INTRODUCTION

Sedentary behavior (SB) is increasingly prevalent and has been recognized as a significant contributor to health risks (1). SB refers to activities requiring less than 1.5 metabolic equivalent tasks while seated or reclined, encompassing a spectrum from TV viewing to driving and reading (1). According to the U.S. National Health and Nutrition Examination Survey and other sources, U.S. adults spend an average of 5.5 to 8.0 h per day engaged in SB, with this trend continuing to rise (2–4).

Extensive research links SB to heightened risks of all-cause mortality, cardiovascular disease (CVD), certain cancers, type 2 diabetes, hypertension, dyslipidemia, osteoporosis, depression, and cognitive impairment (5–8). Recognizing SB as a distinct health concern, public health guidelines emphasize both increasing moderate-to-vigorous physical activity and reducing sedentary time. The 2018 Physical Activity Guidelines Advisory Committee Scientific Report and the 2020 World Health Organization Public Health Guidelines underscore these recommendations (9–11). Nevertheless, a substantial proportion of U.S. adults—80%—remain physically inactive, with 55% classified as sedentary (2,10).

The health risks associated with SB are particularly alarming in clinical populations, which face heightened susceptibility to multimorbidity and disability. Over 129 million Americans live with at least one chronic disease, and more than 68 million contend with two or more chronic conditions (12). The prevalence of SB rises with the number of chronic diseases, from 7.1% in those with no chronic diseases to 24.1% in individuals with more than four (13). Clinical populations engage in more SB because of age-related physical decline, mobility-limiting conditions, loss of independence, and multimorbidity, making them more vulnerable to its harmful effects (13).

Current guidelines advocate “sitting less and moving more,” yet the implementation of specific strategies to reduce SB in clinical settings remains crucial. Broad recommendations provide numerous avenues for mitigating SB, necessitating a better understanding of risk factors, barriers to movement, and effective strategies for fostering healthier lifestyles.

This review aims to synthesize current evidence on SB within clinical populations, propose effective tools and strategies to combat SB, and explore opportunities for integrating these approaches into clinical practice.

SB AND PREVALENCE IN CLINICAL POPULATIONS

SB encompasses various low-energy expenditure activities while sitting, reclining, or lying down, and its prevalence in modern lifestyles is significant. These activities can be classified into mentally passive (e.g., TV viewing, phone use) and mentally active (e.g., reading, studying) tasks. Screen time, often linked to obesity, CVD, and musculoskeletal problems, involves extended periods of sitting while watching TV or using devices. Occupational sitting poses similar risks, highlighting the need for mobility breaks or standing desks. Passive transportation during commutes, such as driving or public transportation, also encourages SB, underscoring the benefits of active options like cycling or walking. Even daily activities like excessive sleeping and leisure-time sitting can negatively impact health (14,15).

Emerging evidence suggests that not all sedentary activities are equal in their potential health risk. For example, a large cohort study that individuals reporting ≥3 h per day of mentally passive SB, such as watching TV or videos, had a higher prevalence of incident depression and greater waist circumference compared with those engaging in mentally active SB, such as work-related activities (16). Additionally, higher amounts of total leisure SB and prolonged TV viewing time are significantly associated with an increased risk of diabetes (17). Screen time of 5 to 6 h per day has been linked to CVD risk comparable to those observed with 10 to 11 h per day of total sedentary time (18). Moreover, the heightened risk of depression associated with passive SB underscores that not all sedentary activities are equally harmful (19). These findings highlight the importance of distinguishing among types of SB during individualized assessments and interventions to better address specific risks (7).

Clinical populations face additional barriers to physical activity, such as pain, disability, and environmental factors like transportation and safety concerns, which exacerbate SB. As a result, clinical populations spend more time sedentary (8.9–10.1 h/d) when compared with the general population (7.7 h/d) (20). These extended periods of sedentary time are particularly concerning, as they can exacerbate existing health conditions and increase the risk of developing additional comorbidities. The relationship between SB and poor health outcomes is bidirectional: whereas underlying health conditions contribute to more sedentary time, prolonged inactivity also worsens health status, creating a vicious cycle of multimorbidity.

BARRIERS TO REDUCING SB

Although the public has a general awareness of the health implications of SB, various barriers can hinder individuals from decreasing their time spent being sedentary. Internal and external perceived barriers to physical activity have been shown to directly influence the likelihood of engaging in leisure-time physical activity and increase SB (21). These barriers are numerous and range from generalized to population specific. Commonly shared barriers seen across clinical populations include limited self-efficacy, lack of time, access, transportation, disability, pain, time burden of treatment, fatigue, comorbidities, high costs, lack of motivation, misconceptions of exercise, lack of awareness of personal SB, and difficulties in identifying alternative behaviors to sitting and strategies to reduce SB (see Figure 1) (20,22–26). Studies conducted utilizing self-report measures and device measures have identified recurring population-specific barriers in the clinical populations of CVD, chronic obstructive pulmonary disease, type 2 diabetes (T2DM), type 1 diabetes, cancer, severe mental illness, and obesity (see Table 1).

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TABLE 1.Common barriers to physical activity in clinical populations.

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To address these barriers, various assessment tools and strategies for SB have been widely utilized, and numerous studies confirm the positive impact of both newly developed and long-standing strategies. The use of these assessment tools and strategies is most effective when tailored to the target population’s capabilities and limitations, allowing for the accurate collection and management of subjective and objective measures. Subjective measures can be more difficult to capture and predominantly include questionnaires, surveys, face-to-face interviews, diaries/logs, and ecological momentary assessments. Although there is a paucity of evidence supporting the validity of these tools in clinical populations, some evidence suggests they are reliable and valid. A study conducted in the primary care setting found the Rapid Assessment Disuse Index, a tool measuring sedentary time and daily physical inactivity, to have good reliability and moderate validity in detecting patients engaged in high SB (27). Alternatively, another study found a popular physical activity monitor (activPAL) to have high test-retest reliability in detecting sedentary time, stepping time, step count, standing time, and sit-to-stand transitions in those living with T2DM (28). Despite this, more research is needed in this area.

With wearable and other technologies becoming increasingly integrated within our daily routines, we now use these devices to collect objective measures. Common examples of wearable devices include heart monitors, accelerometers, inclinometers, and pedometers. Additional devices such as television monitors and car monitors are also used, but with less frequency (29). Choosing which tool(s) to use depends on multiple factors centered around available resources, target population, and outcome measures (see Table 2). Self-report measures typically are the easiest to implement and most cost-effective, and can provide the most detailed information. However, because of the subjective nature of self-report measures, the provided information is not always as reliable as using objective measures, as results tend to underestimate sedentary time (29). Although objective measures can much more accurately capture records of physical activity or inactivity, their largest setbacks can be their cost, required technological literacy, and missing contextual information that self-report measures can provide. For these reasons, multiple assessment tools are suggested to obtain subjective and objective background information based on outcome measures and program protocols.

TABLE 2.Advantages and disadvantages of common subjective and objective physical activity assessments.

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These assessment tools can be extremely useful for exercise professionals in identifying and addressing SB in their patients. With quantification of the time spent performing SBs and physical activity, exercise professionals can better understand their patients’ overall activity levels and make targeted recommendations for improvement. Additionally, identifying the association of SB with all-cause mortality and the development of chronic diseases can help with educating patients on the risks of SB and motivate them to make lifestyle changes. Through evaluation of the health consequences of SB, exercise treatment plans can be created that address the specific health risks associated with SB. Furthermore, tracking progress using these assessment tools can help determine the effectiveness of behavior change interventions and adjust treatment plans as needed. This can be especially useful for patients who have chronic conditions related to SB, such as obesity and/or T2DM (30,31). The clinical significance of these assessment tools lies in their ability to help identify SB, quantify activity levels, evaluate health consequences, and track progress over time. By incorporating these tools into clinical practice, exercise professionals can help their patients make meaningful behavior changes that can improve their overall health and reduce the risk of chronic disease associated with SB.

STRATEGIES FOR REDUCING SB

Exercise professionals may use numerous interventions to help decrease SB in their patients. The primary goal for most strategies is education of patients to build their knowledge and prepare them to obtain desired care. Many patients may be unaware of what SB even means and need to learn the construct before continuing to the next stages of intervention.

Targeting SB may require unique and creative solutions that fall outside typical physical activity recommendations. For instance, in the occupational setting, these strategies may focus on identifying opportunities to interrupt prolonged sitting with simple, practical physical activities. For example, incorporating short activity breaks such as sit-to-stands or calf raises performed for 6 min every 60 min has been shown to effectively reduce postprandial glucose and insulin responses in type 2 diabetics (32). These small, regular movements can improve metabolic health while fitting seamlessly into the workplace routine.

CLINICAL APPLICATION

Although the recommendation to “sit less and move more” is widely accepted, translating this into effective practice poses significant challenges. It is imperative to acknowledge the diversity among clinical populations, considering factors such as care settings, occupational demands, disabilities, and specific diagnoses when devising intervention strategies. To guide exercise professionals in navigating this complexity, we propose a framework encompassing assessment, barrier identification, personalized interventions, behavior modification techniques, and ongoing monitoring (Figure 2).

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The choice between subjective and objective assessment methods should be made judiciously, recognizing their varying efficacy and practical utility (see Table 2). Additionally, addressing population-specific barriers, as outlined in Table 1, is crucial for tailoring interventions effectively. Interventions must be individualized to target core components of SB and address unique barriers within each clinical context. Strategies ranging from low-level activities like seated aerobics to promoting less detrimental forms of SB (e.g., active tasks over passive activities like television watching) should be considered. Ensuring long-term adherence requires motivational interviewing, goal setting, self-monitoring, and other behavioral techniques. Regular follow-ups via in-person visits, text messages, or phone calls are vital for maintaining motivation and tracking progress. Continuous monitoring allows exercise professionals to adjust interventions and track health outcomes, fostering sustained behavior change. Reducing SB is a multifaceted endeavor that necessitates ongoing assessment, adaptive interventions, behavioral reinforcement, and persistent monitoring.

CONCLUSION

SB represents a growing concern associated with adverse health outcomes, particularly in clinical populations. This review underscores the necessity of targeting SB independently or complementarily with traditional physical activity recommendations. Aligned with global health guidelines advocating for reduced sitting and increased movement, our review emphasizes the integration of rigorous assessments and tailored interventions to mitigate SB in clinical settings. Incorporating personalized behavioral strategies alongside comprehensive assessments can lead to significant reductions in SB, thereby enhancing overall health outcomes among individuals living with chronic disease.