Sedentary time assessed by actigraphy and mortality: The Rotterdam Study

doi:10.1016/j.ypmed.2016.11.021

Preventive Medicine

Volume 95, February 2017, Pages 59-65

https://doi.org/10.1016/j.ypmed.2016.11.021 Get rights and content

Highlights

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We measured sedentary behavior with actigraphy in 1839 middle-aged and elderly adults.
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Objectively measured sedentary behavior is associated with increased mortality risk over 11 years follow-up.
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After adjusting for activities of daily living, physical activity and 24h activity measures, the association was attenuated.

Abstract

Research suggests that sedentary behavior is a risk factor for mortality. However, most studies rely on questionnaires, which are prone to reporting error. We examined the association between sedentary time assessed by actigraphy and mortality among 1839 participants, aged 45–98 years, from the prospective population-based Rotterdam Study, enrolled between 2004 and 2007. Participants wore an actigraph around the wrist for seven days. Sedentary time was evaluated continuously, per 1 h/day increase, and categorically in three groups (< 8, 8–11, ≥ 11 h/day). The lowest category was used as reference. Mortality risks were examined using Cox proportional hazard models, adjusted for confounders and biological risk factors. We examined the association between sedentary behavior and mortality over and beyond other activity measures (including physical activity (PA) and activities of daily living (ADL)) in a final model. During 11 years of follow-up (median: 7.5 years, interquartile range: 6.6–8.3 years), 212 participants (11.5%) died. In the multivariable model, the hazard ratio (HR) and 95% confidence interval (95% CI) per 1 more hour/day sedentary time was 1.09 (1.00, 1.18). The HR (95% CI) after adjustment for PA and ADL was 1.04 (0.96, 1.13). Participants sedentary for ≥ 11 h/day had a higher mortality risk (HR: 1.80, 95% CI: 1.14, 2.84) than those sedentary < 8 h/day, in the multivariable model. After adjusting for PA and ADL, this association was clearly attenuated (HR: 1.50, 95% CI: 0.93, 2.41). In conclusion, our study suggests that sedentary behavior is a risk factor for mortality. Further investigation is needed to examine whether this association is distinct from the effect of other measures of activity.

Introduction

Over the last decades, the benefits of physical activity (PA) have been well documented. Several studies have shown that people who do not engage in regular moderate physical activity are at increased risk of mortality (Kujala et al., 1998, Leitzmann et al., 2007, Lollgen et al., 2009). Other studies documented that sedentary behavior is a risk factor for mortality (Biswas et al., 2015). Sedentary behavior is defined as engaging in sitting or reclining behaviors during the waking day, which result in little energy expenditure above rest (Owen et al., 2010, Tremblay, 2012). Recent meta-analyses have shown self-reported sedentary behavior to be associated with all-cause mortality, cardiovascular disease mortality and cancer mortality, independent of self-reported PA (Biswas et al., 2015, Chau et al., 2013). However, self-reported data is known to be prone to reporting errors and recall bias, especially for low intensity behaviors (Ainsworth et al., 1993, Sallis and Saelens, 2000).

To date, few studies examined the association between objectively measured sedentary behavior and mortality (Ensrud et al., 2014, Koster et al., 2012, Schmid et al., 2015). Two studies in middle-aged adults, with an average follow up of 2.8 and 2.9 years, showed that objectively measured sedentary time was associated with mortality independent of PA (Koster et al., 2012, Schmid et al., 2015). This observation is supported by a study in men aged 71 years and older, followed for an average of 4.5 years (Ensrud et al., 2014). Due to the relatively short follow-up, there is a high chance for reverse causation in all of these studies. In this regard, adults could have higher levels of sedentary behavior because of their reduced health status (or underlying disease), and this reduced health could also increase their mortality risk. To minimize the effect of reverse causality, it is warranted to examine the association between sedentary behavior and mortality with longer follow-up and to evaluate the association after excluding the first years of follow-up.

To address the long-term effects of sedentary behavior, we used data from the Rotterdam Study, of adults aged 45 years and older with 11 years of follow-up, and examined the association between sedentary behavior assessed by actigraphy and all-cause mortality.

Section snippets

Study population

This study was embedded in the Rotterdam Study, a prospective population-based cohort in the Netherlands which started in 1990. The aim of the study was to examine the incidence of risk factors for neurological, cardiovascular, psychiatric, and other chronic diseases. Details of the study have been published previously (Hofman et al., 2015).

From December 2004 to April 2007 2632 consecutive participants of the Rotterdam Study were invited to participate in the actigraphy study. The current study

Results

From the 1839 participants in the study, 10,852 valid days were recorded, for an average of 5.8 (SD: 0.5) days per participant. Baseline characteristics of the study population according to categories of sedentary behavior are shown in Table 1. Participants sedentary for ≥ 11 h were older, more often male and more often had prevalent diabetes or coronary heart disease, compared to participants sedentary < 8 h per day. The average time spent in sedentary behavior was 8.8 h (SD: 2.0) per day, which

Discussion

In this population-based cohort study, we found that time spent in sedentary behavior, assessed by actigraphy, was associated with a higher mortality risk in middle-aged and elderly adults. Participants sedentary for > 11 h a day had a significantly higher mortality risk than participants sedentary for < 8 h per day. These associations remained after adjustments for health behaviors and risk factors and after excluding the first two years of follow-up. However, after adjusting for other measures of

Conclusion

In conclusion, in this population of middle-aged and elderly adults, high levels of sedentary time were associated with mortality risk. After adjustment for other measures of activity, the association was clearly attenuated. Further investigation is needed to examine whether sedentary behavior is a risk factor for mortality, distinct from the effect of other measures of activity.

Author contributions

CK, KD, FJAvR, DK, OHF, HT and AH participated actively in each of the following aspects for this article: conception and design or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content and final approval of the version to be published.

Transparency document

Transparency document.

Acknowledgments

All authors declare that there are no competing interests. This work was supported by a Netherlands Organization for Scientific Research grant (017.106.370) awarded to H.T. The Rotterdam Study is funded by Erasmus Medical Center and Erasmus University Rotterdam; Netherlands Organization for the Health Research and Development; the Research Institute for Diseases in the Elderly; the Ministry of Education, Culture and Science; the Ministry for Health, Welfare and Sports; and the European

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Cited by (19)

Device-Measured Physical Activity and Sedentary Behavior in Relation to Cardiovascular Diseases and All-Cause Mortality: Systematic Review and Meta-Analysis of Prospective Cohort Studies
2023, AJPM Focus
This review synthesized evidence from prospective cohort studies on the association of device-measured physical activity and sedentary behavior with cardiovascular disease and all-cause mortality among adults.
Five databases were searched from 2000 through April 29, 2020. Study quality was appraised using the NIH Quality Assessment Tool. Pooled hazard ratio and 95% CI were obtained from random-effects meta-analyses. Subgroup analyses by age and sex were conducted for studies on all-cause mortality.
Of 29 articles included in the systematic review, 5 studies on cardiovascular disease mortality and 15 studies on all-cause mortality were included in meta-analyses. Comparing the highest with the lowest exposure categories, the pooled hazard ratios (95% CIs) for cardiovascular disease mortality were 0.29 (CI=0.18, 0.47) for total physical activity, 0.37 (CI=0.25, 0.55) for moderate-to-vigorous physical activity, 0.62 (0.41–0.93) for light physical activity, and 1.89 (CI=1.09, 3.29) for sedentary behavior. The pooled hazard ratios (95% CIs) for all-cause mortality were 0.42 (CI=0.34, 0.53) for total physical activity, 0.43 (CI=0.35, 0.53) for moderate-to-vigorous physical activity, 0.58 (CI=0.43, 0.80) for light physical activity, and 1.58 (CI=1.19, 2.09) for sedentary behavior. The pooled hazard ratio (95% CI) for all-cause mortality was 0.35 (CI=0.29, 0.42) for steps per day, but the studies available for analysis were conducted in older adults. The results of subgroup analyses were consistent with the main results.
Rapidly accumulating evidence suggests that more physical activity and less sedentary behavior are associated with a lower risk of cardiovascular disease and all-cause mortality. Similar beneficial relationships were found for step counts and all-cause mortality among older adults. Future studies employing standardized research methodologies and up-to-date data processing approaches are warranted to recommend specific amounts of physical activity and limits to sedentary behavior.
Confounding due to pre-existing diseases in epidemiologic studies on sedentary behavior and all-cause mortality: a meta-epidemiologic study
2020, Annals of Epidemiology
Citation Excerpt :
All studies adjusted for (moderate-to-vigorous) physical activity in the models [14–38]. Twenty-two studies [14–26,29–36,38] (88%) reported positive associations between sedentary behavior and all-cause mortality. Among those, E-values ranged from 1.27 [20] to 3.39 [38] (Fig. 2).
We examined the influence of confounding due to pre-existing diseases in prospective studies on sedentary behavior and all-cause mortality.
We analyzed 25 studies included in systematic reviews. The risk of confounding due to pre-existing diseases was assessed by five methodologic characteristics.
Sedentary behavior was associated with higher all-cause mortality. Studies with short average follow-up length had stronger magnitudes of association: 1 to less than 5 years (hazard ratio [HR], 1.58; 95% confidence interval [CI], 1.28–1.94), 5 to 9 years (HR, 1.24; 95% CI, 1.16–1.31), and 10 years or more of follow-up (HR, 1.20; 95% CI, 1.10–1.31). Studies that did not adjust for diseases at baseline, did not exclude deaths in the first years of follow-up, and did not exclude participants with diseases/conditions showed stronger associations. Studies with higher risk of confounding because of pre-existing diseases (HR, 1.40; 95% CI, 1.27–1.54) showed stronger association than lower risk studies (HR, 1.18; 95% CI, 1.10–1.27). Studies excluding participants with diseases at baseline had weaker associations compared with studies adjusting for diseases in models.
Sedentary behavior was associated with increased all-cause mortality, although confounding due to pre-existing diseases may bias the magnitude of the association.
Instrumented measures of sedentary behaviour and physical activity are associated with mortality in community-dwelling older adults: A systematic review, meta-analysis and meta-regression analysis
2020, Ageing Research Reviews
Citation Excerpt :
Table 2 presents an overview of the associations between i-SB or i-PA and mortality. Eight articles reporting on 35,845 participants with 2195 deaths were included (Diaz et al., 2017; Ensrud et al., 2014; Fox et al., 2014; Jefferis et al., 2019; Klenk et al., 2016; Koolhaas et al., 2017; Lee et al., 2018; Schmid et al., 2016). A statistically significant positive association between sedentary behaviour and risk for mortality in all but one study was found (Fox et al., 2014).
Sedentary behaviour (SB) and physical activity (PA) can be objectively assessed with inertial sensors to describe bodily movement. Higher SB and lower PA is associated with higher chronological age and negative health outcomes. This study aimed to quantify the association between instrumented measures of SB (i-SB) and PA (i-PA) and mortality in community-dwelling older adults, to subsequently compare the quantitative effect sizes and to determine the dose-response relationships.
An electronic search in six databases from inception to 27th of June 2019 was conducted. All articles reporting on i-SB or i-PA and mortality in community-dwelling older adults aged 60 years or older were considered eligible. A meta-analysis was conducted for the association between i-SB and i-PA and mortality expressed in Hazard Ratios (HR) and 95% Confidence Intervals (95% CI). A meta-regression analysis was performed to determine the dose-response relationship between i-SB and steps per day and mortality.
Twelve prospective articles representing eleven cohorts, reporting data of 38,141 participants were included. In total 2502 (6.4%) participants died during follow-up (2.0 to 9.8 years). Comparing the most sedentary with the least sedentary groups of participants resulted in a pooled HR of 2.44 (95% CI 1.82–3.25). Comparing the least active with the most active groups of participants resulted in a pooled HR of 1.93 (95% CI 1.39-2.69); 2.66 (95% CI 2.11–3.35); 3.43 (95% CI 2.61–4.52), and 3.09 (95% CI 2.33–4.11) for light, moderate-to-vigorous-, total PA and steps per day, respectively. Meta-regression analyses showed clear dose-response relationships between i-SB and steps per day and mortality risk.
Both i-SB and i-PA are significantly associated with mortality in community-dwelling older adults, showing the largest effect size for total physical activity. Dose-response relationships could be observed for i-SB and steps per day.
Accelerometer-measured daily steps and subjective cognitive ability in older adults: A two-year follow-up study
2020, Experimental Gerontology
Citation Excerpt :
The average accelerometer's wear time was 14.95 (SD = 2.98) hours per day. To include the accelerometer data in the analysis 5 days of recordings with a minimum of 10 h of monitoring time each day were required (Koolhaas et al., 2017). If the requirements were not fulfilled, participants were requested to re-wear the accelerometer (Ku et al., 2017).
There is still a paucity of longitudinal studies examining the relationships between objectively-assessed daily steps and cognitive performance in older adults. The current study aimed to explore whether there is a dose-response relationship between accelerometer-measured daily steps and subjective cognitive decline rate after 2 years in older adults. A total of 285 community-dwelling older adults (age = 74.52 ± 6.12 years, female = 55.4%) wore accelerometers for 7 consecutive days measuring daily steps in 2012. Subjective cognitive ability was measured using a Chinese version of the Ascertain Dementia 8-item Questionnaire (AD8). In total 274 (96.1%) participants completed the follow-up study in 2014. Multivariable negative binomial regression adjusted for confounders was undertaken. Daily steps were linearly related to a reduced decline rate in subjective cognitive ability after 2 years. When daily steps were categorized into groups (<3500, 3500–6999, and ≥7000 steps/day), taking approximately 3500–6999 steps/day was associated with a reduced subjective cognitive decline rate (RR = 0.57, 95% CI = 0.37–0.89) after 2 years compared with <3500 steps/day. When accruing ≥7000 steps/day, the decline rate progressively decreased further (RR = 0.43, 95% CI = 0.23–0.82). Sensitivity analyses supported the stability of these findings. These results suggest that there is an inverse dose-response association of daily steps with subjective cognitive decline rate. Even as few as 3500–6999 steps/day was associated with a lower subjective cognitive decline rate after 2 years. Accumulating ≥7000 steps/day could provide greater protection for subjective cognitive ability.
Objectively measured sedentary time and mental and cognitive health: Cross-sectional and longitudinal associations in The Rotterdam Study
2019, Mental Health and Physical Activity
Based on studies using self-reported sitting time, sedentary behavior has been suggested as a risk factor for poor mental health and cognition. However, it remains unclear whether objectively measured sedentary behavior is longitudinally associated with depression, anxiety disorders or cognition.
In the population-based Rotterdam Study, cross-sectional and longitudinal associations of objectively assessed sedentary time with depressive symptoms, anxiety disorders and cognition were assessed among 1841 participants (mean follow-up: 5.7 years). Participants wore a wrist actigraph for seven days between 2004 and 2007 to assess sedentary time (hours/day). Depression, anxiety disorders and cognition were assessed twice between 2004 and 2014. Depressive symptoms were continuously measured with the Centre for Epidemiologic Studies-Depression scale (CES-D) and a diagnoses of anxiety disorder (n = 147) was obtained by interview, using an adapted version of the Munich Composite International Diagnostic Interview (M-CIDI). Cognition was assessed using a test-battery. Linear regression was performed for all continuous outcomes, and logistic regression for all binary outcomes.
In analyses adjusted for age, sex, cohort and time awake only, 1 h/day more sedentary time was cross-sectionally associated with a 0.25 point (95% confidence interval (95%CI): 0.08, 0.41) higher CES-D score, 1.11 (95%CI: 1.01, 1.21) higher odds of anxiety disorder, and 0.03 (95%CI: 0.05, -0.01) lower global cognition score. After adjustment for confounders, these associations no longer remained. Sedentary time at baseline was not associated longitudinally with changes in depressive symptoms, anxiety disorders and cognition.
No support was found for an association between actigraphically measured sedentary time and mental health or cognition. All observed associations were explained by confounders, in particular, disability, occupational status and smoking. The previously reported association between sitting time and mental health might reflect residual confounding, bias of subjective measures, or the social context of sedentary behavior.
Seasonality of physical activity, sedentary behavior, and sleep in a middle-aged and elderly population: The Rotterdam study
2018, Maturitas
Physical activity (PA) and sedentary behavior (SB) have seasonal patterns. It remains unclear how these patterns are associated with sleep, meteorological factors, and health.
Activity levels were continuously measured with an accelerometer for seven days between July 2011 and May 2016, among middle-aged (50–64 years), young-elderly (65–74 years) and old-elderly (≥75 years) participants of a population-based Dutch cohort study (n = 1116). Meteorological factors (ambient temperature, wind speed, sunlight hours, precipitation, and minimum visibility) were locally recorded. We first examined the seasonality of PA, SB, and nighttime sleep, stratified by age group. Second, we examined the influence of meteorological factors. Third, we modeled the potential seasonality of the all-cause mortality risk due to the seasonality of PA and SB, by using previously published relative risks.
Levels of light and moderate-to-vigorous PA were higher in summer than in winter among middle-aged (seasonal variation = 18.1 and 14.8 min/day) and young-elderly adults (12.8 and 8.6 min/day). The pattern was explained by ambient temperature and sunlight hours. Nighttime sleep was 31.8 min/day longer in winter among middle-aged adults. SB did not show a seasonal pattern. No seasonality in activity levels was observed among old-elderly adults. The all-cause mortality risk may be higher in winter than in summer due to the accumulation of low levels of moderate to vigorous PA and high levels of SB.
PA has a larger degree of seasonality than SB and nighttime sleep among middle-aged and young-elderly adults. SB appears strongly ingrained in daily routine. Recommending the interruption of SB with light PA might be a good starting point for public health institutions.

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Sedentary time assessed by actigraphy and mortality: The Rotterdam Study

Highlights

Abstract

Introduction

Section snippets

Study population

Results

Discussion

Conclusion

Author contributions

Transparency document

Acknowledgments

J. Clin. Epidemiol.

Lancet

Mayo Clin. Proc.

Mayo Clin. Proc.

Am. J. Epidemiol.

Am. J. Prev. Med.

Biol. Psychiatry

Prev. Med.

J. Clin. Epidemiol.

Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis

Ann. Intern. Med.

Importance of all movement behaviors in a 24 hour period for overall health

Int. J. Environ. Res. Public Health

Daily sitting time and all-cause mortality: a meta-analysis

PLoS One

Physical activity patterns assessed by accelerometry in older people

Eur. J. Appl. Physiol.

Objective measures of activity level and mortality in older men

J. Am. Geriatr. Soc.

Measurement of patient outcome in arthritis

Arthritis Rheum.

Objectively assessed physical activity, sedentary time, and coronary artery calcification in healthy older adults

Arterioscler. Thromb. Vasc. Biol.

Physical activity, sedentary time, and pericardial fat in healthy older adults

Obesity (Silver Spring)

Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease

Diabetes

Chapter 7: generalized additive models

The Rotterdam Study: 2016 objectives and design update

Eur. J. Epidemiol.

Evaluation of newer risk markers for coronary heart disease risk classification: a cohort study

Ann. Intern. Med.