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YPMED-04203; No of Pages 5

Preventive Medicine xxx (2015) xxxxxx

Contents lists available at ScienceDirect

Preventive Medicine

Dorte Eriksen a,, Susanne Rosthj b, Hermann Burr c, Andreas Holtermann a

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a r t i c l e

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Available online xxxx

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Keywords:
Public health
Work
Sedentary behavior
Occupational sitting
Change in occupational sitting time
Body mass index

National Research Center for the Working Environment, Copenhagen, Denmark


Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
Bundesanstalt fr Arbeitsschutz und Arbeitsmedizin (BAuA), Germany

i n f o

a b s t r a c t

Objective. The aim of this study is to investigate the association between ve-year changes in occupational sitting and body mass index (BMI) in working adults.
Methods. We analyzed data from The Danish Work Environment Cohort Study (2005 and 2010, n = 3.482).
Data on occupational sitting, weight, height and several potential confounders were self-reported. The association between change in occupational sitting (hours) (categorized as large decrease b7.5, moderate decrease
7.5 to b 2.5, no change 2.5 to 2.5, moderate increase N2.5 to 7.5 and large increase N7.5) and change in
BMI was explored by multiple linear regression analyses.
Results. 43.0% men and 36.1% women had high occupational sitting time (25 h per week) at baseline. 31.8%
men and 27.2% women decreased while 30.0% men and 33.0% women increased occupational sitting. The proportion of obese (BMI 30) increased almost 3% for both genders. BMI changed 0.13 (CI: 0.06; 0.20, p = 0.0003), per
category of change in occupational sitting in women, but no association was found in men.
Conclusion. In women, there is a positive association between ve-year changes in occupational sitting and
BMI in this study.
2015 Elsevier Inc. All rights reserved.

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Sedentary workAssociations between ve-year changes in


occupational sitting time and body mass index

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

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Introduction

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The prevalence of overweight and obesity has been strongly increasing the last decades (Haslam and James, 2005; Kelly et al., 2008). Because overweight and obesity increase the risk for several diseases
such as diabetes, cancer and cardiovascular disease, it is considered to
be among the largest challenges for public health worldwide (Haslam
and James, 2005; Kelly et al., 2008). A contributing factor for the obesity
epidemic could be, that work has changed from mainly involving different forms of physical activity to becoming mainly sedentary for a high
proportion of the working population (Stamatakis et al., 2007; Juneau
and Potvin, 2010; Allman-Farinelli et al., 2010; Church et al., 2011). Because adults often spend more than half of their waking hours at work
(Tudor-Locke et al., 2011), and sedentary behavior is characterized by
a low energy expenditure, this change has potential effects on obesity
(Pate et al., 2008; Church et al., 2011), and, more documentation for
changes in body weight from changes in occupational sitting is needed
(Hamilton et al., 2007). One prospective study found a positive association between sedentary work and body mass index (BMI) (Hu et al.,
2003). However, other prospective studies found no associations

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Corresponding author at: National Research Center for the Working Environment,
Lers Parkall 105, DK-2100 Copenhagen , Denmark.
E-mail address: dorte.eriksen@yahoo.com (D. Eriksen).

between sedentary work and BMI (van Uffelen et al., 2010). The strongest epidemiological evidence for the positive health effects of physical
activity is based on studies investigating associations between changes
in physical activity and risk for impaired health and diseases (Bravata
et al., 2007). However, no previous studies have to our knowledge investigated if changes in sedentary working time are associated with
changes in BMI. The main aim of this study was to investigate the association between changes in occupational sitting time and BMI in a representative sample of the working population in Denmark, testing the
a priori hypothesis of a positive association between these variables.

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Methods

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Participants/study population

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This study used data from The Danish Work Environment Cohort Study
(DWECS), consisting of a representative sample of the Danish working population aged 1859 years at entry. In 2005 the survey used a combination of (postalor internet based) questionnaire (90%) and telephone interview (10%) among a
representative sample of 20,000 workers with a response rate of 63%. In 2010 the
survey was conducted using (postal- or internet based) questionnaire only, and
achieved a response rate of 53% of a representative sample of 30,000 workers.
This study includes data from the 4732 working respondents who participated
in both 2005 and 2010.

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http://dx.doi.org/10.1016/j.ypmed.2014.12.038
0091-7435/ 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Eriksen, D., et al., Sedentary workAssociations between ve-year changes in occupational sitting time and body mass
index, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.038

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D. Eriksen et al. / Preventive Medicine xxx (2015) xxxxxx

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BMI was calculated as weight/height2 from self-reported measures on


height and weight. Height was calculated as mean of self-reported height in
2005 and 2010. BMI was categorized into: Underweight: BMI b 18.5, normal
weight: 18.5 BMI b 25, overweight: 25 BMI b 30 and obesity: BMI 30
(WHO, 2006). The change in BMI was calculated as the subtraction of BMI in
2005 from BMI in 2010. Sex and age were obtained from the personal identication code register in Denmark. Age in years was categorized in ve (b30, 30
39, 4049, 5059 and 60). Socioeconomic status (SES) was dened by selfreported years of vocational training, which is considered a robust measure
(Brnnum-Hansen et al., 2004), and provided in four categories (0, b3, 34
and N4).

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Leisure time physical activity and other lifestyle variables

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Leisure time physical activity in 2005 was self-reported to the question In


the past year, which description ts best regarding your leisure time physical activity?, with four response categories combining intensity, frequency and volume of exercising, previously used in other studies and shown to be strongly
related with cardiovascular disease and mortality (Larsson et al., 2012;
Holtermann et al., 2012). Smoking was self-reported with 3 response categories
(smoker, ex-smoker and never). Job seniority was measured by self-reported
years in the same job and categorized (b 5, 510, N1020 and N20). The respondents were classied according to mode of data collection in 2005, being either
postal- or internet based questionnaire or telephone interview (Holtermann
et al., 2012).

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Statistical analysis

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To examine the difference between subgroups dened by the demographic


variables the KruskalWallis test was applied for quantitative variables and the
Pearson chi-square test for categorical variables. The association between categories of change of occupational sitting time from 2005 to 2010 and change in
BMI during the same time interval was analyzed with multiple linear regression
models. Adjustments were made for: model 1: age, model 2: model 1 +
smoking, baseline BMI, leisure time physical activity, response method, and
job seniority, and model 3: model 2 + vocational training (SES). All analyses
were stratied by gender, because interactions between gender and occupational sitting as well as several of the adjustment variables were found in analyses based on the total sample. If a monotone association between category of
change of occupational sitting as a categorical variable and BMI was seen, the
log-likelihood test was performed to investigate if category of change of occupational sitting could be included as a quantitative variable in the linear regression
model. Due to extreme values in some of the participants working hours, the
study population was restricted to respondents working 2060 h a week
(n = 364 excluded). Because disease can inuence weight change and bias
the results (Hannerz et al., 2004), respondents with bad or very bad self-

Body mass index and sociodemographic variables

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Participants reported their amount of occupational sitting time by answering the question Does your work imply sitting? with six response categories
(Almost all the time, approximately of the time, approximately of the
time, approximately of the time, rarely/very little or never). Similar categorical measures of occupational sitting have been used previously (Choi et al.,
2010; Stock et al., 2005). Accounting for participants having varying number
of working hours, the categories of sitting time were calculated into sitting
hours, based on self-reported weekly working hours achieved by response to
the questions How many hours a week do you work in your main job, including
possible extra hours? and How many hours a week do you normally work in
your secondary job? The total amount of working hours per week was then
multiplied by the constant for occupational sitting, corresponding to the previously mentioned categorical occupational sitting time (0.875, 0.750, 0.500,
0.250, 0.125 and 0.000). The change in occupational sitting time from 2005 to
2010 was calculated by subtracting occupational sitting in 2005 from occupational sitting in 2010, and dened on an ordinal scale with ve categories of
weekly change (hours) (large decrease b7.5, moderate decrease = 7.5 to
b 2.5, no change = 2.5 to 2.5, moderate increase N 2.5 to 7.5 and large increase N7.5). Moreover, the baseline weekly occupational sitting hours was dened on an ordinal scale with three categories (low: 10, moderate: N 10 to b 25
and high: 25).

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reported health were excluded (n = 182). Moreover respondents with extreme


self-reported weight change from 2005 to 2010 greater than 95 kg (n = 4),
self-reported height difference from 2005 to 2010 greater than 10 cm (n =
31) and missing values on exposure, outcome or covariates (n = 669) were excluded. Therefore, 3482 respondents remained in these primary statistical
analyses.
The association between baseline category of occupational sitting time and
both baseline BMI and changes in BMI from 2005 to 2010 was analyzed using
multiple linear regression models based on the same adjustments as described
above (model 13). In these analyses, the study population is slightly larger
(3544), as those with missing values for occupational sitting time in 2010 are
not excluded.
Also, sensitivity analyses excluding respondents with self-reported height
difference greater than 5 cm (n = 74) were done.
The robustness of the results was examined by additional analyses considering the same regression models as described above based on the study populations not excluding those with extreme values of working hours (n = 3.846 and
n = 4.061, respectively).
We present the results as differences with 95% condence intervals. P values
were two-sided and considered signicant if below 5%. Due to multiple testing
in the comparison of the different categories of change in occupational sitting
hours, the condence intervals and p-values in these comparisons were
corrected by the Sidk procedure. We analyzed the data using SAS V9.2. (SAS institute Inc., Cary, NC, USA).

Table 1
t1:1
Characteristics of the study population for each sex separately, numbers (n), percent (%). t1:2
N = 3482. The Danish Work Environment Cohort (NAK), 2005.
t1:3

Occupational sitting

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Males

Females

t1:4

(n = 1679,
48.2%)

(n = 1803,
51.8%)

t1:5
t1:6

Confounders

Age (years)
1829
3039
4049
5059
60

164
429
587
470
29

9.8
25.6
35.0
28.0
1.7

143
497
693
459
11

7.9
27.6
38.4
25.5
0.6

Baseline BMI
Underweight (b18.5)
Normal weight (18.5b25)
Overweight (25b30)
Obesity (30)

5
781
715
178

0.3
46.5
42.6
10.6

51
1198
416
138

2.8
66.4
23.1
7.7

Physical activity in leisure time


Competition level
Strenuous
Light
Inactive

61
437
928
253

3.6
26.0
55.3
15.1

27
360
1182
234

1.5
20.0
65.6
13.0

Smoking status
Smoker
Ex-smoker
Never

430
464
785

25.6
27.6
46.8

457
514
832

25.4
28.5
46.2

Job seniority (years)


b5
510
N1020
N20

455
391
441
392

27.1
23.3
26.3
23.4

452
416
514
421

25.1
23.1
28.7
23.4

Questionnaire method
Postal or internet based questionnaire
Telephone interview

1347
332

80.2
19.8

1493
310

82.8
17.2

SES (years of vocational training)


None
Short (b3)
Medium length (34)
Long (N4)

184
796
354
345

11.0
47.4
21.1
20.6

149
789
659
206

8.3
43.8
36.6
11.4

Occupational sitting time (hours per week)


Low (10)
Moderate (N10b25)
High (25)

607
350
722

36.2
20.9
43.0

683
469
651

37.9
26.0
36.1

Please cite this article as: Eriksen, D., et al., Sedentary workAssociations between ve-year changes in occupational sitting time and body mass
index, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.038

t1:7
t1:8
t1:9
t1:10
t1:11
t1:12
t1:13
t1:14
t1:15
t1:16
t1:17
t1:18
t1:19
t1:20
t1:21
t1:22
t1:23
t1:24
t1:25
t1:26
t1:27
t1:28
t1:29
t1:30
t1:31
t1:32
t1:33
t1:34
t1:35
t1:36
t1:37
t1:38
t1:39
t1:40
t1:41
t1:42
t1:43
t1:44
t1:45
t1:46
t1:47
t1:48
t1:49
t1:50
t1:51

D. Eriksen et al. / Preventive Medicine xxx (2015) xxxxxx


t2:1
t2:2
t2:3

sitting in 2005 and BMI for both genders as in the primary analyses (re- 196
sults not shown).
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Table 2
Characteristics of the study population stratied by BMI and sex, number (n) and percent (%).
N = 3482. The Danish Work Environment Cohort (NAK), 2005 to 2010.

t2:4

Males (n = 1679;
48.2%)

Females (n = 1803;
51.8%)

Discussion

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t2:5

2005

2005

This study is to our knowledge the rst to examine the association


between ve-year changes in occupational sitting time and BMI. The hypothesis of a positive association between changes in sitting time and
BMI was conrmed for women, but not for men. The results suggest
that for women, change in occupational sitting time is associated with
a change in BMI. Specically, BMI increased with 0.13 for each category
of increase in occupational sitting time from 2005 to 2010. In comparison, Pereira found a ve year increase in BMI of 0.33 among men and
women sitting at work at baseline for 23 h/day compared to those sitting 01 h/day, but no trend for work sitting and BMI change was found
(Pinto Pereira and Power, 2013). The different effect size of sitting time
could be due to a different study population (i.e. mid-adulthood British
men and women, whereas our study included a wider age interval) or
methodological differences like estimation of sitting duration. However,
both studies support that occupational sitting is positively associated
with BMI among women.
The causes for the lacking positive association between occupational
sitting and BMI among men are unknown. In principle, the reduced energy expenditure with increasing sitting time ought to lead to comparable increases in BMI among both genders. A potential explanation can
be BMI as an outcome. BMI is criticized for being a poor indicator of
body composition, because it does not distinguish between fat and muscle mass. Men have higher muscle mass than women, and extensive
sedentary behavior is likely to reduce this (Pace et al., 1976; Ferrando
et al., 1999) while increasing fat percentage with no signicant inuence on BMI (Kwasniewska et al., 2014), which may explain the observed lacking association between sitting time and BMI among men.
Therefore, better measures of body composition like fat percentage is
recommended for future studies on the association between changes
in sitting time and body composition.
We found no association between baseline occupational sitting time
and prospective change in BMI in either men or women working 20
60 h a week. This is consistent with previous prospective studies (van
Uffelen et al., 2010), and may explain the importance of analyzing
changes in occupational sitting. In accordance with other studies, our
study found high prevalence of high categories of occupational sitting
among both genders (Brown et al., 2003; Jans et al., 2007; Mummery
et al., 2005). Other studies have found participants do not compensate
for much occupational sitting with less leisure time sitting (Chau et al.,
2012; Jans et al., 2007). Moreover, work occupies approximately half

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2010

2010

t2:6

BMI

t2:7
t2:8
t2:9
t2:10

Underweight (b18.5)
Normal weight (18.5b25)
Overweight (25b30)
Obesity (30)

5
781
715
178

0.3
46.5
42.6
10.6

4
683
772
220

0.2
40.7
46.0
13.1

51
1198
416
138

2.8
66.4
23.1
7.7

41
1079
493
190

2.3
60.0
27.3
10.5

Results

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Table 1 presents an overview of baseline characteristics of the study


population stratied by sex. Men generally have a higher prevalence of
high occupational sitting (25 h/week), overweight and obesity than
women.
Table 2 shows the distribution of the participants in the four BMIcategories in 2005 and 2010, stratied by sex. The prevalence of overweight and obesity increased among both sexes.
Table 3 presents the results for men and women based on the linear
regression analysis on the association between changes in occupational
sitting time and change in BMI. For men, no tendency for an association
between category of change in occupational sitting and BMI was observed. For women, a signicant positive trend was seen between
change in occupational sitting and BMI. Compared to the group with
large increase in sitting time (reference), a positive association with
BMI was found in the groups with large decrease and moderate decrease in occupational sitting. Correcting the results by the Sidk procedure did not alter this nding.
Moreover, a positive association between occupational sitting time
as a quantitative variable and BMI was found in women. Each unit of increase in occupational sitting category was associated with an increase
in BMI. Change in BMI (CI) = 0.13 (0.06; 0.20), p = 0.0003 in model 3
(results not shown). No associations were found between categories
of occupational sitting time in 2005 and both baseline BMI (not
shown) and change in BMI from 2005 to 2010 for men and women respectively (Table 4).
Sensitivity analyses excluding respondents with self-reported height
difference greater than 5 cm showed similar results (Tables 3 and 4).
The additional analyses involving all study participants, independent
of numbers of working hours, found a similar pattern both between
changes in occupational sitting from 2005 to 2010, and occupational

t3:1
t3:2

Table 3
Association between change in occupational sitting time and change in BMI (BMI). N = 3482. The Danish Work Environment Cohort (NAK), 2005 to 2010.

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Crude (Model 1)a

t3:3

BMI

t3:17
t3:18
t3:19
t3:20
t3:21

t3:4
t3:5
t3:6
t3:7
t3:8
t3:9
t3:10
t3:11
t3:12
t3:13
t3:14
t3:15
t3:16

R
O

180
181

178
179

176
177

174
175

172
173

170
171

N
C
O

168
169

165

Males
Large decrease
Moderate decrease
No change
Moderate increase
Large increase
Females
Large decrease
Moderate decrease
No change
Moderate increase
Large increase

CI

Adjusted (Model 2)b


P

BMI

CI

Further adjusted (Model 3)c


P

0.9342

0.04
0.00
0.04
0.06
0

0.27
0.31
0.22
0.27
0.27
0.19
0.27
0.21
Reference

0.7563
0.9750
0.7177
0.6685

0.46
0.50
0.24
0.06
0

0.80
0.12
0.80
0.19
0.50
0.01
0.36
0.25
Reference

0.0077
0.0016
0.0629
0.7092

BMI

CI

0.04
0.02
0.05
0.07
0

0.22
0.31
0.25
0.28
0.27
0.18
0.34
0.20
Reference

0.7446
0.9088
0.6724
0.6013

0.43
0.50
0.25
0.10
0

0.77
0.10
0.81
0.20
0.51
0.00
0.40
0.20
Reference

0.0108
0.0010
0.0502
0.4961

0.9169
0.04
0.01
0.04
0.07
0

0.22
0.31
0.25
0.28
0.26
0.19
0.34
0.20
Reference

0.7415
0.9137
0.7574
0.6166

0.46
0.48
0.23
0.08
0

0.79
0.12
0.79
0.18
0.48
0.03
0.38
0.22
Reference

0.0073
0.0018
0.0811
0.0671

0.0038

*
0.8839

0.0054

0.0058

BMI: Change in BMI from 2005 to 2010. CI: 95% condence interval. P: Signicance level. Bold writing: P b 0.05. *Overall signicance level. Large decrease: b7.5 h. Moderate decrease:
7.5 h to b2.5 h. No change: 2.5 h to 2.5 h. Moderate increase: N2.5 h to 7.5 h. Large increase: N7.5 h.
a
Crude analysis: Adjusted for age.
b
Adjusted for age + baseline BMI, smoking, leisure time physical activity, questionnaire method, and job seniority.
c
Adjusted as in model 2 + SES.

Please cite this article as: Eriksen, D., et al., Sedentary workAssociations between ve-year changes in occupational sitting time and body mass
index, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.038

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t4:1
t4:2

D. Eriksen et al. / Preventive Medicine xxx (2015) xxxxxx

Table 4
Association between level of baseline occupational sitting time and change in BMI (BMI), N = 3544. The Danish Work Environment Cohort (NAK), 2005 to 2010.
Crude (Model 1)a

t4:3

BMI

t4:4
t4:5
t4:6
t4:7
t4:8
t4:9
t4:10
t4:11
t4:12

Males
Low
Moderate
High
Females
Low
Moderate
High

Adjusted (Model 2)b

CI

BMI

Further adjusted (Model 3)c

CI

0.4085
0.11
0.06
0.00

0.05
0.28
0.13
0.27
Reference

0.1843
0.4977

0.20
0.09
0.00

0.00
0.40
0.13
0.31
Reference

0.0496
0.4317

BMI

CI

0.02
0.03
0.00

0.16
0.20
0.17
0.23
Reference

0.8383
0.7742

0.18
0.07
0.00

0.02
0.39
0.15
0.29
Reference

0.0823
0.5436

0.5268
0.09
0.06
0.00

0.07
0.26
0.13
0.26
Reference

0.2663
0.5237

0.22
0.08
0.00

0.02
0.42
0.14
0.30
Reference

0.0297
0.4711

0.1442

0.9554

0.0893

0.2133

BMI: Change in BMI from 2005 to 2010. CI: 95% condence interval. P: Signicance level. *Overall signicance level. Low: 10 h. Moderate: N10 h to b25 h. High: 25 h.
a
Crude analysis: Adjusted for age.
b
Adjusted for age + baseline BMI, smoking, leisure time physical activity, questionnaire method, and job seniority.
c
Adjusted as in model 2 + SES.

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the waking hours for working adults (Tudor-Locke et al., 2011). Therefore, the occupational domain is a relevant setting for intervening on extensive sitting (Chau et al., 2012; Owen et al., 2011).

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Strengths and limitations

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280

The main strength of this study is the prospective study design with
a large representative sample of Danish workers. The question on occupational sitting time has been used in earlier studies and have shown acceptable validity and reliability (Stock et al., 2005; Andersen et al., 2000;
Holtermann et al., 2012; Choi et al., 2010), and the ability to estimate the
weekly number of hours sitting at work strengthens the study (van
Uffelen et al., 2010). Additional strength is the ability to investigate
the association between changes in occupational sitting time and BMI.
We adjusted for baseline BMI and other potential confounders. We did
not adjust for baseline sitting time. Given the chosen analytical approach in this study, including the treatment of ordinal variables as
quantitative, we consider that changes in sitting time are associated
with similar changes in BMI independent of baseline.
The main limitation is the use of self-reported measures of occupational sitting time and BMI, which may have been inuenced by selfreporting bias. Self-reported sitting time is often overestimated (Clark
et al., 2011; Juneau and Potvin, 2010), while self-reported BMI is often
underestimated (Nyholm et al., 2007). These issues might have led to
underestimation of the association between change in occupational sitting time and BMI. It would be a methodological strength for future cohort studies to collect objective data on these variables (LagerstedOlsen et al., 2013). The survey response rate was 63% in 2005 and 53%
in 2010. Additionally the study only included individuals, who
responded in both years. This might have led to selection biases, if participants were healthier than non-participants. Potentially this might
cause underestimation of the association between changes in occupational sitting time and BMI. Moreover some methodological weaknesses
are present, like not being able to estimate the energy expenditure, not
having a clear denition of smoking and not having information on
commuting physical activity, which may have a signicant inuence
on BMI, even independently of occupational and recreational physical
activity. We cannot exclude the risk of reversed causation, since the
changes in occupational sitting and associated changes in BMI are measured during the same time span. Future studies should focus on prospective designs using objective measures for occupational and leisure
time sitting, and might focus on the potential difference between men
and women concerning the association between occupational sitting
and overweight/obesity.

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Conclusion

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We found a positive association between change in occupational sitting time and BMI from 2005 to 2010 in women. More prospective

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Conict of interest statement

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The authors declare that there are no conicts of interest

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Acknowledgment

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studies, with objective measures of occupational sitting time and BMI


are recommended to investigate the importance of occupational sitting.
Moreover, use of better measures of body composition like fat percentage is recommended for future studies on the association between
changes in sitting time and body composition.

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Please cite this article as: Eriksen, D., et al., Sedentary workAssociations between ve-year changes in occupational sitting time and body mass
index, Prev. Med. (2015), http://dx.doi.org/10.1016/j.ypmed.2014.12.038

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