelet function (reducing the risk of acute thrombosis); improve glucose tolerance and insulin sensitivity (reducing the risk of type II diabetes); reduce the sensitivity of the myocardium to catechol amines (reducing the risk of heart arrhythmias)[5]. As to the psychological functioning, physical activity was found to: improve mood, self-esteem, self-concept and self-efficacy; improve the quality of sleep and reduce fatigue [6]. Adaptive changes in opioid systems (e.g. endorphins) are assumed to link regular exercise to the positive psychological responses [7]. More information about health and well-being in workplaces can be found in Health and well-being.

A second health risk of physical inactivity at work is associated with the seated nature of some tasks. Especially office work and driving tasks are characterised by long periods of uninterrupted sitting. Recent research, since the year 2000, has shown that such long periods of uninterrupted sitting entail an independent health risk; independent of the amount of physical activity a person has when he or she is not sitting [8]. This means that persons with sedentary jobs who are engaged in sports several evenings of the week still have a higher health risk than persons with non-sedentary jobs, like construction work, who are also engaged in sports several evenings of the week. The established health risks associated with sedentary work are: premature death in general, type II diabetes and obesity [9]. These health risks have a dose-response relationship with sitting time; more hours of sitting lead to higher risks [10]; [11]. For instance, each 2 hours/day increase in sitting at work was associated with a 5% increase in obesity and a 7% increase in risk of diabetes [10]; and persons who reported to be “sitting almost all of the time” had a 1.5 higher chance to be dead 12 years after the start of the study than persons who reported to be “sitting almost none of the time” [11]. The physiological link between sustained periods of uninterrupted sitting and the health risks mentioned above is assumed to be the lack of weight bearing activity of leg muscles. In rats, forced inactivity of one leg led to a reduction of a muscle protein (lipoprotein lipase, LPL) that is crucial for the uptake of free fatty acids into skeletal muscle and adipose tissue [12]. In turn, low levels of this LPL are associated with increased levels of circulating triglycerides and decreased levels of HDL cholesterol. In humans, an equivalent association between decreased leg muscle inactivity (more hours of sitting) and adverse levels of blood parameters (HDL-cholesterol, triglycerides, insulin) was found <ref.Healy, G.N., Matthews, C.E., Dunstan, D.W., Winkler, E.A.H., Owen, N., ‘Sedentary time and cardio-metabolic biomarkers in US adults: NHANES 2003–06’, European Heart Journal, Vol. 32, No 5, 2011, pp. 590-597</ref>.

The third health risk of a sedentary worker is pain and musculoskeletal disorders MSD in the lower back, shoulders and neck. Prolonged sitting causes an increase of the intra discal load [13] and a sustained stretch of passive lumbar structures in combination with poor back muscle activity [14]; [15]. Although epidemiological reviews provide conflicting evidence for the association between sedentary work and low back pain [16] prolonged sitting is considered as risk factor for developing low back pain. In addition, long periods of visual focus on the computer screen require prolonged static muscle exertions. These may, even at low intensity levels, lead to pain and musculoskeletal disorders in the upper back and neck area [17]. working postures. Since this article focusses on the general (physiological) health risks of physical inactivity, the description of the local (musculoskeletal) health risks is limited to the notion of their presence and nature. The same holds for another local health risk, deep vein thrombosis in the lower limbs, for which the risk was found to increase by 10% per hour longer seated [18].

Recommendations to reduce physical inactivity and sedentary time at the workplace

Although the link between sitting at work and an increased risk of coronary heart disease was already established in the 1950s [1],this did not lead to guidelines about physical activity and interventions to reduce physical inactivity at work. Instead, researchers focussed on the health effects of physical exercise and sports in leisure time. It should be noted that physical exercise implies a structured, more or less regular, leisure-time pursuit, whereas physical activity also arises in domestic or occupational tasks. All research on the health effects of physical exercise led to a general guideline of the American College of Sports Medicine [19] promoting at least 20 minutes of vigorous-intensity physical activity (i.e. exercise) on at least three days of the week. In 1996 the US Surgeon General added a recommendation to this guideline, promoting at least 30 minutes of moderate-intensity physical activity on most, preferably all days of the week [20]. Thus, physical activities others than exercise and sports were acknowledged to be beneficial for one’s health as well. The most recent update of the US Guidelines on Physical Activity and Public Health was issued in 2007 [21] and declares:

  • “To promote and maintain health, all healthy adults aged 18 to 65 year need moderate-intensity aerobic (endurance) physical activity for a minimum of 30 minutes on five days each week or vigorous-intensity aerobic physical activity for a minimum of 20 minutes on three days each week.”
  • “Combinations of moderate- and vigorous-intensity activity can be performed to meet this recommendation. For example, a person can meet the recommendation by walking briskly for 30 minutes twice during the week and then jogging for 20 minutes on two other days.”
  • “Moderate-intensity aerobic activity, which is generally equivalent to a brisk walk and noticeably accelerates the heart rate, can be accumulated toward the 30-minutes minimum by performing bouts each lasting 10 or more minutes. Vigorous-intensity activity is exemplified by jogging, and causes rapid breathing and a substantial increase in heart rate.”
  • “This recommended amount of aerobic activity is in addition to routine activities of daily living of light intensity (e.g. self-care, cooking, casual walking or shopping) or activities of daily living of moderate intensity lasting less than 10 minutes in duration (e.g. walking around home or office, walking from the parking lot).”
  • “In addition, every adult should perform activities that maintain or increase muscular strength and endurance. It is recommended that 8-10 exercises be performed on two or more non-consecutive days each week using the major muscles of the body.”
  • ”Because of the dose-response relation between physical activity and health, persons who wish to further improve their personal fitness, reduce their risk for chronic diseases and disabilities or prevent unhealthy weight gain may benefit by exceeding the minimum recommended amounts of physical activity.”

The physical activity advised in these guidelines is assumed to take place in leisure time. Though the recommendations are not specifically aimed at working time, moderate to vigorous-intensity physical activity bouts of at least 10 minutes at the workplace do meet the guidelines as well. However, the guidelines do not include activities at work of light intensity (e.g. walking around or working at a sit-stand desk) or of moderate intensity lasting less than 10 minutes (e.g. walking the stairs). Recent studies suggest, though, that activities of light intensity have beneficial health effects as well [8]Ekblom-Bak, E., Hellénius, M.-L., Ekblom, B., ‘Are we facing a new paradigm of inactivity physiology?’, British Journal of Sports Medicine, Vol. 44, No 12, 2010, pp. 834-835</ref>, which implies that the US Guidelines on Physical Activity and Public Health do not yet cover the full spectrum of health enhancing activities. A draft recommendation for activities of light intensity is presented below. It should be noted that the US Guidelines concern healthy American adults aged 18 to 65 year and that specific guidelines are available for children, adolescents and older people, for adults with chronic diseases that impair their ability to exercise and for women in their pregnancy or post-partum. Furthermore, most countries outside the USA have translated the US guidelines to national guidelines on physical activity and public health. As the current Pan-European and national physical activity recommendations in Europe are mainly based on the 1996 US Guidelines, Oja et al. [22] propose to review these European recommendations and update them with the most recent research evidence.

At this moment (April 2012) there is no international legislation concerning physical activity promotion at the workplace. At a national level, however, initiatives towards guidelines are present in Norway, Germany, Poland and The Netherlands. In Norway, since 2006 legislation states that “The employer must, in relation to the systematic management of health, environment and safety, consider initiatives to promote physical activity among the employees” (§3–4) [23]. In the same year, the Netherlands Organisation for Applied Scientific Research TNO published its “Recommendations for sufficient physical activity at work” [24]. These advice that: “On an 8-hours workday, an adult employee accumulates 30 minutes or more of moderate-intensity physical activity, either during work, during the lunch break, or on his/her way to or from work.” The Norwegian and Dutch initiatives have not yet been systematically implemented at the workplace nor evaluated with respect to their health improving effects. In 2007, a new occupational safety and health (OSH) strategy was adopted in Germany [25]. This promotes the systematic protection of occupational safety and health in companies with tasks involving “imbalanced stress or low mobility”. The strategy does not yet seem to be translated into specific legislation or regulations, though. Finally, in Poland a Council for Dietary, Physical Activity and Health was established in November 2007 [26]. Its main aim is to increase awareness of the influence of dietary habits and physical activity on health. Given the involvement of the Polish Labour Inspectorate, the Council wishes to reach both the public and occupational domains. To our knowledge, no regulations or guidelines have been issued to date.

As explained in the Health risks paragraph, physical inactivity is not the same as being sedentary. A person with a sedentary (e.g. office) job can be sufficiently active, according to the US Guidelines, in leisure time or on his way to work. Likewise, a person with a non-sedentary job (e.g. construction) can still fail to meet the US Guidelines if he does not engage in moderate- to vigorous-intensity activity in leisure time or on his way to work. Given the recently discovered health risks of sedentary behaviour and the fact that these risks seem to have other physiological mechanisms than the health risks associated with a lack of physical activity, separate guidelines are advocated by various authors. Ekblom-Bak et al. [8]Ekblom-Bak, E., Hellénius, M.-L., Ekblom, B., ‘Are we facing a new paradigm of inactivity physiology?’, British Journal of Sports Medicine, Vol. 44, No 12, 2010, pp. 834-835</ref> state that: “…the focus in clinical practice and guidelines should not only be to promote and prescribe exercise, but also to encourage people to maintain their intermittent levels of non-exercise daily activities.” Based on epidemiological studies on sedentary behaviour and health parameters, Healy et al.[27] advise to both limit the total daily sedentary time and to break up the sedentary time with non-seated activities. Hildebrandt et al.[28] seem the first to issue a guideline on sedentary behaviour. They propose to “limit the total daily sedentary time” and to break up prolonged sitting “every half hour for at least two minutes with standing and/or walking”. Given the limited number of intervention studies (see next paragraph), the recommendations proposed here should be considered as preliminary guidelines.

Interventions

Following the first scientific evidence about the health effects of a sedentary versus physically active job in 1953 [1], numerous exercise promotion interventions for the general population [29]; [30] and for professionals with physically demanding jobs have been designed [31]. Though potentially beneficial for a worker’s health, most of these interventions did not involve the workplace. In the 1980s, the awareness arose that the workplace could be a platform for physical activity interventions too. Since then, various initiatives are described, for instance: a fitness program aimed at reducing work related stress [32], cycling to and from work [33], walking during lunchtime [34], promoting stair use [35], a workplace-based physical activity intervention program [36], active computer breaks in which the employee typically performs a set of flexibility and/or strength exercises [37] and walking or cycling while performing the usual work tasks [38] ; [39]. Two types of interventions can be distinguished: physical activity programmes organised in an occupational setting that do not involve the actual work; and physical activity modes performed at the workplace, during the actual work. The latter are called ‘dynamic workstations’ [40] or ‘active workstations’ [41].

Physical activity programmes in an occupational setting

Numerous worksite health promotion programmes (WHPPs) have been implemented and tested in the past decades. work health promotion. Five recent reviews (i.e. after 2005) summarise the effects of these programmes, that combine physical activity with dietary interventions. On psychosocial health (stress, mood, emotional well-being), the reviews report the most conclusive evidence for positive effects of WHPPs [42]. The evidence on physical health (body weight, body fat or BMI, blood pressure) is mixed: both positive results [43], modest effects [42]; [44] and no evidence [45] are reported. As to physical activity levels, the evidence is either positive [46] or inconclusive [45]. For work related parameters (performance, 'presenteeism', well-being), the evidence is either modest [42] or inconclusive [47].

Dynamic workstations

Dynamic workstations seem a promising intervention to reduce the physical inactivity related health risks at work. Given the dose-response relationship between physical activity and health, and the long hours spent behind a computer every day, the potential benefits of combining physical exercise with computer work are huge musculoskeletal disorders in VDUs task. Moreover, dynamic workstations have the ability to tackle the problem at the source: the workplace itself. Recent studies have investigated the combination of computer work and walking [38]; [48];[39]; [49]; [50]; [41], cycling [39]; [51]; [52]or stepping [53]. In general, these studies report positive health outcomes, though sometimes at the expense of diminished work performance.

Figure 1: Example of a Dynamic Workstation; a treadmill desk


Mynewimage.jpg

Source: Reproduced with written permission of Steelcase, Amsterdam, the Netherlands


Walking while working is not sufficiently intensive to meet the US Guidelines on Physical Activity and Public Health, but it does increase the energy expenditure to 100 kcal/day in average persons [48] and 120 kcal/hour in obese subjects [38]Levine, J.A., Miller, J.M., ’The energy expenditure of using a “walk-and-work” desk for office workers with obesity’, British Journal of Sports Medicine, No 41, 2007, pp. 558-561</ref>. The consecutive weight loss in the latter case could be 20-30 kg per year if 2-3 hours of daily sitting at the computer were replaced by walking. The body movements related to walking were found to influence computer tasks requiring hand or finger use, such as typing and mouse pointing, which were performed slower and with more errors [49]; [39]; [41]. However, mental tasks were unaffected [49]; [50]; [41]. Both stepping and cycling while working increase the energy expenditure even more (compared to sitting, respectively: +289 kcal/hour,[53]; +186 kcal/day, [49] and are for most persons sufficiently intensive to meet the US Guidelines on Physical Activity and Public Health. However, the body movements associated with more intensive cycling can lead to more errors in work performance [39]. Even passive cycling (with a motor driving the pedals) was found increase the energy expenditure, compared to resting levels [52].

Reducing and breaking up sedentary time

As physical inactivity and being sedentary have dissimilar health risks and determinants, interventions should be dissimilar as well. To tackle the sedentary problem, any activity that breaks up the sitting posture with sufficient leg muscle activity has a potential health benefit. Until 2010, interventions always focussed on increasing physical activity with, sometimes, a secondary aim to decrease sedentary time [54]. None of the physical inactivity interventions proved to decrease sedentary time. The first studies aimed at decreasing and breaking up sedentary time show promising short-term effects with respect to sedentary time and health parameters. Decreases in sedentary time of 8% [55] and 6.8% [56] are reported as a result of, respectively, a mixed exercise-lifestyle intervention and a computer “prompt to stand one minute every 30 minutes”. Sitting more than normal (“as much as possible”) was shown to decrease the insulin sensitivity in humans after seven days [57], whereas sitting less than normal (a two-minutes break every 20 minutes) led to a decrease in blood glucose and insulin in non-diabetic persons after seven hours [58]. Remarkably, both light and moderate-intensity activities during the two-minute break yielded these positive blood parameters. Use of a sit-stand desk is one solution to break up and reduce sedentary time.

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Links for further reading

EUROFOUND – European Foundation for the Improvement of Living and Working Conditions, Musculoskeletal disorders and organisational change, 2007. Available at: http://www.eurofound.europa.eu/pubdocs/2007/114/en/1/ef07114en.pdf

EU-OSHA – European Agency for Safety and Health at Work, ‘Risk Observatory; Expert forecast on emerging physical risks related to occupational safety and health’, chapter 5.1: Lack of Physical Activity, European Communities, Brussels, Belgium, 2005. Available at: http://osha.europa.eu/en/publications/reports/6805478/view

European Parliament, ‘New Forms of Physical and Psychosocial Health Risks at Work’, chapter 3.1: Physical inactivity/lifestyle at work/obesity; chapter 7.3.1: National approaches to physical inactivity at work, European Parliament, Policy Department Economy and Science, Brussels, Belgium, 2008.

EU-OSHA – European Agency for Safety and Health at Work (no publishing date). Work Place Health promotion (Single entry point). Retrieved 16 April 2012, from: http://osha.europa.eu/en/topics/whp

EU-OSHA – European Agency for Safety and Health at Work. MSDs (Single entry point). Retrieved 16 April 2012, from: http://osha.europa.eu/en/topics/msds

ENWHP – The European Network for Workplace Health Promotion; European Toolbox. Retrieved 16 April 2012, from: http://www.enwhp.org/european-toolbox.html