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 Global Burden of Disease Study (2017) estimates that, in the EU, in 2017 low physical activity accounted for almost 152,000 deaths and more than 2.1 million Disability-Adjusted Life Years (DALYs). It has also been calculated that physical inactivity cost the EU 80.4 billion euro per year, through four major non-communicable diseases (coronary heart disease, type II diabetes, colorectal and breast cancer), and through the indirect costs of inactivity-related mood and anxiety disorders [5].

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)[6]. 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 [7]. Adaptive changes in opioid systems (e.g. endorphins) are assumed to link regular exercise to the positive psychological responses [8]. 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 [9]. 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 [10]. These health risks have a dose-response relationship with sitting time: more hours of sitting lead to higher risks [11] [12]. 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 [11]; 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” [12]. 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 [13]. 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 [14].

The third health risk of a sedentary worker is pain and musculoskeletal disorders (MSDs) in the lower back, shoulders and neck. Prolonged sitting causes an increase of the intra discal load [15] and a sustained stretch of passive lumbar structures in combination with poor back muscle activity [16] [17]. The relationship between prolonged sitting and MSDs is not unclear [18]. Research has not found a clear link between occupational sitting and adverse musculoskeletal health outcomes such as low back pain, lower limb disorders or pain to the neck or shoulders [19]. Also the EU-OSHA report (2019) could not show a significant relationship between MSDs and sitting. The researchers compared data on self-reported MSDs and exposure to risk factors from the European Working Conditions Survey (EWCS). In the case of lower limb disorders, the results show that, the more workers sit, the less likely they are to report MSD complaints in the lower limbs[20]. The reason why studies find conflicting evidence for the association between sedentary work and MSDs might be due to the fact that MSD complaints are only partially linked to sitting behaviour itself, and that because of the multifactorial nature of MSDs also other factors such as general fitness, work organisation, and psychological stress etc. play a role[21].

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 [22].

Recommendations to reduce physical inactivity and sedentary time at the workplace

Global recommendations

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 [23] 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 [24]. Thus, physical activities others than exercise and sports were acknowledged to be beneficial for one’s health as well.

The Physical Activity Guidelines for Americans (2019) contain guidelines for different age groups [25]. The Key Guidelines for Adults declare:

  1. Adults should move more and sit less throughout the day. Some physical activity is better than none. Adults who sit less and do any amount of moderate-to-vigorous physical activity gain some health benefits.
  2. For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) to 300 minutes (5 hours) a week of moderate-intensity, or 75 minutes (1 hour and 15 minutes) to 150 minutes (2 hours and 30 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Preferably, aerobic activity should be spread throughout the week.
  3. Additional health benefits are gained by engaging in physical activity beyond the equivalent of 300 minutes (5 hours) of moderate-intensity physical activity a week.
  4. Adults should also do muscle-strengthening activities of moderate or greater intensity and that involve all major muscle groups on 2 or more days a week, as these activities provide additional health benefits.

These guidelines from 2019 replace the previous recommendations dating from 2007. The most important change is the introduction of a key recommendation on "sitting", and moreover it is considered as the first main point: Adults should move more and sit less throughout the day. Some physical activity is better than none[25]. The other recommendations (2 to 4) are similar to the recommendations for adults from the WHO Global recommendations on physical activity for health (2010)[26]. These global recommendations are used worldwide as the basis for national policies and strategies to promote physical activity.

EU Policy

In 2013 the EU issued the council recommendation on promoting health-enhancing physical activity across sectors (HEPA) [27]. This recommendation includes actions to be undertaken both by the member states and by the EU Commission and lists 23 indicators for measuring progress (the monitoring framework). The EU HEPA recommendation is closely linked with the WHO Global recommendations and asks member states for instance to measure the number of "Adults reaching the minimum WHO recommendation on physical activity for health or equivalent national recommendations. Percentage of adults reaching a minimum of 150 minutes of moderate-intensity physical activity per week, or 75 minutes of vigorous-intensity activity, or an equivalent combination".

Two indicators of the HEPA recommendation are specific to the workplace:

  • Schemes to promote active travel to work: Existence of a national or sub-national (where relevant) incentive scheme for companies or employees to promote active travel to work (e.g. walking, cycling)
  • Schemes to promote physical activity at the work place: Existence of a national or sub-national (where relevant) incentive scheme for companies to promote physical activity at the work place (e.g. gyms, showers, walking stairs etc.) [27].

The HEPA Recommendation called on each member state to appoint a national HEPA focal point to coordinate the collection at national level of information for the monitoring framework. Every 3 years a report is issued on the progress made in the member states on policies to promote health-enhancing physical activity and to evaluate physical activity levels [27]. All data on the state of affairs for each of the 23 indicators are available on the WHO European region information gateway [13].

The policy and strategy of the EU is aligned with the WHO European region. In 2015 the Physical activity strategy for the WHO European Region 2016–2025 has been published [28]. The strategy focuses on physical activity as a leading factor in health and well-being in the European Region, with particular attention to the burden of noncommunicable diseases associated with insufficient activity levels and sedentary behaviour. It aims to cover all forms of physical activity throughout the life-course. Objective 3.2. of this strategy focusses on the workplace and asks governments to Provide opportunities and counselling for physical activity at the workplace. More in particular: Member States may consider adopting appropriate measures, such as regulations and guidelines concerning health at the workplace, to enable more physical activity during the working day. The measures could include action to address the workplace layout, such as the provision of adjustable desks, prominent and promotional signs on staircases encouraging their use, regular breaks during the day to allow for physical activity and membership of a gym or sports club, or, for larger companies, company-run sports facilities and programmes. Implementation should be supported by occupational health and safety officers. Special attention could be paid to the diverse needs of different kinds of workplaces, sectors and employees, including the informal sector, and the self-employed population.

National policies

Since the publication of the HEPA Council recommendation in 2013 most of the member states have set national recommendations on physical activity for health. A study by Gelius et al. (2020)[29] makes a systematic comparative analysis between the different national recommendations and found that 23 out of 28 countries established such guidelines and 4 are currently developing them. Most countries follow the 2010 WHO Global Recommendations for Physical Activity, but there are notable differences in the delimitation of age groups (children/adolescents/adults/older adults). Some countries (11) have additional advice on avoiding inactivity and sitting among adults [29]. On the basis of a survey in 20 countries (2016) [30], it was found that in 12 countries (Belgium, Denmark, Finland, France, Germany, Ireland, Italy, Netherlands, Poland, Slovenia, Ukraine and United Kingdom) the promotion of physical health activity in the workplace setting is part of the national HEPA policies. The survey also indicated that in 8 countries financial incentives are used to support employers and employees for setting up actions that enhance physical activity in the workplace. Examples of such systems include tax refunds or benefits in general or concerning active travel to work and leisure time physical activity, and funding for workplace HEPA related activities [30].

Recommendations on sedentary behaviour

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 WHO global recommendations [26], 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 WHO global recommendations if he does not engage in moderate-to vigorous-intensity activity in leisure time or on his way to work. Given the health risks of sedentary behaviour, there is a growing demand for health guidelines to tackle sedentary behaviour. The fact that the 2019 US recommendations (see above) include now the recommendation to "move more and sit less" is significant. The guidelines are based on research concluding that the mortality risk related to sedentary behaviour is not observed among people who do 60 to 75 minutes of moderate-intensity physical activity a day. This amount of activity is far more than most Americans obtain. Therefore, both reducing sitting time and increasing physical activity will provide benefits. All types of activities such as taking stairs, doing errands by walking, or breaking up sedentary behaviour by standing and moving during the workday, increase the total physical activity over a day [25]. The global WHO recommendations don't yet (2020) include a guideline to reduce prolonged sitting but many countries have already integrated such guidelines in their national HEPA recommendations (see above). Some of the additions made by individual countries may be reflected in the planned update to the 2010 WHO Global Recommendations, work on which began in 2019 [29] [31]. Furthermore, based on scientific research various authors have advocated separate guidelines to tackle the health risks associated with sedentary behaviour. Ekblom-Bak et al. [9] 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.[32] advise to both limit the total daily sedentary time and to break up the sedentary time with non-seated activities. Hildebrandt et al.[33] 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”. Although the 'breaking of sedentary time at least twice an hour' can be found in the majority of experimental studies, there seems to be no sufficient evidence to determine if the length or breaks in sedentary behaviour are associated with health outcomes. Therefore, it appears difficult to support a clear recommendation for adults to limit time spent in total daily sitting to a specific value, as well as the length and frequency of breaks [34].

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 [35] [36] and for professionals with physically demanding jobs have been designed [37]. 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 [38], cycling to and from work [39], walking during lunchtime [40], promoting stair use [41], a workplace-based physical activity intervention program [42], active computer breaks in which the employee typically performs a set of flexibility and/or strength exercises [43] and walking or cycling while performing the usual work tasks [44] [45]. 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’ [46] or ‘active workstations’ [47].

Physical activity programmes in an occupational setting

Numerous worksite health promotion programmes (WHPPs) have been implemented and tested in the past decades. 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 [48]. The evidence on physical health (body weight, body fat or BMI, blood pressure) is mixed: both positive results [49], modest effects [48] [50] and no evidence [51] are reported. As to physical activity levels, the evidence is either positive [52] or inconclusive [51]. For work related parameters (performance, 'presenteeism', well-being), the evidence is either modest [48] or inconclusive [53]. A report elaborated for the EU Commission (2017) brings together available evidence on the effectiveness of initiatives to enhance physical activity at the workplace. The report concludes that some of the most successful examples of workplace physical activity interventions are those which allow physical activity to become embedded in the company’s culture and daily practices. More successful interventions tend to integrate regular moderate physical activity as part of employees’ daily work schedule [54]

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. 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 [44] [55][45] [56] [57] [47], cycling [45] [58] [59]or stepping [60]. 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 WHO global recommendations, but it does increase the energy expenditure to 100 kcal/day in average persons [55] and 120 kcal/hour in obese subjects [44]. 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 [56] [45] [47]. However, mental tasks were unaffected [56] [57] [47]. Both stepping and cycling while working increase the energy expenditure even more (compared to sitting, respectively: +289 kcal/hour,[60]; +186 kcal/day, [56] and are for most persons sufficiently intensive to meet the WHO global recommendations. However, the body movements associated with more intensive cycling can lead to more errors in work performance [45]. Even passive cycling (with a motor driving the pedals) was found increase the energy expenditure, compared to resting levels [59].

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 [61]. 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% [62] and 6.8% [63] are reported as a result of, respectively, a mixed exercise-lifestyle intervention and a computer “prompt to stand one minute every 30 minutes”. Taking short breaks (one to two minutes every half hour) seems to reduce time spent sitting at work by 15 to 66 minutes per day more than taking long breaks (two 15-minute breaks per workday) [64]. Sitting more than normal (“as much as possible”) was shown to decrease the insulin sensitivity in humans after seven days [65], 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 [66]. Remarkably, both light and moderate-intensity activities during the two-minute break yielded these positive blood parameters. The use of a sit-stand desk is one solution to break up and reduce sedentary time. Research shows that the use of sit-stand desks may reduce workplace sitting [64] and MSDs [67]. An important point to note is that the availability of a sit-stand desk not automatically leads to the use of the sit-stand feature. Reasons for low utilisation include that users consider it too much trouble to adjust the desk and the difficulty of getting comfortable in the standing position. Therefore, companies need to invest in awareness raising and training to motivate users for sit-stand workstation use[67].

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Links for further reading

EU-OSHA – European Agency for Safety and Health at Work, Work-related musculoskeletal disorders: prevalence, costs and demographics in the EU, 2019. Available at: [14]

EU-OSHA - European Agency for Safety and Health at Work, Practical tools and guidance on musculoskeletal disorders, Available at: [15]

EU-OSHA – European Agency for Safety and Health at Work, Factsheet 93 - Workplace Health Promotion for Employers, 2010. Available at: [16]

ENWHP – The European Network for Workplace Health Promotion [17]

EU Science Hub, Health promotion and disease prevention, knowledge gateway, Physical activity and sedentary behaviour. Retrieved 8 April 2020 from [18]