Abstract
Background
The prominence of sedentary behavior research in health science has grown rapidly. With this growth there is increasing urgency for clear, common and accepted terminology and definitions. Such standardization is difficult to achieve, especially across multi-disciplinary researchers, practitioners, and industries. The Sedentary Behavior Research Network (SBRN) undertook a Terminology Consensus Project to address this need.
Method
First, a literature review was completed to identify key terms in sedentary behavior research. These key terms were then reviewed and modified by a Steering Committee formed by SBRN. Next, SBRN members were invited to contribute to this project and interested participants reviewed and provided feedback on the proposed list of terms and draft definitions through an online survey. Finally, a conceptual model and consensus definitions (including caveats and examples for all age groups and functional abilities) were finalized based on the feedback received from the 87 SBRN member participants who responded to the original invitation and survey.
Results
Consensus definitions for the terms physical inactivity, stationary behavior, sedentary behavior, standing, screen time, non-screen-based sedentary time, sitting, reclining, lying, sedentary behavior pattern, as well as how the terms bouts, breaks, and interruptions should be used in this context are provided.
Conclusion
It is hoped that the definitions resulting from this comprehensive, transparent, and broad-based participatory process will result in standardized terminology that is widely supported and adopted, thereby advancing future research, interventions, policies, and practices related to sedentary behaviors.
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Background
There has been rapid and progressive growth in research studying sedentary time and sedentary behaviors [1,2,3,4,5,6,7,8]. Increasing evidence of the link between excessive sedentary behavior and adverse health indicators or outcomes has perpetuated this interest [3, 5,6,7, 9,10,11,12,13,14,15]. The American Heart Association recently issued a science advisory on sedentary behavior and cardiovascular morbidity and mortality [16]. As this field of research has grown, so too has confusion over the definition of sedentary behavior (see Table 1 for a sample of definitions) and other related terms (e.g., screen time, sedentary behavior patterns, bouts, breaks) [4, 7, 17,18,19,20,21,22]. For example, Altenburg and Chinapaw [17] recently recommended that to advance the field of sedentary behavior epidemiology, standardized procedures for accelerometer data collection and data reduction should be defined; standardized operational definitions of sedentary bouts and breaks are needed; sedentary bouts should be operationally defined as a minimum period of uninterrupted sedentary time; total time accumulated in sedentary bouts per day (or per week) should be calculated rather than using average bout duration; and the best mathematical adjustment that converts accelerometer data into sedentary patterns should be further explored. The majority of sedentary behavior self- and proxy-report questionnaires in the published literature have not undergone psychometric testing [10]. Of those that have undergone testing, a small number have acceptable levels of reliability, although the validity of most questionnaires is low [23]. Several other large-scale projects are currently underway to produce a common taxonomy, harmonized measurement protocols, consistent data reduction and analytic procedures, and a framework for establishing research priorities (Table 2). However, a collaborative global initiative to arrive at consensus definitions on key terms has remained elusive.
In 2012, the Sedentary Behaviour Research Network (SBRN; a network connecting sedentary behavior researchers and health professionals from around the world interested in sedentary behavior research [24]) published a letter proposing definitions aimed at clarifying differences between “sedentary behaviour” and “physical inactivity” [25]. This clarification, authored by 52 SBRN members, achieved wide acceptance and was published in English [25, 26] and was subsequently translated and published in French [27], Portuguese and Spanish [28]. There remains, however, a need for further refinement and consensus on a variety of related and emergent terms (e.g., screen time, standing, sitting, reclining), and it has become clear that some commonly used terms are ill-suited for specific populations, such as young children (e.g., before they can sit or stand), those with chronic disease (e.g., hyperthyroidism), or those with mobility impairment (e.g., where postural challenges with standing may represent light or moderate physical activity). Furthermore, the standardized use of key terms (e.g., sedentary behavior vs physical inactivity) has had variable uptake across disciplines (e.g., behavioral science vs exercise physiology) and medical subject headings (MESH) continue to use physical inactivity when sedentary behavior would be more appropriate. Collectively, these issues underscore the need for standardization of terminology, and for definitions that have utility across all ages and physical abilities.
Building on previous work, the SBRN orchestrated a comprehensive effort to further develop consensus definitions for terms related to sedentary behavior research, for all age groups and for all physical abilities, through engagement of its membership. The purpose of this paper is to report on the process employed, conceptual model created, and consensus definitions developed for terms routinely used in research related to sedentary behavior.
Methods
A series of sequential processes were employed in an effort to derive consensus definitions for key terms in sedentary behavior research (Fig. 1). These processes included i) a literature search, ii) establishment of a Steering Committee of SBRN members, iii) invitation to all SBRN members to participate in the consensus project, iv) selecting a list of key terms, v) developing a conceptual model, vi) drafting definitions for key terms, vii) collecting input and feedback on the conceptual model and draft definitions from participating SBRN members, viii) compiling input and finalizing (reaching consensus on) the conceptual model and definitions, ix) preparing the manuscript with sign-off by all participants, x) and finally disseminating project results through publication and presentation.
Terminology Consensus Project timeline
A literature search was performed in March 2016 to i) review the current use of the SBRN [25] definition, and potential deviations from this definition, and ii) examine current operational definitions of sedentary behavior and related terms (e.g., screen time, sedentary behavior patterns, bouts and breaks) and any evidence of inconsistencies, differences, conflicts, or concerns over variations in definitions employed. To identify current relevant articles a search with filters capturing papers published in the past 5 years (May 2011 to May 2016) was conducted in PubMed (see Table 3 for search terms). The articles were selected if there was mention of sedentary behavior and/or related term definitions, cut-points, measurement challenges/recommendations or standard processing techniques for accelerometer data in the title or abstract, with no regard to the population (e.g., child or adult; healthy or unhealthy), type of study, intervention, or comparison being explored. After reviewing the included full-text articles, data were extracted from relevant articles including the aim of the study, defined/discussed terms, targeted population, and definitions/relevant information.
In addition to gathering background information for the project, the literature search allowed for the identification of authors of key papers who were invited to form a Steering Committee for the SBRN Terminology Consensus Project (MST (Chair), TJS, VC, AEL, SFMC, TA, MJMC and project management support from SA and JDB from SBRN). Key terms from the literature search were collated and the Steering Committee members were asked to add or remove key terms from the list. A final draft list of terms was agreed upon by this Committee. An email was sent to the SBRN membership, consisting of researchers, scholars, practitioners, trainees and students interested in sedentary behavior (1094 members worldwide in April, 2016), soliciting interest in participating in the project and asking for suggestions for key terms to be included in the survey.
The Steering Committee identified the most common key terms reported and deliberated through a short survey and email communication to arrive at draft definitions for each term, important caveats for certain age and ability groups, examples to assist with interpretation and, when available, references for the proposed definition. The final list of terms included stationary behavior, sedentary behavior, standing, screen time, non-screen-based sedentary time, sitting, reclining, lying, and sedentary behavior pattern. This process also led to the development of a conceptual model to help position the key terms in relation to one another. The draft definitions, caveats, examples, references, and conceptual model were included in a survey developed for distribution to participating SBRN members. The survey asked participants to assess the clarity of, and agreement with, the conceptual model and proposed definitions (using a five point scale from strongly agree to strongly disagree), while also providing an opportunity for general comments. Consensus was determined a priori to have been achieved if ≥75% of respondents strongly agreed or somewhat agreed with a particular question (see Additional file 1: for complete survey). Note that the term “physical inactivity” was not included in the survey because there were no suggested changes to the existing SBRN [25] definition.
Input from all participants, including the Steering Committee, was consolidated (by MST, SA, JDB) and revisions to the conceptual model, definitions, caveats, examples, and references were made by the Steering Committee. The draft manuscript, including the revised conceptual model and definitions, was sent to all participants for additional review and comments. After additional revisions, a revised draft of the manuscript was resent to all participants for comments, group consensus, and assessment of likelihood of use. Finally, the further revised manuscript (third review) was recirculated to the project participant group for final comments and sign-off for submission.
Results
Literature review
The literature search identified 997 articles, and after screening for inclusion criteria, 14 were used for the identification and definition of key terms in sedentary behavior research. The definition of sedentary behavior as “any waking behaviour characterized by an energy expenditure ≤1.5 METs while in a sitting or reclining posture,” proposed by SBRN [25] was widely adopted as evidenced by frequent citations (558 according to SCOPUS, March 20, 2017), though at least one article claimed that there is still not a real consensus on the definition [20]. Support for the SBRN definition was found for adults [29] and children [21].
The SBRN definition has dual components, including both energy expenditure and posture. The postural aspect is easily operationalized and widely used to identify sedentary behavior using questionnaires, direct observation or inclinometers, but tends to ignore the energetic component. In contrast, the energetic aspect, often determined by indirect calorimetry or accelerometry, has received criticism in relation to its inability to discriminate between postures. However, it should be noted that accelerometers assess movement rather than energy expenditure, and therefore at best represent an indirect method of assessing energy expenditure in any population.
Mansoubi et al. [29] concluded that the 1.5 metabolic equivalent (MET) intensity threshold used in the SBRN definition of sedentary behavior was generally appropriate for distinguishing between common sitting and standing activities in healthy weight and obese adults; however, some common sitting behaviors (e.g., typing) sometimes have a MET level above this threshold. In a recent study that compared MET-defined cut-points used to classify sedentary behaviors in children aged 7–13 years in simulated free-living conditions, it was reported that adult MET thresholds may not be appropriate for children and that the upper limit of the MET threshold for sedentary behavior in children should be increased from 1.5 to 2.0 METs [22]. These authors suggested that a more precise, age-specific definition of sedentary behavior in children may improve overall physical activity (mis)classification in the population and may be of value in quantifying the health burden of sedentary behaviors in youth. In contrast, using whole-room calorimetry as the criterion measure, Reilly et al. [21] and others [30] concluded that the current MET threshold recommendation of ≤1.5 METs seems appropriate for young children (mean age of 5.3 years). Other research supports the inclusion of postural condition (“while in a sitting or reclining posture”) in the sedentary behavior definition instead of just using a definition based on energy cost (≤1.5 METs) [31, 32]. Despite a few inconsistencies, in general, there was broad support in the published literature for the SBRN [25] definition of sedentary behavior, at least in individuals without mobility impairment.
The SBRN [25] definition has also been used for individuals with mobility impairment, for example in studies of people with multiple sclerosis [33,34,35] and community-dwelling older adults (≥60 years of age) who self-reported mobility impairments [36]. The cut-point of ≤1.5 METs was accepted and used for these populations to distinguish between sedentary behavior and light physical activity. There is much debate concerning how to measure sedentary behavior with accelerometers in individuals with different mobility impairments. While the threshold of ≤100 cpm is the most commonly used cut-point [35], Ezeugwu and colleagues [33] suggested that it may actually represent light intensity activity for some people with mobility impairment and that there is still a need for further research to determine appropriate accelerometer cut-points among groups with different mobility impairments.
Altenburg and colleagues [18] examined the occurrence and duration of sedentary bouts, and explored the cross-sectional associations of various operational definitions of sedentary bouts with health indicators in children. Their study highlighted the potential influence of varying definitions of a sedentary bout or sedentary break on their association with health indicators, and provided support for the need for a consensus definition of these terms. Altenburg and Chinapaw [17] discussed and proposed definitions of sedentary bouts and breaks in studies among children. They recommended that a sedentary bout should be defined as a minimum period of uninterrupted sedentary time, not allowing any “tolerance time” (e.g., time spent in non-sedentary behaviors). They further recommended calculating the total time spent in sedentary bouts (per day or per week) instead of average bout duration and they proposed that a sedentary break be defined as a non-sedentary period in between two sedentary bouts. Based on analyses of associations between accelerometer-derived sedentary bout length and cardiovascular disease risk factors using the U.S. National Health and Nutrition Examination Survey, Kim et al. [37] proposed that a threshold of 5 or 10 min be used to define a sedentary bout.
The literature search gathered evidence supporting, and related to, the standardization, harmonization and consensus initiatives summarized in Table 2. For example, several articles highlighted the need for evidence-based and standardized accelerometer cut-points, data collection protocols and data reduction procedures for assessing sedentary time in children and adults [19, 38,39,40,41,42,43]. These are important areas for future work but beyond the scope of this Terminology Consensus Project.
SBRN participant survey findings
The Terminology Consensus Project survey included an overarching conceptual model and draft definitions of key terms identified through the literature search and from project participants. The complete survey (i.e., survey 3 in Fig. 1) sent to respondents is provided in Additional file 1. The survey was organized to be consistent with the hierarchical structure of the conceptual model and the results are presented in the order asked in the survey. Our initial invitation to participate in the process was sent to all 1094 SBRN members. Of these, 390 SBRN members opened the email (36%), 134 SBRN members (12% of total and 34% of those that opened the email) indicated interest, and 87 (8% of total and 22% of those that opened the email) completed the survey, including Steering Committee members (n = 9). Respondents were from 20 countries and represented researchers, trainees, graduate students, practitioners and government employees (see Terminology Consensus Project Participant list below for specific affiliations). Survey results regarding clarity and agreement with the draft definitions, caveats and examples are provided in Table 4. Levels of agreement with the proposed conceptual model and all definitions, caveats and examples were very high (i.e., average ≥ 92%, see Table 4), indicating strong support overall, even before modifications were made to address survey feedback. One survey respondent requested their name be removed as a project participant because of disagreements with the paper content and two others because they felt they had not made a sufficient contribution to warrant coauthorship. In each of these cases the survey results were retained in analyses. In the end, survey results for 87 participants are reported while the manuscript has 84 Terminology Consensus Project coauthors.
In addition to the closed-ended question results presented in Table 4, survey respondents were given the opportunity to provide written comments on all aspects of the consensus project. A total of 420 comments from the respondents were collected (see Fig. 2 for distribution of written responses). With respect to the conceptual model circulated in the survey (see Additional file 1), 17 respondents expressed concerns about the amount of space allocated to each type of activity (e.g., sleep, physical activity, stationary time); and the use of colors. Six respondents commented that it was unclear what time, bouts, interruptions and/or breaks meant in the figure, and five suggested to move or link standing still to the light physical activity section. Finally, four respondents had concerns about the title of the figure because it contained “24-h movement behaviors” but was including a lot of “non-movement behaviors”.
Concerning the definition and caveats for stationary behavior bouts and breaks, seven respondents asked to specify a minimum and a maximum amount of time for a bout and/or break. Four respondents suggested organizing the examples by presenting the most common types of actions first and two asked to put standing still in the light physical activity category. For the definitions related to sedentary behavior, four respondents asked again to specify duration of bout and/or break and three suggested that we should use the interval of 1 to 1.5 METs, instead of ≤1.5 METs. The most recurrent feedback for the standing still section concerned the proposed MET value (≤2.0 METs): six respondents thought that it was too high, too low, or not adapted to everyone, and two suggested adding the definition of 1 MET in this section. Two respondents were against the use of the term “standing still” given that one may be moving weight from one leg to the other when standing, and again, two suggested to put this definition in the light physical activity section. Similar to the previous sections, two respondents asked for a specific length of time for a bout and/or break. Lastly, two criticized the inclusion of “using a standing desk” as an example of standing still.
With regard to the definitions related to screen time, there were a few comments about the examples used: six respondents asked for and suggested more examples, and three suggested specifically adding “video games” in the examples. For non-screen-based sedentary time, seven respondents also gave example suggestions, and four asked for more consistency in the examples (concerning the wording, the hierarchical organization and the use of the “non-recreational/occupational” language present in other sections).
Several relevant comments were made in the sections concerning the proposed definitions for sitting, reclining and lying. For the sitting definition, 15 respondents asked for or suggested further clarifications and examples for active sitting and five for its distinction with passive sitting. Seven respondents also expressed concerns over the evidence supporting the proposed MET-value, and five asked to add specific examples for persons with disabilities, and for infants and toddlers. Concerning the reclining definition, four respondents asked for or suggested more examples, three said that reclining does not have to be “relaxed” or passive, and two wanted to state that body weight is supported by some particular parts of the body (e.g., lower back, buttocks). Finally, for lying, seven respondents suggested clarifying being asleep or being awake in the caveats, three asked for or suggested examples (especially for children) and two suggested to specify the distinction between active and passive lying, as it was done for sitting. Finally, concerning the sedentary behavior pattern definition and caveats, 21 respondents asked for the definition of specific values, cut-points or details for the definitions of breaker, prolonger, extended sitting bout, the distinction between long- and short-bouts, and frequent breaks.
After analysis of the qualitative and quantitative survey data, feedback from the participating SBRN members was taken into account and several major edits were made to the Figure and the definitions by the Steering Committee. First, the conceptual model colors were reorganized and an explanation was added stating that the proportion of space is not representative of the recommended time that should be spent in each behavior category. The definitions were modified to ensure all examples were organized in a consistent fashion, with the most common examples occurring first; the standing still term was changed to standing with clarifications of passive standing and active standing (both stationary behaviors); and examples of active screen time were added to the screen time definition. Changes to definitions were recirculated to all Terminology Consensus Project participants with the draft manuscript and additional reviews and comments were received. These reviews led to several additional minor changes to definitions, caveats and examples. The standing definition was significantly modified with a clarification and examples of passive vs active standing added. The operational definition of “MET” was also added as a footnote to the Table 5 list of definitions. Finally, the conceptual model was further refined based on comments received, removing the term “stationary behavior” and rearranging the illustration to explicitly present the dual components of energy expenditure (inner ring) and posture (outer ring).
The further revised manuscript, table of definitions, and conceptual model was recirculated to all participants for a final review and sign-off. In conjunction with this final review, participants were also asked three questions: 1. Do you agree that your view has been listened to and taken account during this process? (yes/no) 2. Has your level of agreement/support for the consensus definitions changed since you completed the survey? (increased/decreased/no change) 3. Are you likely to use the consensus definitions? (yes/no). Of the 84 final coauthors 100% answered “yes” to questions one and three providing strong support for the participatory consensus process. For question two, 73% responded “increased” and 27% responded “no change”, no one responded decreased. With the already strong support reported in response to the initial survey it is reasonable to believe that the revisions made in response to feedback received resulted in final definitions and a conceptual model that has very strong support from participants. Subjective comments received with participant responses to the various reviews support this observation.
Final conceptual model and consensus definitions
The final conceptual model, presented in Fig. 3, illustrates how the various terms fit together structurally and provides support for the definitions included in this project. Final consensus definitions for key terms (physical inactivity, stationary behavior, sedentary behavior, standing, screen time, non-screen-based sedentary time, sitting, reclining, lying, sedentary behavior pattern), caveats related to age and/or ability differences, examples and related references are provided in Table 5. For the purpose of these consensus definitions, the following age groups were used: Infants – ages 3 months to <1 year; Toddlers and preschoolers – ages 1 to 4 years; Children and youth – ages 5 to 17 years; Adults and Older Adults – age ≥ 18 years. The age ranges for 1- to 4-year-olds and for children and youth are consistent with those used in the Canadian Physical Activity Guidelines for the Early Years and the Canadian 24-Hour Movement Guidelines for Children and Youth respectively [44, 45]. Adults and Older Adults were grouped given that definitions did not differ across the adult lifespan. The definitions were developed with attention to being inclusive in language and examples. Specifically, examples of interpretations of definitions for people with mobility impairment(s) are provided where appropriate.
Illustration of the final conceptual model of movement-based terminology arranged around a 24-h period. The figure organizes the movements that take place throughout the day into two components: The inner ring represents the main behavior categories using energy expenditure. The outer ring provides general categories using posture. Detailed definitions, caveats and examples related to sedentary behavior are provided in Table 5. The proportion of space occupied by each behavior in this figure is not prescriptive of the time that should be spent in these behaviors each day
Discussion
In this paper we describe the processes and outcomes of a comprehensive initiative to establish consensus definitions for terms relevant to sedentary behavior research and to develop a conceptual model to illustrate the hierarchical structural connections among the various terms. This Terminology Consensus Project had several novel and progressive elements: it was informed by the best available evidence; it built on the previous SBRN definition project [25] and other related initiatives (Table 2); it leveraged the diverse membership base of SBRN using an open participatory process; it significantly expanded the scope of terminology covered compared to earlier efforts; it developed a conceptual model to illustrate the structural connections among the various terms; it was observant of nuances for all age groups; it added examples to help interpret the terms; and it was attentive to the interpretation and application of the terminology for people with varying physical abilities. SBRN now has 1273 members from 35 countries (as of March 20, 2017) representing all inhabited continents, of which 84 members from 20 countries and multiple employment sectors participated in all aspects of this project (see Terminology Consensus Participants section below for details).
This project resulted in several notable advances in terminology standardization in the field of sedentary behavior. For example, the addition of the term “lying” to the widely used definition of sedentary behavior [25] fills an obvious gap in the earlier definition. The introduction of the term “stationary behavior” provides a behavioral classification home for “standing”. The consensus definition suggests “passive standing” is a stationary, non-sedentary behavior ≤2.0 METs and that “active standing” is a stationary physical activity >2.0 METs (see Table 5 definitions for more details). Also, for clarity, researchers can now use the term “stationary time” when reporting data collected from an accelerometer that does not measure posture. The consensus definitions add clarity on the distinction between sedentary “behaviors” (with context) and “time” at an established level of intensity (absent of context, which includes most accelerometer and inclinometer data) as well as a standardized approach for defining bouts and interruptions/breaks. Although there is currently no consensus on a minimum duration of a sedentary bout, the work of Kim et al. [37] provide support for 10 min as a conservative sedentary bout threshold. The applicability of these movement behaviors for individuals with mobility impairment was also a distinct improvement.
The conceptual model, with clear definitions of terminology related to sedentary behavior, provides clarity for researchers interested in exploring the relationships between, and among, the various movement behaviors across the whole day (i.e., sleep, sedentary behaviors and various intensities of physical activity) [44, 46] and may facilitate future research exploring behavior substitutions aimed to improve health [47]. Consensus definitions, as presented here, were derived to assist with the standardization, or at least harmonization, of measurement procedures, data processing, and data analytics. Ultimately, common definitions form the foundation upon which related measurement decisions are based. It is hoped that these consensus definitions will help facilitate standardization efforts, reduce confusion, and advance initiatives and research related to sedentary behavior.
There has been much debate around the appropriate MET threshold to use when describing or characterizing sedentary behavior and standing. While there will always be exceptions, the consensus definitions proposed in this paper (sedentary behavior ≤1.5 METs, passive standing ≤2.0 METs; Table 5) have a broad base of support. Several recent studies have shown that a variety of sedentary behaviors were ≤1.5 METs for children and youth [21, 48,49,50,51,52], while others suggested that the threshold may be too low for many childhood behaviors that would be considered sedentary by observation [53, 54]. There is general agreement that determining METs in children should use a VO2 standard that is higher than 3.5 ml/kg/min [55], and when this is employed, there is broad support for the ≤1.5 MET threshold for preschool-aged [21, 51] and school-aged children and youth [48,49,50, 52]. For adults, the sedentary behavior threshold of ≤1.5 METs has been widely recommended and accepted [4, 7, 25, 56].
The MET threshold for passive standing (e.g., not working on an assembly line or painting) is also supported by the literature. For example, the compendium of energy expenditures for youth reports the following MET values: sending text messages while standing, 1.8 METs; talking while standing, 1.8 METs; standing quietly, 1.5 METs; arts and crafts while standing, 1.9 METs; reading while standing, 1.8 METs; drinking while standing, 2.0 METs; and eating while standing, 2.0 METs [55]. The standing threshold of ≤2.0 METs for adults also has support in the literature [29, 31]. Values from the highly cited physical activity compendium also support this threshold, for example: standing doing miscellaneous, 2.0 METs; standing doing arts and crafts (light effort), 1.8 METs; cooking or food preparation while standing, 2.0 METs; standing quietly in a line, 1.2 METs; standing while talking or talking on the phone, 1.8 METs; and standing while reading, 1.8 METs [57].
Strengths and limitations
A strength of this project was the systematic approach taken to determine the list of key terms and arrive at consensus definitions for these terms. The use of a large, broad, diverse and global cohort of participants to provide input to the consensus definitions is a clear strength and should help with the uptake and acceptance of these definitions. Yet, the participants were limited to SBRN members and the overall participation rate by SBRN members was only 8%. However, for SBRN members that opened the email invitation to participate, the rate was 22%, slightly lower than the participation rate of 34% (52/155) for the first SBRN consensus definitions project [25]. It is possible that the participants do not represent the larger population of sedentary behavior researchers and practitioners. A limitation to work of this nature is that there will always be situations and/or circumstances where the proposed definitions are sub-optimal or not wholly satisfactory. Furthermore, there will likely be different conceptual models and other definitions that exist for good reasons or that will emerge as research evolves. The goal of this project was not to marginalize such opinions, but rather respond to calls for better standardization and harmonization of work in the field at this point in time.
Future directions and research needs
There are many future research needs directly related to the definitions proposed in this manuscript. For example, the validity of the proposed terms needs to be tested and further work is necessary to study their content and face validity. In addition, refinements of MET-value thresholds for different ages (e.g., young adults vs older adults), different situations (e.g., while sitting and typing; in different environmental conditions; or in short vs extended durations) or as measured using alternate measurement methods (e.g., measuring muscle activity), and the consequent MET-value-related health implications, requires further exploration [29, 32]. The importance of sedentary behavior context (e.g., leisure time vs school vs work) and modality (e.g., television viewing vs reading vs talking on the phone) in relation to health indicators and outcomes is poorly understood and additional clarity may lead to refinement of the conceptual model and/or the consensus definitions. Additional research is required in populations with mobility impairments or disease conditions where different cut-points/thresholds may exist and there may be different relationships with health indicators than in the general population. Research into the health impact of standing is just beginning to emerge [58,59,60,61,62,63]. How standing interacts with sedentary behaviors and/or sedentary time, sleep and physical activities of various intensities, and how these interactions relate to health outcomes and indicators, needs further research. Through the survey responses SBRN members asked for more research to arrive at specific MET-values and related accelerometer cut-points for categorizing sedentary time. Further research to understand and compare accelerometer data collected from different placement locations (e.g., hip vs wrist) when assessing sedentary time is also required. There were also requests from respondents for standard criteria for defining sedentary bouts and breaks to classify people as “Breakers” or “Prolongers” [1]. Similarly, further research exploring health indicators and outcomes associated with sitting bouts of different durations, distinguishing between long- and short-bouts, and operationalizing “frequent breaks” were all recommended. How the intensity of movement of a “break” affects resultant health-related indictors also requires further exploration. Although questionnaires are frequently used to assess sedentary behavior, few have undergone psychometric testing [10]. Further research is needed to identify the most valid and reliable means of assessing total sedentary behaviour, specific forms of sedentary behaviour, and sedentary behaviour patterns via self- and proxy-report questionnaires. Finally, the physiological impact of ‘transitions’ (e.g., sleep-awake, sit-stand, stand-step) needs to be elucidated [64].
Conclusion
The definitions arrived at through the SBRN Terminology Consensus Project are presented as standardized definitions that we encourage researchers to embrace, use and promote. With the assistance of international SBRN volunteers, efforts are underway to ensure these definitions are translated into several other languages, including French, Spanish, Portuguese, Dutch, Korean, German and others. Copies of all language versions of the consensus definitions are available on the SBRN website [24]. Periodic reviews of these consensus definitions should be done, and updates made when appropriate. It is hoped that the definitions resulting from this comprehensive, transparent and broad-based participatory process will result in widely supported and adopted standardization of terminology, and advance future research, interventions, policies and practices related to sedentary behaviors.
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Acknowledgements
None.
Terminology Consensus Project Participants (in alphabetical order)
Teatske M. Altenburg (t.altenburg@vumc.nl), Department of Public and Occupational Health, Amsterdam Public Health research institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands; Saeideh Aminian (saeideh_612@yahoo.com), Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Unit 1607, 9939, 109 Street, Edmonton, AB Canada T5 K 1H6, Canada; Lauren Arundell (lauren.arundell@deakin.edu.au), Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia; Andrew J. Atkin (A.Atkin@uea.ac.uk), School of Health Sciences, Faculty of Medicine and Heath Sciences, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ; Salomé Aubert (saubert@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Joel Barnes (jbarnes@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Bethany Barone Gibbs (bbarone@pitt.edu), University of Pittsburgh, Departments of Physical Activity and Health, and Clinical and Translational Science, Physical Activity and Weight Management Research Center, University of Pittsburgh, 32 Oak Hill Court Pittsburgh, PA 15216, USA; Rebecca Bassett-Gunter (rgunter@yorku.ca), School of Kinesiology and Health Science York University, 310 Stong College School of Kinesiology and Health Science York University, 4700 Keele Street Toronto, Ontario M3J1P3, Canada; Kevin Belanger (kbelanger@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Stuart Biddle (stuart.biddle@usq.edu.au), Institute for Resilient Regions, University of Southern Queensland, Springfield Central, Queensland 4300, Australia and Victoria University, Melbourne, VIC 8001 Australia; Aviroop Biswas (avi.biswas@mail.utoronto.ca), Institute for Work and Health, 8th Floor, 481 University Avenue, Toronto, M5G2E9 Ontario, Canada; Valerie Carson (vlcarson@ualberta.ca), University of Alberta, 8840–114 Street, Van Vliet Complex, University of Alberta, Edmonton, AB T6G 2H9, Canada; Jean-Philippe Chaput (jpchaput@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Sebastien Chastin (Sebastien.Chastin@gcu.ac.uk), Institute of Applied Health Research, Glasgow Caledonian University, Glasgow, Scotland and Department of Movement and Sport Sciences, Ghent University, Ghent, Belgium; Josephine Chau (josephine.chau@sydney.edu.au), Prevention Research Collaboration, School of Public Health, University of Sydney, 6 N51 Level 6 The Hub D17 The Charles Perkins Centre University of Sydney NSW 2006 Australia; Mai ChinAPaw (m.chinapaw@vumc.nl), Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands; Rachel Colley (rachel.colley@canada.ca), Statistics Canada, 150 Tunney’s Pasture Driveway Ottawa, Ontario K1A 0 T6, Canada; Tara Coppinger (tara.coppinger@cit.ie), Department of Sport, Leisure & Childhood Studies, Cork Institute of Technology, Rossa Avenue Cork, Ireland; Catharine Craven (cathy.craven@uhn.ca), University of Toronto, Department of Medicine, Division of Physical Medicine and Rehabilitation Toronto Rehabilitation Institute - University Health Network, Toronto Rehab, Lyndhurst Centre 520 Sutherland Drive Rm 206-J Toronto, ON M4G 3 V9, Canada; Carlos Cristi-Montero (carlos.cristi.montero@gmail.com), IRyS Group, Physical Education School, Pontificia Universidad Católica de Valparaíso, Av. el bosque 1290, Viña del Mar, Chile; Douglas de Assis Teles Santos (datsantos@uneb.br), College of Physical Education, Department of Education, University of the State of Bahia, Avenue: Presidente Getúlio Vargas, n°7100, house 43, Teixeira de Freitas City, Bahia, Brazil; Borja del Pozo Cruz (b.delpozocruz@auckland.ac.nz), Department of Exercise Science, Faculty of Sciences, The University of Auckland, 261 Morrin Rd., St Johns, 1072 Auckland, New Zealand; Jesus del Pozo-Cruz (jpozo2@us.es), Department of Physical Education and Sports, University of Seville, Spain. Pirotecnia street s/n, 41,013, Seville, Spain; Paddy Dempsey (paddy.dempsey@baker.edu.au), Physical Activity, Metabolic & Vascular Physiology and Behavioural Epidemiology Laboratories, Baker Heart and Diabetes Institute Level 4, 99 Commercial Rd., Melbourne VIC 3004, Australia; Ricardo Filipe do Carmo Santos Gonçalves (ricardo.goncalves@ismat.pt), Instituto Superior Manuel Teixeira Gomes, Morada: Dr. Estêvão de Vasconcelos n° 33 A, 8500–656 Portimão, Portugal; Ulf Ekelund (ulf.ekelund@nih.no), Department of Sport Medicine, Norwegian School of Sport Sciences, PO Box 4014, Ulleval Stadion, 0806 Oslo, Norway; Laura Ellingson (ellingl@iastate.edu), Iowa State University, Department of Kinesiology, ISU 534 Wallace Rd. Ames, IA 50011, USA; Victor Ezeugwu (ezeugwu@ualberta.ca), University of Alberta, Faculty of Rehabilitation Medicine, 3–48 Corbett Hall, Edmonton Alberta T6G 2G4, Canada; Claire Fitzsimons (claire.fitzsimons@ed.ac.uk), University of Edinburgh, Physical Activity for Health Research Centre Institute Sport, Physical Education and Health Sciences, The University of Edinburgh, St Leonard’s Land, Edinburgh, United Kingdom EH8 8AQ; Alberto Florez-Pregonero (floreza@javeriana.edu.co), Pontificia Universidad Javeriana, Carrera 7 No. 40–62, Bogotá, Colombia; Ciarán P. Friel (cpf2111@tc.columbia.edu), Teachers College, Columbia University, 525 W 120th St, New York, NY 10027, USA; Andreas Fröberg (andreas.froberg@gu.se), Department of Food and Nutrition, and Sport Science, University of Gothenburg, Pedagogen, Hus C, Läroverksgatan 5, PO Box 300, SE-405 30, Gothenburg, Sweden; Lora Giangregorio (lora.giangregorio@uwaterloo.ca), Department of Kinesiology, University of Waterloo, 200 University Ave W, Waterloo ON N2L3G1, Canada; Linda Godin (linda.godin@hamilton.ca), Healthy Living Division, City of Hamilton Public Health Services, 110 King Street West, 4th floor, Hamilton, Ontario L8P 4S6, Canada; Katie Gunnell (kgunnell@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Shannon Halloway (shannon_halloway@rush.edu), Rush University College of Nursing, 600 S. Paulina, Suite 1080 Chicago, IL 60612, USA; Trina Hinkley (trina.hinkley@deakin.edu.au), Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia; Jill Hnatiuk (jill.hnatiuk@deakin.edu.au), Deakin University, Institute for Physical Activity and Nutrition (IPAN), School of Exercise and Nutrition Sciences, 221 Burwood Highway, Burwood, Victoria 3125, Australia; Pauliina Husu (pauliina.husu@uta.fi), UKK Institute for Health Promotion Research, PO Box 30, FI-33501, Tampere, Finland; Mohammad Kadir (m.kadir@griffith.edu.au), Research Fellow, Social Marketing @ Griffith and Menzies Health Institute Queensland, Griffith University, 170 Kessels Road, Nathan, Brisbane, Queensland 4111 Australia; Leonidas G. Karagounis (leonidas.karagounis@rdls.nestle.com), Nestlé Research Center, Institute of Nutritional Science, Lausanne, Switzerland and The University of St. Mark & St. John, Experimental Myology and Integrative Biology Research Cluster, Faculty of Sport and Health Sciences, Plymouth, UK; Annemarie Koster (a.koster@maastrichtuniversity.nl), Maastricht University, CAPHRI School for Public Health and Primary Care, Department of Social medicine, P.O. Boxes 616, 6200 MD Maastricht, The Netherlands; Jeroen Lakerveld (j.lakerveld@vumc.nl), Department of Epidemiology and Biostatics, VU University Medical Center Amsterdam, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands; Martin Lamb (m.lamb@shu.ac.uk), Sheffield Hallam University, Health & Wellbeing Research Institute, Chestnut Court Collegiate Crescent, Sheffield, UK S10 2BP; Richard Larouche (rlarouche@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Amy Latimer-Cheung (amy.latimer@queensu.ca), School of Kinesiology and Health Studies, Queen’s University,28 Division Street Kingston Ontario K7 L 3 N6 Canada; Allana G. LeBlanc (allanagwleblanc@gmail.com), University of Ottawa Heart Institute, Division of Prevention and Rehabilitation, 20 Ruskin St., Ottawa K1Y 4 W7, Ontario, Canada; Eun-Young Lee (elee2@ualberta.ca), Faculty of Physical Education & Recreation, University of Alberta, Edmonton, AB. Canada, 1–149 Van Vliet Complex, Edmonton, AB. Canada T6G2H9; Paul Lee (paul.h.lee@polyu.edu.hk), School of Nursing, Hong Kong Polytechnic University, GH527, School of Nursing, Hunghom, Hong Kong; Luis Lopes (luis.iec.um@hotmail.com), Research Centre for Physical Activity, Health and Leisure (CIAFEL), Faculty of Sports, University of Porto, Porto, Portugal, Rua Dr. Plácido Costa n°91, 4200–450 Porto, Portugal; Trish Manns (trish.manns@ualberta.ca), Department of Physical Therapy, University of Alberta, Edmonton, AB T6G2G4, Canada; Taru Manyanga (tmanyanga@cheo.on.ca), HALO Research Group, CHEO Research Institute,401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada; Kathleen Martin Ginis (kathleen_martin.ginis@ubc.ca), University of British Columbia, School of Health and Exercise Sciences, 1147 Research Road Kelowna BC V1 V 1 V7, Canada; Joanne McVeigh (joanne.mcVeigh@curtin.edu.au), School of Occupational Therapy and Social Work, Curtin University, Perth, Australia and Exercise Laboratory, School of Physiology, University of Witwatersrand, South Africa; Joilson Meneguci (joilsonmeneguci@yahoo.com.br), Federal University of Triangulo Mineiro, Av Tutunas, 490, Tutunas, Uberaba, MG, Brazil, CEP: 38,066–030; Carla Moreira (carla_m_moreira@sapo.pt), Research Centre in Physical Activity, Health and Leisure, Faculty of Sport, University of Porto, Portugal, Rua de Cela, n° 475, S. Miguel Couto 4780–254 Santo Tirso, Portugal; Elaine Murtagh (elaine.murtagh@mic.ul.ie), Mary Immaculate College, University of Limerick, South Circular Road, Limerick, Ireland; Freda Patterson (fredap@udel.edu), Center for Biomedical Research Excellence in Cardiovascular Health, College of Health Sciences, University of Delaware, 019 Carpenter Sports Building Newark, DE 19716; Danilo Rodrigues Pereira da Silva (danilorpsilva@gmail.com), State University of Londrina, Physical Education and Sport Centre, Celso Garcia Cid, Pr. 445, Km 380, 86,057,970, Londrina, PR, Brazil; Arto J. Pesola (arto.pesola@gmail.com), Neuromuscular Research Center, Unit of Biology of Physical Activity, University of Jyväskylä and South-Eastern Finland University of Applied Sciences, Patteristonkatu 3 D, 50,101 Mikkeli, Finland; Neil Peterson (neil-peterson@byu.edu), Brigham Young University College of Nursing, 500 Spencer W. Kimball Tower Provo, UT 84602, USA; Cherie Pettitt (cherie.pettitt@mnsu.edu), Minnesota State University Mankato, HC 1400 Mankato, MN 56001 USA; Lara Pilutti (lpilutti@uottawa.ca), University of Ottawa, E250G 200 Lees Avenue, Ottawa, ON, K1 N 6 N5, Canada; Snehal Pinto Pereira (snehal.pereira@ucl.ac.uk), UCL Great Ormond Street Institute of Child Health, 30 Guilford Street London WC1N 1EH, UK; Veronica Poitras (veronicap@cadth.ca), Canadian Agency for Drugs and Technologies in Health, 865 Carling Avenue, Suite 600, Ottawa K1S 5S8, Ontario, Canada; Stephanie Prince (sprinceware@ottawaheart.ca), University of Ottawa, Heart Institute, Division of Prevention and Rehabilitation, 40 Ruskin Street, H2353 Ottawa, Ontario K1Y 4 W7, Canada; Apoorva Rathod (apoorva.rathod@gu.se), Unit for Human Geography, University of Gothenburg, Viktoriagatan 13 40,530 Göteborg Sweden; Fabien Rivière (fbn.riviere@gmail.com), EA 4360 APEMAC, University of Lorraine, Paris-Descartes University, Nancy 54,505, France; Sara Rosenkranz (sararose@ksu.edu), Department of Food, Nutrition, Dietetics and Health, and Physical Activity and Nutrition Clinical Research Consortium, Rm 212 Justin Hall, 1324 Lovers Lane, Kansas State University, Manhattan, KS 66506, USA; François Routhier (francois.routhier@rea.ulaval.ca), Center for interdisciplinary research in rehabilitation and social integration and Department of Rehabilitation, Faculty of Medicine, Université Laval, Québec G1 M 2S8, Canada; Rute Santos (rutes@uow.edu.au; rsantos.ciafel@fade.up.pt), Early Start Research Institute, Faculty of Social Sciences, University of Wollongong, Building 21, room 214 Northfields Avenue 2522 NSW, Australia and Research Centre in Physical Activity and Health, Faculty of Sport, University of Porto, Portugal; Travis Saunders (trsaunders@upei.ca), Department of Applied Human Sciences, University of Prince Edward Island, 550 University Avenue Charlottetown, PE C1A 4P3, Canada; Brett Smith (smithbs@bham.ac.uk), School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT UK; Olga Theou (olga.theou@dal.ca), Department of Medicine, Dalhousie University, 5955 Veterans’ Memorial Lane, Rm 1313 Halifax, NS, B3H2E1, Canada; Jennifer Tomasone (tomasone@queensu.ca), School of Kinesiology and Health Studies, Queen’s University, 28 Division Street, KHS 301F Kingston, ON K7L3N6, Canada; Mark Tremblay (mtremblay@cheo.on.ca), HALO Research Group, CHEO Research Institute, 401 Smyth Road, Ottawa K1H 8 L1, Ontario, Canada and and Department of Pediatrics, University of Ottawa, Ottawa, Canada; Patricia Tucker (ttucker2@uwo.ca), University of Western Ontario, 1201 Western Road London, Ontario, Canada N6G 1H1; Renée Umstattd Meyer (renee_umstattd@baylor.edu), Baylor University, Public Health, Department of Health, Human Performance and Recreation Robbins College of Health and Human Sciences, One Bear Place, #97313 Waco, TX 76798; Hidde van der Ploeg (hp.vanderploeg@vumc.nl), Department of Public and Occupational Health, Amsterdam Public Health Research Institute, VU University Medical Center, Van der Boechorststraat, 7 1081BT Amsterdam, The Netherlands and Sydney School of Public Health, University of Sydney, Australia; Tania Villalobos (tania.villalobos@gmail.com), Departamento de Nutrición y Bromatología I, Facultad de Farmacia, Universidad Complutense de Madrid, General Guisan Strasse 14, Arlesheim BL 4144, Switzerland; Toni Viren (toni.viren@outlook.com), Metropolia University of Applied Sciences, Unit of Physiotherapy, Vanha Viertotie 23, 00350 Helsinki, Finland; Birgit Wallmann-Sperlich (birgit.sperlich@uni-wuerzburg.de; b.sperlich@dshs-koeln.de), Institute for Sports Science, Julius-Maximilians University Würzburg, Judenbühlweg 11, 97,082 Würzburg, Germany and Institute of Health Promotion and Clinical Movement Science, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50,933 Köln, Germany; Katrien Wijndaele (katrien.wijndaele@mrc-epid.cam.ac.uk), MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Box 285, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge CB2 0QQ, United Kingdom; Roderick Wondergem (r.wondergem@fontys.nl), Center for Physical Therapy Research and Innovation in Primary Care, Julius Health Care Centers, Utrecht and, Department of Rehabilitation, Physical Therapy Research and Sport, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht and Department of Health Innovations and Technology, Fontys University of Applied Sciences, Ds. Th. Fliednerstraat 2, P.O box 347, Eindhoven, The Netherlands.
Funding
There was no funding for this project.
Availability of data and materials
All data generated or analysed during this study are included in this published article and its supplementary information files.
Authors’ contributions
The literature review was run by SA. The identified key terms were reviewed and modified by the Steering Committee formed by MST, SA, JDB, TJS, VC, AELC, SFMC, TMA and MJMC. Next, all Terminology Consensus Project Participants reviewed and provided feedback on the proposed list of terms. JDB created the online Survey 1 for the final key term list modification/approval/shortening that was completed by the Steering Committee members (MST, SA, JDB, TJS, VC, AELC, SFMC, TMA and MJMC) and prepared a compilation of the collected data. MST, SA and JDB did the analysis of Survey 1 and finalized the key term list. Then JDB created the Survey 2 (asking for first proposition of definitions of each key term and caveats) that was completed by the Steering Committee members and JDB compiled the collected data. MST, SA and JDB analysed the collected data and created the first draft of definition of each key term and caveats, and created the conceptual model. JDB created the draft of the online Survey 3 (asking level of agreement and feedback on proposed model, key term definitions and caveats) that was reviewed by the Steering Committee members and then completed by all Terminology Consensus Project Participants. JDB did the analysis of quantitative data and SA of qualitative data collected by Survey 3. Based on those analyses, modifications to model and key term definitions were made by MST, SA and JDB. MST wrote the manuscript with the help of SA and JDB, and then the manuscript (including the definitions and the conceptual model) was reviewed 2 times by the Steering Committee members and 3 times by all Terminology Consensus Project Participants who all give their final sign-off for submission. All authors read and approved the final manuscript.
Competing interests
BBG has received research support from Humanscale. SB has received funding since 2013 for consultancy work from Fitness First, Nuffield Health, and Unilever (none of these are currently active); funding was received in 2016 for consultancy work for Halpern PR Limited; in-kind support through the provision of a sit-to-stand desk was provided by Ergotron from 2012 to 2014; advice has been requested by and offered to Active Working, Get Britain Standing, and Bluearth, none with funding. LG has consulted on physical function in individuals with osteoporosis for ICON on behalf of Eli Lilly. TJS is supported by the Jeanne and J.-Louis Lévesque Research Professor in Nutrisciences and Health, and has received research and/or in-kind support from Stepscount, Ergotron, and Fitabase. No other authors declare any conflict of interest.
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Additional file 1:
SBRN Terminology Consensus Project survey. (DOCX 435 kb)
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Tremblay, M.S., Aubert, S., Barnes, J.D. et al. Sedentary Behavior Research Network (SBRN) – Terminology Consensus Project process and outcome. Int J Behav Nutr Phys Act 14, 75 (2017). https://doi.org/10.1186/s12966-017-0525-8
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DOI: https://doi.org/10.1186/s12966-017-0525-8