YPMED-04298; No of Pages 11

Preventive Medicine xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Preventive Medicine

journal homepage: www.elsevier.com/locate/ypmed

1 Review

2Q1 Accelerometer-measured sedentary time and cardiometabolic

3 biomarkers: A systematic review

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4Q2 Laura A. Brocklebank a,b,⁎, Catherine L. Falconer a,b, Angie S. Page a,b, Rachel Perry b, Ashley R. Cooper a,b

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5 a
Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 12 Woodland Road, Bristol BS8 1UQ, UK
6 b
National Institute for Health Research (NIHR), Bristol Nutrition Biomedical Research Unit in Nutrition, Diet and Lifestyle, University of Bristol, Education and Research Centre,
7 Upper Maudlin Street, Bristol BS2 8AE, UK

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8 a r t i c l e i n f o a b s t r a c t

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9 17
10 Available online xxxx Objective. We conducted a systematic review to investigate the cross-sectional and prospective associations 18

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of accelerometer-measured total sedentary time and breaks in sedentary time with individual cardiometabolic 19
11 Keywords: biomarkers in adults ≥18 years of age. 20
12 Systematic review Methods. Ovid Medline, Embase, Web of Science and the Cochrane Library were searched for studies meeting the 21
13 Accelerometer
inclusion criteria. Due to inconsistencies in the measurement and analysis of sedentary time, data was synthesised
D 22
14 Sedentary time
15 Breaks in sedentary time
and presented narratively rather than as a meta-analysis. 23
16 Cardiometabolic risk factors Results. Twenty-nine studies were included in the review; twenty-eight reported on total sedentary time and six 24
on breaks in sedentary time. There was consistent evidence from cross-sectional data of an unfavourable association 25
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between total sedentary time and insulin sensitivity. There was also some evidence of unfavourable associations 26
with fasting insulin, insulin resistance and triglycerides. Furthermore, there was some evidence from cross- 27
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sectional data of a favourable association between breaks in sedentary time and triglycerides. 28
Conclusion. Total sedentary time was consistently shown to be associated with poorer insulin sensitivity, even 29
after adjusting for time spent in physical activity. This finding supports the proposed association between sedentary 30
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time and the development of Type 2 diabetes and reinforces the need to identify interventions to reduce time spent 31
sedentary. 32
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© 2015 Published by Elsevier Inc. 33

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38 Contents
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40 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
41 Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
42 Search strategy and inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
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43 Quality assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
44 Data extraction and synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
45 Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
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46 Total sedentary time and cardiometabolic health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

47 Fasting plasma glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
48
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Fasting insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
49 2-Hour plasma glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
50 HOMA-IR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
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51 Insulin sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
52 Total cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
53 HDL-cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
54 LDL-cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
55 Triglycerides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
56 Overview of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
57 Breaks in sedentary time and cardiometabolic health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
58 Fasting plasma glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
59 Fasting insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

⁎ Corresponding author at: Centre for Exercise, Nutrition and Health Sciences, School for Policy Studies, University of Bristol, 12 Woodland Road, Bristol BS8 1UQ, UK.
E-mail address: laura.brocklebank@bristol.ac.uk (L.A. Brocklebank).

http://dx.doi.org/10.1016/j.ypmed.2015.04.013
0091-7435/© 2015 Published by Elsevier Inc.

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 2 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

60 2-Hour plasma glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

61 HOMA-IR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
62 Insulin sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
63 HDL-cholesterol. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
64 LDL-cholesterol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
65 Triglycerides . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
66 Overview of findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
67 Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
68 Study strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
69 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
70 Funding source . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
71 Conflict of interest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
72 Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
73 Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0
74 References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0

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75

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76 Introduction of total sedentary time and/or breaks in sedentary time with at least one cardio- 123
metabolic biomarker of interest. Studies were excluded if they defined sedentary 124
77 Physical activity is considered to be central to the prevention and behaviour as failure to meet the current physical activity recommendations. 125

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Titles and abstracts were independently reviewed by LB and CF for retrieval 126
78 management of Type 2 diabetes because of its potential to improve
of full-text articles meeting the inclusion criteria. If any uncertainty or disagree- 127
79 glycaemic control, lipid profiles and blood pressure, and in combination
ment existed, the full-text was obtained for discussion with AC. Studies that did 128
80 with dietary intervention, to aid weight loss and maintenance (Colberg

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not meet the inclusion criteria were disregarded at this stage. 129
81 et al., 2010). However, fewer people with Type 2 diabetes meet physical
82 activity recommendations (at least 150 min of moderate-to-vigorous-
Quality assessment 130

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83 intensity physical activity [MVPA] per week) than in the general popu-
84 lation (Morrato et al., 2007) and people with Type 2 diabetes often find LB and CF developed a quality assessment tool with reference to the 131
85 it difficult to increase their physical activity levels by a sufficient amount Newcastle-Ottawa Scale (Wells et al., 2014) and the STROBE (Strengthening
D 132
86 to improve cardiometabolic health outcomes (Andrews et al., 2011). the Reporting of Observational studies in Epidemiology) Statement (von Elm 133
87 Therefore, alternative interventions for improving cardiometabolic et al., 2008). The total score available was 7 points: 1 point for reporting a prospec- 134
88 health may be required. tive association(s), 1 if analysis adjusted for MVPA (studies reporting on total 135
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89 Recent interest has focussed on the potential role of sedentary sedentary time) or MVPA and total sedentary time (studies reporting on breaks 136
90 behaviour in the development of chronic diseases. Sedentary behaviour in sedentary time), 1 if analysis adjusted for body mass index (BMI) and/or 137
138
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waist circumference (WC), 1 if analysis adjusted for sex (if males and females
91 is defined as any waking behaviour characterised by an energy expendi-
combined), age and ethnicity, 1 for an objective measure of the health outcome(s), 139
92 ture ≤1.5 metabolic equivalents (METs) whilst in a sitting or reclining
1 for at least 7 valid days (≥10 h) of accelerometer wear time (Matthews et al., 140
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93 posture. Sedentary behaviour is distinct from physical inactivity, 2002) and 1 for an adequate description of the population, including sex, age, 141
94 which is defined as failure to meet the current physical activity recom- BMI and metabolic health. Two authors (LB and AC) independently assessed all 142
95 mendations (Sedentary Behaviour Research, 2012). studies for quality and any discrepancies were discussed with CF. A score of 5 to 143
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96 In previous systematic reviews, more time spent in sedentary 7 was considered high quality, 3 or 4 moderate quality and 0 to 2 poor quality. 144
97 behaviours has been shown to be adversely associated with both risk
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98 of chronic diseases and with poorer cardiometabolic health (de Data extraction and synthesis 145
99 Rezende et al., 2014; Edwardson et al., 2012; Wilmot et al., 2012).
100 However, the majority of the studies included in these reviews Two authors (LB and AC) independently extracted data using a data extraction 146
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101 measured sedentary time with self-report questionnaires, which are form developed for this review. The primary outcomes were the cross-sectional 147
102 susceptible to recall and social desirability bias (Clark et al., 2009; and prospective associations of total sedentary time and breaks in sedentary 148
149
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103 Corder et al., 2007). Therefore, the aim of the current systematic review time with individual cardiometabolic biomarkers (Pearson correlation coeffi-
cients, regression coefficients and P for trend). Due to inconsistencies in the 150
104 is to investigate the cross-sectional and prospective associations of
way in which sedentary time was measured, defined and analysed, data was 151
105 accelerometer-measured total sedentary time and breaks in sedentary
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synthesised and presented narratively rather than as a meta-analysis. 152

106 time with individual cardiometabolic biomarkers in adults ≥18 years The findings for each cardiometabolic biomarker were interpreted on the 153
107 of age. following basis: there was no evidence of an association if more than 50% of 154
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the cross-sectional and prospective studies reported no association; the 155

evidence for an association was inconclusive if 50% of the studies reported no 156
108 Methods
association and 50% reported a positive or negative association; there was 157
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109 Search strategy and inclusion criteria some evidence of an association if more than 50% of the studies reported a 158
positive or negative association; and there was consistent evidence of an 159
110 Ovid Medline, Embase, Web of Science and the Cochrane Library were association if all of the studies reported a positive or negative association. 160
111 searched for relevant publications (24 June 2014). The search strategy used in
112 Ovid Medline is shown in Supplementary methods and the same search terms Results 161
113 were used in the other databases.
114 To be included in the systematic review, studies had to meet the following The initial search identified 4858 studies (Fig. 1). Twenty-nine studies 162
115 inclusion criteria: (1) written in English; (2) cross-sectional or prospective study
were included in the systematic review; twenty-eight reported on total 163
116 design; (3) report data on adults ≥18 years of age; (4) use an accelerometer to
sedentary time and six on breaks in sedentary time(4, 9, 15, 16, 18, 27). 164
117 measure total sedentary time and/or breaks in sedentary time; (5) measure at
118 least one cardiometabolic biomarker of interest (fasting plasma glucose, fasting in- Four studies were prospective(9, 10, 20, 29) and the remaining were cross- 165
119 sulin, 2-hour plasma glucose, insulin sensitivity, homeostasis model assessment of sectional. Twenty-two studies adjusted for MVPA and total sedentary 166
120 insulin resistance [HOMA-IR], total cholesterol, high-density lipoprotein choles- time (if applicable), fourteen adjusted for BMI and/or WC and eight 167
121 terol [HDL-cholesterol], low-density lipoprotein cholesterol [LDL-cholesterol] adjusted for sex (if applicable), age and ethnicity. However, only five 168
122 and triglycerides); and (6) report cross-sectional and/or prospective associations studies adjusted for all of these confounding variables(12, 16, 18, 22, 24). 169

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx 3

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Fig. 1. Flow diagram of study selection process, from initial search to included studies. N, number of studies.

170 Sample sizes ranged from 35(23) to 4935(4). The majority of studies analyses(3, 4, 7, 9, 11, 13, 16–18, 20, 22, 24, 27) and two of three prospective 215

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171 were conducted in the US or the UK. Five studies included women analyses(9, 29) reported no association. 216
172 only(13, 21–24) and the remaining included both men and women. Mean
ages ranged from 24.0(13) to 74.6 years(12) and mean body mass indexes

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173 Fasting insulin 217
174 ranged from 23.2(1) to 32.9 kg/m2(26). Sixteen studies investigated adults
175 without diagnosed diabetes, four investigated adults with a higher risk of There was some evidence from cross-sectional data of an 218

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176 developing Type 2 diabetes(10, 11, 18, 29), two investigated adults with unfavourable association between total sedentary time and fasting insu- 219
177 newly diagnosed Type 2 diabetes(8, 9) and seven did not give an adequate lin, but the evidence from prospective data was inconclusive. Nine of 220
178 description of metabolic health(5, 6, 12, 22, 25, 27). Three studies were of high twelve cross-sectional analyses reported a positive association between
D 221
179 quality, seventeen were of moderate quality and nine were of low quality. total sedentary time and fasting insulin(3, 4, 6, 9, 11, 16, 23–25); six following 222
180 Full descriptions of included studies can be seen in Table 1. adjustment for MVPA(4, 6, 9, 16, 24, 25), but only one following additional 223
181 Table 2 describes the methods used to measure and analyse sedentary adjustment for WC(16). The remaining three analyses reported no 224
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182 time in the included studies. Twenty-two studies measured sedentary association(10, 13, 20). 225
183 time with an Actigraph accelerometer, two used ActiTrainer(5, 6), two Four studies analysed the prospective association between total 226
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184 used Sensewear Pro Armband(7, 27), one used Actical(4), one used sedentary time and fasting insulin. One study reported a positive associa- 227
185 Actiheart(8) and one used Active Style Pro(19). All of the studies analysed tion between baseline total sedentary time and fasting insulin at 6-month 228
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186 accelerometer data as frequency counts. Twenty-three studies measured follow-up, following adjustment for MVPA and WC(9). Another study also 229
187 sedentary time for 7 days, four measured it for four days(8, 10, 11, 29) reported a positive association between baseline total sedentary time and 230
188 and two measured it for 8 days(2, 20). Eleven studies required at least 4 3-year change in fasting insulin, but only in the 50% of participants who 231
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189 valid days of accelerometer wear time to be included in the final analysis, had increased their BMI by ≥0.3 kg/m2 (MVPA was not adjusted for in 232
190 two studies used a criterion of ≥1 day(12, 28), six used ≥3 days(2, 9–11, 20, the analysis)20. The remaining two studies reported no association; one 233
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29)
191 , three used ≥5 days(7, 14, 15), one used ≥6 days(27), one used between baseline total sedentary time and fasting insulin at 1-year 234
192 ≥7 days(19) and five did not report any inclusion criteria for days of follow-up(10) and the other between 6-year change in total sedentary 235
193 wear(8, 17, 21, 23, 24). Twenty-one studies defined sedentary time as b100 time and 6-year change in fasting insulin(29). 236
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194 counts per minute (cpm), four used ≤1.5 METs(7, 8, 19, 27), one used
195 b150 cpm(13), one used b25 counts per 15 s(18), one used b200 cpm(28) 2-Hour plasma glucose 237
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196 and one did not report how sedentary time was defined(21).
197 Twenty-three studies presented total sedentary time as average The evidence for a cross-sectional association between total sedentary 238
198 minutes or hours per day, three presented it as percentage of wear time and 2-hour plasma glucose was inconclusive and no prospective 239
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199 time(1, 2, 26), one presented it as percentage of monitoring time(17), one analyses were available. Three of six cross-sectional analyses reported a 240
200 presented it as percentage of waking hours(14), one presented it as total positive association, following adjustment for MVPA, between total sed- 241
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201 hours(20) and one did not report any units for total sedentary time(21). entary time and 2-hour plasma glucose(14, 18, 25); two following additional 242
202 Four of the six available studies presented breaks in sedentary time as adjustment for WC(14) or BMI(18). The remaining three analyses reported 243
203 average number per day(4, 9, 18, 27), whilst the remaining two presented no association(16, 20, 26). 244
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204 total breaks in sedentary time(15, 16). Seventeen studies analysed total
205 sedentary time and/or breaks in sedentary time as continuous variables, HOMA-IR 245
206 six analysed them as categorical variables(5, 12, 16, 20, 21, 24) and
207 six analysed them as both continuous and categorical variables(6, 9, 14, 15, There was some evidence from cross-sectional data of an 246
18, 25)
208 . Of the twelve studies that analysed total sedentary time and/or unfavourable association between total sedentary time and HOMA-IR, 247
209 breaks in sedentary time as categorical variables, nine used quartiles(6, 9, but the evidence from prospective data was inconclusive. Five of 248
12, 14–16, 20, 24, 25)
210 and three used tertiles (5, 18, 21). nine cross-sectional analyses reported a positive association between 249
total sedentary time and HOMA-IR(5, 6, 9, 21, 24); four following 250
211 Total sedentary time and cardiometabolic health adjustment for MVPA(5, 6, 9, 24), but only one following additional 251
adjustment for BMI and WC(5). The remaining four analyses reported 252
212 Fasting plasma glucose no association(10, 13, 20, 26). 253
Three studies analysed the prospective association between total 254
213 There was no evidence of an association between total sedentary sedentary time and HOMA-IR. One study reported a positive association 255
214 time and fasting plasma glucose; thirteen of eighteen cross-sectional between baseline total sedentary time and HOMA-IR at 6-month 256

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 4
t1:1 Table 1
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,

t1:2 Descriptions of all the studies included in the systematic review.

t1:3 ReferenceSN Exposure(s) Outcome(s) Variables adjusted for in the analysis Cross-sectional Population (n [sex], age [M ± SD], country, BMI Quality
or prospective? [M ± SD], metabolic health) score
t1:4 Socio-demographic Medical history Behaviour

t1:5 Aadland ST (% valid wear time) TC (mmol/L) Sex, age, WC Diet Cross-sectional 78 (58% ♀), 40.7 ± 10.9 (♂) and 40.4 ± 10.6 3
t1:6 et al. HDL-C (mmol/L) years (♀), Norway, 25.2 ± 3.2 (♂) and 23.2 ±

t1:7
(2013)1

Balkau et al. ST (% wear time)

U
LDL-C (mmol/L)
TG (mmol/L)⁎
IS (μmol/min/kgFFM/nmol/L)⁎ Age, sex, recruitment centre Total activity, LPA, activity Cross-sectional
2.2 kg/m2 (♀), not diagnosed with T2DM

801 (57% ♀), 43 ± 9 (♂) and 45 ± 8 years (♀), 2

(2008)2

FPG (mmol/L)⁎
N intensity Europe, 25.9 ± 3.1 (♂) and 24.4 ± 4.1 kg/m2
(♀), not diagnosed with DM

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t1:8 Buman et al. ST (30 min/d) Age, sex, ethnicity, marital Depressive symptoms, general Smoking, EI, saturated fat, Cross-sectional 2187 (52% ♀), 46.6 ± 18.4 years, US, 6.3% 3
(2014)3 FI (pmol/L)⁎ status, education, work health rating, previous diagnosis caffeine, alcohol use, sleep diagnosed with DM, mean BMI not reported
HOMA-%S⁎ status, poverty of cancer/malignancy, CVD or duration, LPA, MVPA
HDL-C (mmol/L)⁎
LDL-C (mmol/L)⁎
TG (mmol/L)⁎ O diabetes, current diabetic,
antihypertensive, lipidemic or
other CVD medications
t1:9 Carson et al.
(2014)4
ST (h/d)
BST (10/d)
FPG (mmol/L)⁎
FI (pmol/L)⁎ cycle
R
Age, sex, income, survey Blood pressure medication,
medical history of Type 2 diabetes,
Smoking, alcohol use, MVPA,
ST
Cross-sectional 4935 (50% ♀), 45.9 ± 15.1 years, Canada, 5%
diagnosed with T2DM, mean BMI not reported
2

L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

HDL-C (mmol/L) heart disease or cancer

t1:10 Celis-Morales ST (min/d)

LDL-C (mmol/L)
TG (mmol/L)⁎
HOMA-IR⁎
R
Age, sex, environment, Smoking status, accelerometer Cross-sectional 472 (63% ♀), Chile, not taking any diabetes 3
t1:11 et al.
(2011)5
socio-economic level,
education level, BMI, WC, E wear time, MVPA, fitness and
EI
medication, mean age and BMI not reported

t1:12
t1:13
Celis-Morales ST (100 min/d and
et al. min/d)
FPG (mmol/L)
FI (mU/L)
body fat
Age, sex, ethnicity,
environment, SES C Smoking status, MVPA Cross-sectional 317 (56% ♀), 37.5 ± 12.8 years, Chile, 29.2 ± 5.1 3
kg/m2, not taking any diabetes medication
(2012)6 HOMA-IR
TC (mmol/L)
T
E
HDL-C (mmol/L)
LDL-C (mmol/L)
TG (mmol/L)
t1:14 Chase et al.
(2014)7
ST (min/d) FPG (mmol/L)⁎
HDL-C (mmol/L)
LDL-C (mmol/L)
TG (mmol/L)⁎
D Cross-sectional 50 (54% ♀), 71.5 ± 0.6 years, Canada, 24.2 ± 0.4 2
kg/m2, not diagnosed with DM

t1:15 Cooper et al.

(2014)8
ST (h/d) HDL-C (mmol/L)
TG (mmol/L)⁎
Age, sex, intervention group,
occupational socioeconomic
Use of lipid-lowering drugs
P
Smoking status, sleep duration, Cross-sectional
EI, % of energy from fat, alcohol
394 (37% ♀), 60.2 ± 7.4 (♂) and 60.5 ± 7.4
years (♀), UK, 31.6 ± 5.1 (♂) and 32.9 ± 6.0
4

t1:16 Cooper et al.

(2012)9
ST (h/d)
BST (#/d)
FPG (mmol/L)
FI (pmol/L)
class, WC
Age, sex, deprivation score,
WC
Family history of diabetes,
relevant lipid- and
intake, MVPA

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Smoking, accelerometer wear
time, MVPA, ST, BST
Prospective
kg/m2 (♀), newly diagnosed T2DM
528 (35% ♀), 59.8 ± 10.0 years, UK, 31.5 ± 5.6
kg/m2, newly diagnosed T2DM
5

t1:17 Ekelund ST (min/d)

HOMA-IR
HDL-C (mmol/L)
FI (pmol/L)⁎ Age, sex, WC, baseline FI,
glucose-lowering medication
O
Smoking status, follow-up time Prospective 192 (58% ♀), UK, 28.3 ± 4.5 (♂) and 27.5 ± 5.0 3
t1:18

t1:19
et al.
(2009)10
Ekelund ST (min/d)
HOMA-IR⁎

FPG (mmol/L)
baseline HOMA-IR

Age, sex, WC
O
Cross-sectional
kg/m2 (♀), parental history of T2DM, mean age
not reported
258 (60% ♀), 40.9 ± 6.4 (♂) and 40.7 ± 6.4 3
t1:20

t1:21
et al.
(2007)11

Gennuso ST (h/d)
FI (mol/L)⁎
HDL-C (mmol/L)
TG (mmol/L)⁎
FPG (mg/dL)⁎ Age, sex, ethnicity, education, CVD Alcohol consumption, current Cross-sectional
F
years (♀), UK, 28.4 ± 4.6 (♂) and 27.4 ± 5.1
kg/m2, parental history of T2DM

1914 (48% ♀), 74.6 ± 6.5 years, US, mean BMI 4

t1:22 et al. TC (mg/dL) income, marital status, BMI smoking status, accelerometer and diabetes status not reported
(2013)12 HDL-C (mg/dL)⁎ wear time, MVPA
LDL-C (mg/dL)
TG (mg/dL)⁎
t1:23 Green et al. ST (min/d) FPG (mmol/L) Body mass, fat mass, fat-free MVPA, VO2peak Cross-sectional 50 women, 24.0 ± 4.8 years, US, 27.0 ± 4.8 3
(2014)13 FI (pmol/L)⁎ mass kg/m2, not diagnosed with DM
HOMA-IR⁎
TC (mmol/L)
HDL-C (mmol/L)
 LDL-C (mmol/L)
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,

TG (mmol/L)⁎
t1:24 Healy et al. ST (h/d and % waking FPG (mmol/L) Age, sex, height, WC, Family history of diabetes Time accelerometer worn, Cross-sectional 173 (61% ♀), 53.3 years, Australia, 27.2 kg/m2, 4
(2007)14 hours) 2hPG (mmol/L) education, income accelerometer unit, alcohol 2% newly diagnosed DM
intake, smoking status, MVPA
t1:25 Healy et al. BST (total) FPG (mmol/L) Age, sex, employment, Family history of diabetes, Alcohol intake, smoking, diet Cross-sectional 168, 53.4 ± 11.8 years, Australia, 27.2 ± 4.7 2
(2008a)15 2hPG (mmol/L) income, education lipid-lowering medication quality, MVPA, mean intensity kg/m2, not diagnosed with DM, percentage fe-

U
HDL-C (mmol/L) of breaks, ST male not reported
TG (mmol/L)⁎
t1:26 Healy et al. ST (h/d) FPG (mmol/L)⁎ Age, sex, ethnicity, education, Diabetes, cancer, MVPA, ST, smoking, % Cross-sectional 4757 (50% ♀), 46.5 ± 14.2 years, US, 7.5% 4
(2011)16 BST (total)

N
FI (pmol/L)⁎
2hPG (mmol/L)⁎
HOMA-%S⁎
height, marital status, anti-hypertensive medication,
poverty-to-income ratio, WC other CVD medications, family
history of CHD, family history of
saturated fat, alcohol intake, EI,
potassium, caffeine
diagnosed with DM or borderline DM, mean BMI
not reported

t1:27 Healy et al. ST (% monitoring

HDL-C (mmol/L)⁎
TG (mmol/L)⁎
FPG (mmol/L)
C diabetes, CVD history, lipidemic
medication
Age, sex, employment status, Family history of diabetes, Alcohol intake, smoking status, Cross-sectional 169 (60% ♀), 53.4 years, Australia, not diagnosed 1

t1:28
(2008b)17

Henson et al.
time)

ST (h/d)
HDL-C (mmol/L)
TG (mmol/L)⁎
FPG (mmol/L)⁎
O
income, education,

Age, sex, ethnicity, social

lipid-lowering medication

Family history of Type 2 diabetes,

diet quality, MVPA

Smoking status, time Cross-sectional

with DM, mean BMI not reported

878 (41% ♀), 58.4 ± 13.8 years, UK, 32.5 ± 5.2 5

(2013)18 BST (#/d) 2hPG (mmol/L)⁎
HDL-C (mmol/L)⁎
TG (mmol/L)⁎
R
deprivation, BMI beta-blockers, lipid-lowering
medication
accelerometer worn, MVPA, ST kg/m2, with known risk factors for T2DM

L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

t1:29 Kim et al. ST (h/d) FPG (mg/dL) Age, sex Smoking status, calorie intake, Cross-sectional 483 (63% ♀), 47.9 ± 9.0 years, Japan, 25.6 ± 4.0 4
(2013)19 HDL-C (mg/dL) accelerometer wear time, kg/m2, not diagnosed with DM

t1:30 Lahjibi et al.

(2013)20
ST (h)
TG (mg/dL)
FPG (mmol/L)
FI (pmol/L)⁎
Age, sex, recruiting centre
E MVPA
MVPA Prospective 727 (57% ♀), 43 ± 9 (♂) and 45 ± 8 years (♀),
Europe, 25.8 ± 3.1 (♂) and 24.3 ± 4.0 kg/m2
4

2hPG (mmol/L)
HOMA-IR⁎
IS (μmol/min/kgFFM/nmol/L)⁎
C (♀), not diagnosed with DM

TC (mmol/L)
HDL-C (mmol/L) T
LDL-C (mmol/L)
TG (mmol/L)⁎
E
D
t1:31 LeCheminant ST (units not HOMA-IR Age, weight, BMI, body fat %, Cross-sectional 264 women, 40.1 ± 3.0 years, US, 23.8 ± 3.3 2
t1:32 and Tucker reported) abdominal circumference kg/m2, healthy (PAR-Q)
(2011)21
t1:33 Loprinzi ST (min/d) FPG (mg/dL) Age, education, marital Gestation Smoking, MVPA Cross-sectional 206 pregnant women, 28.4 years, US, 29.2 4
t1:34 et al.
(2013)22
TC (mmol/L)
HDL-C (mg/dL)
LDL-C (mg/dL)
status, poverty-to-income
ratio, ethnicity, BMI
P kg/m2, diabetes status not reported

t1:35 Lynch et al.

(2010)23
ST (h/d)
TG (mg/dL)
FI (pmol/L)⁎ Age, ethnicity MVPA
R Cross-sectional 111 women — 35 in FI analysis, 69.2 ± 13.0 4

O
years, US, 27.6 ± 6.4 kg/m2, 24.3% diagnosed
with DM or borderline DM
t1:36 Lynch et al. ST (h/d) FPG (mmol/L)⁎ Age, marital status, annual Age at last period, years of MVPA, alcohol intake, smoking Cross-sectional 467 postmenopausal women, 62.4 ± 9.5 years, 5
FI (pmol/L)⁎

O
(2011)24 family income, ethnicity, WC hormone replacement therapy status US, 27.1 kg/m2, not diagnosed with DM
HOMA-IR⁎ use, age at first birth
t1:37 Maher et al. ST (h/d and min/d) FPG (mmol/L)⁎ Age-squared, educational Relative with diabetes, CVD Accelerometer wear time, Cross-sectional 4618 (48% ♀), US, 28.2 (♂) and 28.0 kg/m2 (♀), 2
FI (pmol/L)⁎

F
(2014)25 attainment, medication, diabetes medication, smoking status, % saturated fat, mean age and diabetes status not reported
2hPG (mmol/L)⁎ poverty-to-income ratio ever been told cancer, ever been alcohol intake, EI, MVPA, total
HOMA-%S⁎ told diabetes, ever been told CVD, physical activity
HDL-C (mmol/L)⁎ hypertension medication,
TG (mmol/L)⁎ lipidemic medication
t1:38 McGuire and ST⁎ (min/d and % 2hPG (mmol/L) Sex, age, WC Time accelerometer worn, LPA, Cross-sectional 135 (68% ♀), 53.1 ± 7.6 years, Canada, 32.9 ± 4
t1:39 Ross wear time) HOMA-IR⁎ MVPA 4.6 kg/m2, not diagnosed with DM
(2011)26 TC (mmol/L)
HDL-C (mmol/L)⁎
TG (mmol/L)⁎
t1:40 Scheers et al. ST (h/d) FPG (mg/dL) Sex, age, education Smoking status, alcohol Cross-sectional 370 (52% ♀), 41.7 ± 9.8 years, Belgium, mean 1
(2013)27 BST (#/d) HDL-C (mg/dL) consumption BMI and diabetes status not reported
TG (mg/dL)
t1:41 Stamatakis ST (10 min/d) TC (mmol/L) Age, sex, social class, Depression, CVD medication Smoking, alcohol consumption, Cross-sectional 1150 — 971 in TC and HDL-C analyses (55% ♀), 2

(continued on next page)

5
6 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

percentage; min, minute(s); h, hour(s), #, number; d, day(s); FPG, fasting plasma glucose; FI, fasting insulin; 2hPG, 2-hour plasma glucose; HOMA-IR, homeostasis model assessment of insulin resistance; HOMA-%S, homeostasis model assessment

cardiovascular disease; CHD, coronary heart disease; LPA, light-intensity physical activity; EI, energy intake; MVPA, moderate-to-vigorous-intensity physical activity; VO2peak, maximal aerobic capacity; ♀, female; ♂, male; T2DM, Type 2 diabetes; DM,
SN, study number; n, sample size; M, mean; SD, standard deviation; BMI, body mass index; quality score, methodological quality score (range 0–7, higher score indicates better quality); ST, total sedentary time; BST, breaks in sedentary time; %,

of insulin sensitivity; IS, insulin sensitivity; TC, total cholesterol; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TG, triglycerides; *, log transformed; WC, waist circumference; SES, socio-economic status; CVD,
follow-up, following adjustment for MVPA and WC(9). Another study 313

Quality
score
also reported a positive association between baseline total sedentary 314

4
time and 3-year change in HOMA-IR, but only in the 50% of participants 315

Population (n [sex], age [M ± SD], country, BMI

who had increased their BMI by ≥0.3 kg/m2 (MVPA was not adjusted 316

UK, mean age, mean BMI and diabetes status not

171 (54% ♀), 42.5 ± 6.2 years, UK, 28.0 ± 4.8

for in the analysis)20. The remaining study reported no association 317
between baseline total sedentary time and HOMA-IR at 1-year follow- 318
up(10). 319

kg/m2, parental history of T2DM

[M ± SD], metabolic health)

Insulin sensitivity 320

There was consistent evidence from cross-sectional data of an 321

unfavourable association between total sedentary time and insulin 322
sensitivity. All of the five available cross-sectional analyses reported 323
reported

F
a negative association between total sedentary time and insulin 324
sensitivity(2, 3, 16, 20, 25); three following adjustment for MVPA(16, 20, 25), 325
but only one following additional adjustment for WC(16). However, to 326

O
or prospective?
Cross-sectional

our knowledge, no studies to date have analysed the prospective associa- 327
Prospective

tion between accelerometer-measured total sedentary time and insulin 328

O
sensitivity. 329
change in monitor wear time,

R
follow-up time, baseline and
consumption, accelerometer

Total cholesterol 330

change in smoking status,
Baseline ST, baseline and
wear time, frequency of
unhealthy foods, MVPA

There was no evidence of an association between total sedentary 331

P
fruit and vegetable

time and total cholesterol; six of eight cross-sectional analyses reported 332
change in MVPA

no association(1, 12, 13, 20, 22, 26) and no prospective analyses were 333
Behaviour

available.
D 334

HDL-cholesterol 335
E
dyslipidaemia and dysglycaemia
Baseline FPG, FI, HDL-C and TG,

The evidence for an association between total sedentary time and 336
change in medication for

HDL-cholesterol was inconclusive. Eleven of twenty cross-sectional 337

analyses reported no association between total sedentary time and 338
HDL-cholesterol(1, 3, 4, 7, 11–13, 17, 22, 26, 28). The remaining nine analyses 339
C
Medical history

reported a negative association(6, 8, 9, 16, 18–20, 25, 27); eight following 340
adjustment for MVPA(6, 8, 9, 16, 18–20, 25), but only four following 341
E

additional adjustment for WC(8, 9, 16) or BMI(18). Two studies analysed

Variables adjusted for in the analysis

342
the prospective association between total sedentary time and HDL- 343
R

cholesterol; one reported a negative association, following adjustment 344

Baseline age, sex, baseline

for MVPA and WC, between baseline total sedentary time and HDL- 345
cholesterol at 6-months follow-up(9), whilst the other reported no asso- 346
R
Socio-demographic

occupational status

ciation between 6-year change in total sedentary time and 6-year change 347
in HDL-cholesterol(29). 348
O
SES,

LDL-cholesterol 349
C

There was no evidence of an association between total sedentary 350

time and LDL-cholesterol; six of nine cross-sectional analyses reported 351
N

no association(1, 3, 4, 12, 13, 20) and no prospective analyses were 352

diabetes; PAR-Q, Physical Activity Readiness Questionnaire.
HDL-C (mmol/L)

HDL-C (mmol/L)

available. 353
FPG (mmol/L)⁎

TG (mmol/L)
U
Outcome(s)

FI (pmol/L)

Triglycerides 354

There was some evidence from both cross-sectional and prospective 355
data of an unfavourable association between total sedentary time and 356
triglycerides. Twelve of eighteen cross-sectional analyses reported a pos- 357
Exposure(s)

itive association between total sedentary time and triglycerides(1, 3, 6, 8, 358

ST (h/d)

13, 16–20, 25, 27)

; nine following adjustment for MVPA(6, 8, 13, 16–20, 25), 359

but only three following additional adjustment for WC(8, 16) or BMI(18). 360
Table 1 (continued)

The remaining six analyses reported no association(4, 7, 11, 12, 22, 26). The 361
ReferenceSN

one available prospective analysis reported a positive association, follow- 362

(2012)28

(2014)29
Wijndaele

ing adjustment for MVPA, between 6-year change in total sedentary time 363
et al.

et al.

and 6-year change in triglycerides (neither BMI nor WC was adjusted for 364
in the analysis)29. 365
t1:43
t1:44

t1:45
t1:46
t1:47
t1:48
t1:49

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,

U
N
t2:1 Table 2
t2:2 Descriptions of the methods used to measure and analyse sedentary time in the included studies.

t2:3
t2:4
Study
number
Exposure(s) Device

C Monitoring
period (days)
Accelerometer inclusion
criteria
How was
sedentary time
defined?
Was sedentary
time analysed
as frequency
Effect measure(s)

t2:5 1 ST (% valid wear time) Actigraph GT1M or GT3X+ O 7 ≥10 h/d for ≥4 d b100 cpm
counts?

Yes Pearson
t2:6
t2:7
t2:8
2
3
4
ST (% wear time)
ST (30 min/d)
ST (h/d)
Actigraph AM7164-2.2
Actigraph 7164
Actical
8
7
7 R N10 h/d for ≥3 d
≥10 h/d for ≥4 d
≥10 h/d for ≥4 d (including 1 weekend day)
b100 cpm
b100 cpm
b100 cpm
Yes
Yes
Yes
Regression
Regression
Regression

L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

BST (10/d)
t2:9 5 ST (min/d) ActiTrainer 7 ≥10 h/d for ≥4 d b100 cpm Yes Ptrend (tertiles)
t2:10
t2:11
t2:12
6
7
8
ST (100 min/d and min/d)
ST (min/d)
ST (h/d)
ActiTrainer
Sensewear Pro Armband
Actiheart
7
7
4 E
≥10 h/d for ≥4 d
≥21 h/d for ≥5 d
Not reported
b100 cpm
b1.5 METs
b1.5 METs
Yes
Yes
Yes
Regression and Ptrend (quartiles)
Pearson
Regression
t2:13 9 ST (h/d)
BST (#/d)
Actigraph GT1M 7 N10 h/d for ≥3 d
C b100 cpm Yes Regression and Ptrend (quartiles)

t2:14
t2:15
10
11
ST (min/d)
ST (min/d)
Actigraph 7164
Actigraph 7164
4
4
≥500 min/d for ≥3 d
≥500 min/d for ≥3 d
T b100 cpm
b100 cpm
Yes
Yes
Regression
Regression (standardised)

E
t2:16 12 ST (h/d) Actigraph AM-7164 7 ≥10 h/d for ≥1 d b100 cpm Yes Ptrend (quartiles)
t2:17 13 ST (min/d) Actigraph GT3X+ 7 ≥10 h/d for ≥4 d (including 1 weekend day) b150 cpm Yes Pearson and regression (standardised)
t2:18 14 ST (h/d and % waking hours) Actigraph 7164 7 ≥10 h/d for ≥5 d (including ≥1 weekend day) b100 cpm Yes Regression and Ptrend (quartiles)
t2:19
t2:20
15
16
BST (total)
ST (h/d)
BST (total)
Actigraph 7164
Actigraph 7164
7
7 D
≥10 h/d for ≥5 d (including ≥1 weekend day)
≥10 h/d for ≥4 d (including ≥1 weekend day)
b100 cpm
b100 cpm
Yes
Yes
Regression (standardised) and Ptrend (quartiles)
Ptrend (quartiles)

P
t2:21 17 ST (% monitoring time) Actigraph 7164 7 Not reported b100 cpm Yes Regression (standardised)
t2:22 18 ST (h/d) Actigraph GT3X 7 ≥10 h/d for ≥4 d b25 counts per 15 s Yes Regression (standardised) and Ptrend (tertiles)
BST (#/d)
t2:23
t2:24
19
20
ST (h/d)
ST (h)
Active Style Pro (HJA-350IT)
Actigraph AM7164-2.2
7
8
≥10 h/d for 7 d
N10 h/d for ≥3 d R
≤1.5 METs
b100 cpm
Yes
Yes
Regression
Ptrend (quartiles)
t2:25
t2:26
t2:27
21
22
23
ST (units not reported)
ST (min/d)
ST (h/d)
Actigraph
Actigraph 7164
Actigraph 7164
7
7
7
Not reported
≥10 h/d for ≥4 d
≥10 h/d O
Not reported
b100 cpm
b100 cpm
Yes
Yes
Yes
Ptrend (tertiles)
Regression
Regression
t2:28
t2:29
t2:30
24
25
26
ST (h/d)
ST (h/d and min/d)
ST (min/d and % wear time)
Actigraph 7164
Actigraph 7164
Actigraph GT3X
7
7
7
≥10 h/d
≥10 h/d for ≥4 d (including ≥1 weekend day)
≥10 h/d for ≥4 d (including 1 weekend day)
b100 cpm
b100 cpm
b100 cpm
O
Yes
Yes
Yes
Ptrend (quartiles)
Regression and Ptrend (quartiles)
Regression
t2:31

t2:32
t2:33
27

28
29
ST (h/d)
BST (#/d)
ST (10 min/d)
ST (h/d)
Sensewear Pro 3 Armband

Actigraph GT1M
Actigraph
7

7
4
≥1368 min/d for ≥6 d (including Saturday and Sunday)

≥10 h/d for ≥1 d

N500 min/d for ≥3 d
≤1.5 METs

0–199 cpm
b100 cpm
Yes

Yes
Yes
F Pearson

Regression
Regression

t2:34 ST, total sedentary time; BST, breaks in sedentary time; %, percentage; min, minute(s); h, hour(s); #, number; d, day(s); cpm, counts per minute; METs, metabolic equivalents.

7
 8 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

366 Overview of findings no prospective studies were available. One study reported a negative 392
association between breaks in sedentary time and 2-hour plasma 393
367 For each cardiometabolic biomarker, an overview of findings, method- glucose, following adjustment for MVPA and total sedentary time, but 394
368 ological quality scores and sample sizes are presented in Table 3. There the association did not survive additional adjustment for BMI(18). 395
369 was consistent evidence from cross-sectional data of an unfavourable Another study also reported a negative association, following adjust- 396
370 association between total sedentary time and insulin sensitivity. ment for MVPA and total sedentary time, when breaks in sedentary 397
371 There was also some evidence that total sedentary time was unfavourably time were analysed as a continuous variable, but no association when 398
372 associated with fasting insulin, HOMA-IR and triglycerides. The majority 2-hour plasma glucose was compared across quartiles of breaks in 399
373 of analyses adjusted for MVPA, with unfavourable associations surviving sedentary time (neither BMI nor WC was adjusted for in the analyses)15. 400
374 this adjustment. However, fewer analyses additionally adjusted for The remaining study reported no association(16). 401
375 BMI and/or WC. The evidence for associations of total sedentary time
376 with 2-hour plasma glucose and HDL-cholesterol was inconclusive and HOMA-IR 402
377 there was no evidence of associations with fasting plasma glucose, total
378 cholesterol or LDL-cholesterol. There was no evidence of an association between breaks in sedentary 403

F
time and HOMA-IR in the one available prospective study(9). 404
379 Breaks in sedentary time and cardiometabolic health

O
Insulin sensitivity 405
380 Fasting plasma glucose
There was no evidence of an association between breaks in sedentary 406

O
381 There was no evidence of an association between breaks in sedentary time and insulin sensitivity in the one available cross-sectional study(16). 407
382 time and fasting plasma glucose; five of six cross-sectional analyses(9, 15,
16, 18, 27)
and the one available prospective analysis(9) reported no HDL-cholesterol 408

R
383

384 association.
The evidence for an association between breaks in sedentary time and 409

P
385 Fasting insulin HDL-cholesterol was inconclusive. Two of six cross-sectional analyses 410
reported a positive association between breaks in sedentary time and 411
386 There was no evidence of an association between breaks in sedentary HDL-cholesterol(4, 18); one following adjustment for MVPA and total
D 412
387 time and fasting insulin; two of three cross-sectional analyses(9, 16) and sedentary time(4), but none following additional adjustment for BMI or 413
388 the one available prospective analysis(9) reported no association. WC. Another study also reported a positive association, following adjust- 414
ment for MVPA, total sedentary time and WC, when HDL-cholesterol was 415
E
389 2-Hour plasma glucose compared across quartiles of breaks in sedentary time, but no association 416
when breaks in sedentary time were analysed as a continuous variable(9). 417
T

390 The evidence for a cross-sectional association between breaks The remaining three analyses reported no association(15, 16, 27). The one 418
391 in sedentary time and 2-hour plasma glucose was inconclusive and available prospective analysis reported no association between the 419
C

t3:1 Table 3
t3:2 Cross-sectional and prospective associations of accelerometer-measured total sedentary time with cardiometabolic biomarkers: overview of findings, methodological quality scores and
E

t3:3 sample sizes.

R
R
O
C
N
U

*, listed twice because different findings were reported depending on whether total sedentary time was analysed as a continuous or categorical variable. #, listed twice because different
t3:5
findings were reported depending on body mass index (BMI) strata. a, association survived adjustment for moderate-to-vigorous-intensity physical activity (MVPA). b, association survived
t3:6
adjustment for BMI and/or waist circumference (WC). Dark shading = positive association; light shading = no association; medium shading = negative association. FPG, fasting plasma
t3:7
glucose; FI, fasting insulin; 2hPG, 2-hour plasma glucose; HOMA-IR, homeostasis model assessment of insulin resistance; IS, insulin sensitivity; TC, total cholesterol; HDL-C, high-density
t3:8
lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; TG, triglycerides; X, cross-sectional association; P, prospective association; quality, methodological quality score (range
t3:9
0–7, higher score indicates better quality); SN, study number; N, sample size.
t3:10

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx 9

420 number of breaks in sedentary time at baseline and HDL-cholesterol at Discussion 446
421 6-month follow-up(9).
The current systematic review investigated the cross-sectional and 447
prospective associations of accelerometer-measured total sedentary 448
422 LDL-cholesterol time and breaks in sedentary time with individual cardiometabolic bio- 449
markers in adults ≥18 years of age. There was consistent evidence from 450
423 There was no evidence of an association between breaks in sedentary five cross-sectional analyses of an unfavourable association between 451
424 time and LDL-cholesterol in the one available cross-sectional study(4). total sedentary time and insulin sensitivity. Three of these associations 452
survived adjustment for MVPA, but only one analysis additionally 453
adjusted for WC. There was also some evidence that total sedentary 454
425 Triglycerides
time was unfavourably associated with fasting insulin, HOMA-IR and 455
triglycerides. Furthermore, there was some evidence from three out of 456
426 There was some evidence from cross-sectional data of a favourable
427 association between breaks in sedentary time and triglycerides. Three five cross-sectional studies of a favourable association between breaks 457
in sedentary time and triglycerides. Two of these associations survived 458
428 of five cross-sectional studies reported a negative association between

F
adjustment for MVPA and total sedentary time, but none survived 459
429 breaks in sedentary time and triglycerides(4, 15, 18); two following
additional adjustment for BMI or WC. 460
430 adjustment for MVPA and total sedentary time(4, 15), but none following

O
A previous meta-analysis reported that the risk of Type 2 diabetes 461
431 additional adjustment for BMI or WC. The remaining two studies reported
was 112% greater in adults with the highest compared to the lowest 462
432 no association(16, 27). However, to our knowledge, no studies to date have
self-reported sedentary time (Wilmot et al., 2012). Insulin resistance 463
433

O
analysed the prospective association between accelerometer-measured
434 breaks in sedentary time and triglycerides. is a precursor to Type 2 diabetes and thus, this finding supports the 464
consistent, unfavourable association between total sedentary time and 465

R
insulin sensitivity that was reported in the current review. An 466
435 Overview of findings unfavourable association between total sedentary time and insulin 467
sensitivity was mostly reported after adjusting for MVPA, which 468

P
436 For each cardiometabolic biomarker, an overview of findings, method- suggests that this association is not entirely mediated by a decrease in 469
437 ological quality scores and sample sizes are presented in Table 4. There the amount of time spent in MVPA. The physiological mechanism(s) by 470
438 was some evidence from cross-sectional data of a favourable association which sedentary behaviour adversely affects insulin sensitivity are
D 471
439 between breaks in sedentary time and triglycerides. The majority of currently debated, but potential mechanisms include a reduction in 472
440 studies reported a favourable association following adjustment for contraction-stimulated capillary recruitment and/or glucose transporter 473
441 MVPA and total sedentary time, but none following additional adjustment 4 (GLUT4) translocation (Hamburg et al., 2007; Lund et al., 1995). 474
E
442 for BMI and/or WC. The evidence for associations of breaks in sedentary A recent systematic review investigated the cross-sectional associa- 475
443 time with 2-hour plasma glucose and HDL-cholesterol was inconclusive tions between sedentary time and individual cardiometabolic biomarkers 476
T

444 and there was no evidence of associations with fasting plasma glucose, in adults ≥60 years of age, showing unfavourable associations with HDL- 477
445 fasting insulin, HOMA-IR, insulin sensitivity or LDL-cholesterol. cholesterol, but not triglycerides (de Rezende et al., 2014). These findings 478
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do not support the unfavourable association between total sedentary 479

time and triglycerides that was reported in the current review. However, 480
t4:1 Table 4 only three studies reported on triglycerides in the review by de Rezende 481
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t4:2 Cross-sectional and prospective associations of accelerometer-measured breaks in sedentary

et al. (2014); two measured sedentary time with a self-report question- 482
t4:3 time with cardiometabolic biomarkers: overview of findings, methodological quality scores
t4:4 and sample sizes. naire and one was evaluated as very low quality. In contrast, in the current 483
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review, nineteen studies (including one prospective study) analysed 484

the association between total sedentary time and triglycerides; all of 485
the studies measured total sedentary time with an accelerometer and 486
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fourteen were evaluated as moderate-to-high quality. 487

Another explanation for why the two reviews reported different 488
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findings could be that the association between sedentary time and 489
cardiometabolic health is different among younger (≥18 years of age) 490
and older (≥ 60 years of age) adults. Nybo et al. (2003) previously 491
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reported that smoking, obesity and alcohol consumption were less 492
predictive of mortality in older adults (≥75 years of age) (Nybo et al., 493
N

2003). In support of this, three studies included in the current review 494
analysed the cross-sectional association between total sedentary time 495
and triglycerides in older adults (mean age ≥60 years) and two reported 496
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no association. The association between total sedentary time and triglyc- 497
erides may have differed by age because older adults tend to have a 498
poorer cardiometabolic profile or because older adults tend to spend 499
more time in sedentary behaviours (de Rezende et al., 2014). 500
The physiological mechanism(s) by which sedentary behaviour 501
adversely affects triglycerides are currently poorly understood. However, 502
*, listed twice because different findings were reported depending on whether breaks
t4:6 an experimental study conducted in rats suggests that it could be due to 503
in sedentary time were analysed as a continuous or categorical variable. a, association
t4:7 a reduction in skeletal muscle lipoprotein lipase (LPL) activity (Bey and 504
survived adjustment for moderate-to-vigorous-intensity physical activity (MVPA) and
t4:8
total sedentary time. Dark shading = positive association; light-shading = no association; Hamilton, 2003). 505
t4:9
t4:10
medium shading = negative association. FPG, fasting plasma glucose; FI, fasting insulin; To our knowledge, the current review is the first to investigate the 506
2hPG, 2-hour plasma glucose; HOMA-IR, homeostasis model assessment of insulin association between breaks in sedentary and cardiometabolic health 507
t4:11
resistance; IS, insulin sensitivity; HDL-C, high-density lipoprotein cholesterol; LDL-C,
t4:12 and provides some evidence of a favourable association between breaks 508
low-density lipoprotein cholesterol; TG, triglycerides; X, cross-sectional association;
t4:13 in sedentary time and triglycerides. A favourable association was mostly 509
P, prospective association; quality, methodological quality score (range 0–7, higher
t4:14
score indicates better quality); SN, study number; N, sample size. reported following adjustment for MVPA and total sedentary time, 510
t4:15

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 10 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx

511 suggesting that the health benefits associated with regularly breaking Another limitation of the current review is that only one study 575
512 up sedentary time are additional to those associated with increasing required at least 7 valid days of accelerometer wear time to be included 576
513 time spent in MVPA and reducing total sedentary time. in the final analysis (Kim et al., 2013), suggesting that current studies 577
have undersampled total sedentary time (Matthews et al., 2002). 578
514 Study strengths and limitations Causality cannot be inferred from the findings of the current review 579
because only four studies were prospective. Furthermore, we cannot 580
515 The main strength of the current systematic review is that it only in- rule out the possibility that physical inactivity and/or obesity at least 581
516 cludes studies that used an accelerometer to measure total sedentary partially mediated the reported associations because not all of the 582
517 time and/or breaks in sedentary. This is in contrast to previous reviews studies adjusted for MVPA plus BMI and/or WC. 583
518 which have relied on self-report questionnaires (de Rezende et al.,
519 2014; Edwardson et al., 2012; Wilmot et al., 2012). Self-report question- Conclusion 584
520 naires provide information on the type of sedentary behaviours being
521 undertaken and the social and environmental contexts in which they In conclusion, there was consistent evidence from cross-sectional data 585
522 occur, which is useful for choosing which behaviour(s) to target during that accelerometer-measured total sedentary time was unfavourably 586

F
523
Q3 public health interventions (Atkin et al., 2012; Corder et al., 1985, 2007). associated with insulin sensitivity, supporting a detrimental association 587
524 However, they are vulnerable to recall and social desirability bias, between self-reported sedentary time and risk of Type 2 diabetes that 588

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525 making them less suitable for use during association studies (Clark was reported in a previous meta-analysis. There was also some evidence 589
526 et al., 2009; Corder et al., 2007). Accelerometers are currently the that total sedentary time was unfavourably associated with fasting insu- 590
527 most valid and reliable tool for measuring sedentary time (de Rezende lin, HOMA-IR and triglycerides. Finally, there was some evidence from 591

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528 et al., 2014). However, hip-mounted accelerometers, such as the cross-sectional data that accelerometer-measured breaks in sedentary 592
529 Actigraph accelerometer, are incapable of distinguishing between time were favourably associated with triglycerides. However, further 593
530 postures. Consequently, time spent standing may be misclassified as

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studies are required to investigate the prospective associations of 594
531 sedentary time, resulting in an overestimation of total sedentary time accelerometer-measured total sedentary time and breaks in sedentary 595
532 (Clemes et al., 2012). Future association studies should consider using time with individual cardiometabolic biomarkers. Consistent methods of 596

P
533 the activPAL accelerometer to measure sedentary time. The activPAL measuring, defining and analysing sedentary time should also be used 597
534 accelerometer is worn on the thigh and uses information about thigh to enable comparison between such studies. Nonetheless, data presented 598
535 inclination to estimate the amount of time spent sitting or lying, here support the suggestion that greater volumes of sedentary time are
D 599
536 standing and walking (Atkin et al., 2012; Ryan et al., 2006). detrimental to health and reinforce the need to identify interventions to 600
537 Another strength of the current review is that it investigates individual reduce time spent sedentary. 601
538 cardiometabolic biomarkers rather than global measures of cardiometa-
E
539 bolic health, such as risk of Type 2 diabetes and CVD (Wilmot et al.,
Funding source 602
540 2012) or clustered metabolic risk (Edwardson et al., 2012). Global
603
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541 measures may be more important to patients and clinicians, but individ-
This review was supported by the NIHR Bristol Nutrition Biomedical 604
Q4
542 ual biomarkers allow a better understanding of the sedentary behaviour
Research Unit based at University Hospitals NHS Foundation Trust and 605
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543 physiology, which is currently poorly understood (de Rezende et al.,

the University of Bristol. 606
544 2014).
545 The majority of studies included in the current review investigated
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546 adults without diagnosed diabetes, but other populations were also Conflict of interest 607
The authors declare that there are no conflicts of interest. 608
547 investigated. Individuals with Type 2 diabetes or with a higher risk of
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548 developing Type 2 diabetes are different from healthy individuals

549 because they have a poorer cardiometabolic profile. In addition, they Acknowledgments 609
550 may spend more time in sedentary behaviours and less in MVPA.
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551 Despite this, the different populations showed similar associations, LB and RP developed the search strategy for the electronic databases. 610
552 suggesting that the findings are generalisable. However, only six studies LB and CF independently reviewed the titles and abstracts from the 611
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553 investigated adults with newly diagnosed Type 2 diabetes or with a database search. LB and AC independently extracted data from the 612
554 higher risk of developing Type 2 diabetes and therefore, future studies included studies and assessed them for quality. LB synthesised the 613
555 should investigate further whether the relationship between sedentary data and presented it narratively. CF, AC and AP provided writing 614
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556 behaviour and cardiometabolic health differs by the presence or assistance and proof read the final manuscript. 615
557 absence of Type 2 diabetes.
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558 The main limitation of the current review is that it was not possible Appendix A. Supplementary data 616
559 to conduct a meaningful meta-analysis due to inconsistencies in the
560 way in which sedentary time was measured, defined and analysed. Supplementary data to this article can be found online at http://dx. 617
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561 For example, different accelerometer cut points were used to define doi.org/10.1016/j.ypmed.2015.04.013. 618
562 sedentary time. The majority of studies defined sedentary time as
563 b100 cpm, which has been shown to underestimate total sedentary References 619
564 time by 16.9 min (Kozey-Keadle et al., 2011). Kozey-Keadle et al.
565 (2011) found that the cut point with the lowest bias was 150 cpm, but Aadland, E., Andersen, J.R., Anderssen, S.A., Kvalheim, O.M., 2013. Physical activity versus 620
sedentary behavior: associations with lipoprotein particle subclass concentrations in 621
566 only one study used this cut point in the current review (Green et al., healthy adults. PLoS One 8, e85223. 622
567 2014). Cut points greater than 150 cpm have been shown to overesti- Andrews, R.C., Cooper, A.R., Montgomery, A.A., et al., 2011. Diet or diet plus physical 623
568 mate total sedentary time, probably due to misclassification of time activity versus usual care in patients with newly diagnosed type 2 diabetes: the 624
569 spent in light-intensity physical activity as sedentary time. To improve early ACTID randomised controlled trial. Lancet 378, 129–139. 625
Atkin, A.J., Gorely, T., Clemes, S.A., et al., 2012. Methods of measurement in epidemiology: 626
570 comparability between studies in the future, methods of measuring sedentary behaviour. Int. J. Epidemiol. 41, 1460–1471. 627
571 and defining sedentary time need to be standardised. Furthermore, to Balkau, B., Mhamdi, L., Oppert, J.M., et al., 2008. Physical activity and insulin sensitivity: 628
572 aid data synthesis, future association studies should report the unit the RISC study. Diabetes 57, 2613–2618. 629
Bey, L., Hamilton, M.T., 2003. Suppression of skeletal muscle lipoprotein lipase activity 630
573 change in each cardiometabolic biomarker per 1-hour increase in total during physical inactivity: a molecular reason to maintain daily low-intensity activity. 631
574 sedentary time and/or 1-break increase in breaks in sedentary time. J. Physiol. 551, 673–682. 632

Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013
 L.A. Brocklebank et al. / Preventive Medicine xxx (2015) xxx–xxx 11

633 Buman, M.P., Winkler, E.A., Kurka, J.M., et al., 2014. Reallocating time to sleep, sedentary Henson, J., Yates, T., Biddle, S.J., et al., 2013. Associations of objectively measured 697
634 behaviors, or active behaviors: associations with cardiovascular disease risk sedentary behaviour and physical activity with markers of cardiometabolic health. 698
635 biomarkers, NHANES 2005–2006. Am. J. Epidemiol. 179, 323–334. Diabetologia 56, 1012–1020. 699
636 Carson, V., Wong, S.L., Winkler, E., Healy, G.N., Colley, R.C., Tremblay, M.S., 2014. Patterns Kim, J., Tanabe, K., Yokoyama, N., Zempo, H., Kuno, S., 2013. Objectively measured light- 700
637 of sedentary time and cardiometabolic risk among Canadian adults. Prev. Med. 65, intensity lifestyle activity and sedentary time are independently associated with 701
638 23–27. metabolic syndrome: a cross-sectional study of Japanese adults. Int. J. Behav. Nutr. 702
639 Celis-Morales, C.A., Perez-Bravo, F., Ibanes, L., et al., 2011. Insulin resistance in Chileans Phys. Act. 10, 30. 703
640 of European and indigenous descent: evidence for an ethnicity × environment Kozey-Keadle, S., Libertine, A., Lyden, K., Staudenmayer, J., Freedson, P.S., 2011. Validation 704
641 interaction. PLoS One 6, e24690. of wearable monitors for assessing sedentary behavior. Med. Sci. Sports Exerc. 43, 705
642 Celis-Morales, C.A., Perez-Bravo, F., Ibanez, L., Salas, C., Bailey, M.E., Gill, J.M., 2012. Objec- 1561–1567. 706
643 tive vs. self-reported physical activity and sedentary time: effects of measurement Lahjibi, E., Heude, B., Dekker, J.M., et al., 2013. Impact of objectively measured sedentary 707
644 method on relationships with risk biomarkers. PLoS One 7, e36345. behaviour on changes in insulin resistance and secretion over 3 years in the RISC 708
645 Chase, J.M., Lockhart, C.K., Ashe, M.C., Madden, K.M., 2014. Accelerometer-based measures study: interaction with weight gain. Diabetes Metab. 39, 217–225. 709
646 of sedentary behavior and cardio-metabolic risk in active older adults. Clin. Invest. Lecheminant, J.D., Tucker, L.A., 2011. Recommended levels of physical activity and insulin 710
647 Med. 37, E108–E116. resistance in middle-aged women. Diabetes Educ. 37, 573–580. 711
648 Clark, B.K., Sugiyama, T., Healy, G.N., Salmon, J., Dunstan, D.W., Owen, N., 2009. Validity Loprinzi, P.D., Fitzgerald, E.M., Woekel, E., Cardinal, B.J., 2013. Association of physical 712
649 and reliability of measures of television viewing time and other non-occupational activity and sedentary behavior with biological markers among U.S. pregnant 713
650 sedentary behaviour of adults: a review. Obes. Rev. 10, 7–16. women. J Womens Health (Larchmt) 22, 953–958. 714
651 715

F
Clemes, S.A., David, B.M., Zhao, Y., Han, X., Brown, W., 2012. Validity of two self-report Lund, S., Holman, G.D., Schmitz, O., Pedersen, O., 1995. Contraction stimulates transloca-
652 measures of sitting time. J. Phys. Act. Health 9, 533–539. tion of glucose transporter GLUT4 in skeletal muscle through a mechanism distinct 716
653 Colberg, S.R., Sigal, R.J., Fernhall, B., et al., 2010. Exercise and type 2 diabetes: the American from that of insulin. Proc. Natl. Acad. Sci. U. S. A. 92, 5817–5821. 717

O
654 College of Sports Medicine and the American Diabetes Association: joint position Lynch, B.M., Dunstan, D.W., Healy, G.N., Winkler, E., Eakin, E., Owen, N., 2010. Objectively 718
655 statement. Diabetes Care 33, e147–e167. measured physical activity and sedentary time of breast cancer survivors, and associ- 719
656 Cooper, A.R., Sebire, S., Montgomery, A.A., et al., 2012. Sedentary time, breaks in sedentary ations with adiposity: findings from NHANES (2003–2006). Cancer Causes Control 720
657 time and metabolic variables in people with newly diagnosed type 2 diabetes. 21, 283–288. 721

O
658 Diabetologia 55, 589–599. Lynch, B.M., Friedenreich, C.M., Winkler, E.A., et al., 2011. Associations of objectively 722
659 Cooper, A.J., Brage, S., Ekelund, U., Wareham, N.J., Griffin, S.J., Simmons, R.K., 2014. assessed physical activity and sedentary time with biomarkers of breast cancer risk 723
660 Association between objectively assessed sedentary time and physical activity with in postmenopausal women: findings from NHANES (2003–2006). Breast Cancer 724

R
661 metabolic risk factors among people with recently diagnosed type 2 diabetes. Res. Treat. 130, 183–194. 725
662 Diabetologia 57, 73–82. Maher, C., Olds, T., Mire, E., Katzmarzyk, P.T., 2014. Reconsidering the sedentary behaviour 726
663
Q6 Corder, K., Ekelund, U., Steele, R.M., Wareham, N.J., Brage, S., 1985. Assessment of physical paradigm. PLoS One 9, e86403. 727
664 728

P
activity in youth. J. Appl. Physiol. 105, 977–987. Matthews, C.E., Ainsworth, B.E., Thompson, R.W., Bassett JR., D.R., 2002. Med. Sci. Sports
665 Corder, K., Brage, S., Ekelund, U., 2007. Accelerometers and pedometers: methodology Exerc. 34, 1376–1381. 729
666 and clinical application. Curr. Opin. Clin. Nutr. Metab. Care 10, 597–603. Mcguire, K.A., Ross, R., 2011. Sedentary behavior is not associated with cardiometabolic 730
667 De Rezende, L.F., Rey-Lopez, J.P., Matsudo, V.K., Do Carmo Luiz, O., 2014. Sedentary risk in adults with abdominal obesity. PLoS One 6, e20503. 731
668 behavior and health outcomes among older adults: a systematic review. BMC Public Morrato, E.H., Hill, J.O., Wyatt, H.R., Ghushchyan, V., Sullivan, P.W., 2007. Physical activity
D 732
669 Health 14, 333. in U.S. adults with diabetes and at risk for developing diabetes, 2003. Diabetes Care 733
670 Edwardson, C.L., Gorely, T., Davies, M.J., et al., 2012. Association of sedentary behaviour 30, 203–209. 734
671 with metabolic syndrome: a meta-analysis. PLoS One 7, e34916. Nybo, H., Petersen, H.C., Gaist, D., et al., 2003. Predictors of mortality in 2,249 735
E
672 Ekelund, U., Griffin, S.J., Wareham, N.J., 2007. Physical activity and metabolic risk in nonagenarians—the Danish 1905-cohort survey. J. Am. Geriatr. Soc. 51, 1365–1373. 736
673 individuals with a family history of type 2 diabetes. Diabetes Care 30, 337–342. Ryan, C.G., Grant, P.M., Tigbe, W.W., Granat, M.H., 2006. The validity and reliability of a 737
674 Ekelund, U., Brage, S., Griffin, S.J., Wareham, N.J., 2009. Objectively measured moderate- novel activity monitor as a measure of walking. Br. J. Sports Med. 40, 779–784. 738
T

675 and vigorous-intensity physical activity but not sedentary time predicts insulin Scheers, T., Philippaerts, R., Lefevre, J., 2013. SenseWear-determined physical activity and 739
676 resistance in high-risk individuals. Diabetes Care 32, 1081–1086. sedentary behavior and metabolic syndrome. Med. Sci. Sports Exerc. 45, 481–489. 740
677 Gennuso, K.P., Gangnon, R.E., Matthews, C.E., Thraen-Borowski, K.M., Colbert, L.H., 2013. Sedentary Behaviour Research, N., 2012. Letter to the editor: standardized use of the 741
C

678 Sedentary behavior, physical activity, and markers of health in older adults. Med. terms “sedentary” and “sedentary behaviours”. Appl. Physiol. Nutr. Metab. 37, 742
679 Sci. Sports Exerc. 45, 1493–1500. 540–542. 743
680 Green, A.N., Mcgrath, R., Martinez, V., Taylor, K., Paul, D.R., Vella, C.A., 2014. Associations of Stamatakis, E., Hamer, M., Tilling, K., Lawlor, D.A., 2012. Sedentary time in relation to 744
E

681 objectively measured sedentary behavior, light activity, and markers of cardiometa- cardio-metabolic risk factors: differential associations for self-report vs accelerometry 745
682 bolic health in young women. Eur. J. Appl. Physiol. 114, 907–919. in working age adults. Int. J. Epidemiol. 41, 1328–1337. 746
683 Hamburg, N.M., Mcmackin, C.J., Huang, A.L., et al., 2007. Physical inactivity rapidly induces Von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gotzsche, P.C., Vandenbroucke, J.P., 2008. 747
R

684 insulin resistance and microvascular dysfunction in healthy volunteers. Arterioscler. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) 748
685 Thromb. Vasc. Biol. 27, 2650–2656. statement: guidelines for reporting observational studies. J. Clin. Epidemiol. 61, 749
686 Healy, G.N., Dunstan, D.W., Salmon, J., et al., 2007. Objectively measured light-intensity 344–349. 750
687 physical activity is independently associated with 2-h plasma glucose. Diabetes Wells, G.A., Shea, B., O'Connell, D., et al., 2014. The Newcastle-Ottawa Scale (NOS) for 751
R

688 Care 30, 1384–1389. assessing the quality of nonrandomised studies in meta-analyses [online]. Available, 752
689 Healy, G.N., Dunstan, D.W., Salmon, J., et al., 2008a. Breaks in sedentary time: beneficial http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp (Accessed 21 753
690 associations with metabolic risk. Diabetes Care 31, 661–666. January 2015). 754
O

691 Healy, G.N., Wijndaele, K., Dunstan, D.W., et al., 2008b. Objectively measured sedentary Wijndaele, K., Orrow, G., Ekelund, U., et al., 2014. Increasing objectively measured 755
692 time, physical activity, and metabolic risk: the Australian Diabetes, Obesity and Life- sedentary time increases clustered cardiometabolic risk: a 6 year analysis of the 756
693 style Study (AusDiab). Diabetes Care 31, 369–371. ProActive study. Diabetologia 57, 305–312. 757
694 758
C

Healy, G.N., Matthews, C.E., Dunstan, D.W., Winkler, E.A., Owen, N., 2011. Sedentary time Wilmot, E.G., Edwardson, C.L., Achana, F.A., et al., 2012. Sedentary time in adults and the
695 and cardio-metabolic biomarkers in US adults: NHANES 2003–06. Eur. Heart J. 32, association with diabetes, cardiovascular disease and death: systematic review and 759
696 590–597. meta-analysis. Diabetologia 55, 2895–2905. 760
N
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Please cite this article as: Brocklebank, L.A., et al., Accelerometer-measured sedentary time and cardiometabolic biomarkers: A systematic review,
Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2015.04.013