Association of Sitting Time With Mortality and Cardiovascular Events in High-Income, Middle-Income, and Low-Income Countries

Li S 1 , Lear SA 2 , Rangarajan S 3 , Hu B 1 , Yin L 1 , Bangdiwala SI 3 Show all authors , Alhabib KF 4 , Rosengren A 5 , Gupta R 6 , Mony PK 7 , Wielgosz A 8 , Rahman O 9 , Mazapuspavina MY 10 , Avezum A 11 , Oguz A 12 , Yeates K 13 , Lanas F 14 , Dans A 15 , Abat MEM 16 , Yusufali A 17 , Diaz R 18 , Lopez-Jaramillo P 19 , Leach L 20 , Lakshmi PVM 21 , Basiak-Rasala A 22 , Iqbal R 23 , Kelishadi R 24 , Chifamba J 25 , Khatib R 26 , Li W 1 , Yusuf S 3

Affiliations 

  • 1 National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
  • 2 Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada
  • 3 Population Health Research Institute, Hamilton Health Sciences & McMaster University, Hamilton, Ontario, Canada
  • 4 Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
  • 5 Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
  • 6 Eternal Heart Care Centre and Research Institute, Jawahar Circle, Jaipur, India
  • 7 St John's Medical College & Research Institute, Bangalore, India
  • 8 Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
  • 9 University of Liberal Arts, Dhaka, Bangladesh
  • 10 Department of Primary Care Medicine, Faculty of Medicine UiTM Sg Buloh Campus, University Teknologi MARA UiTM, Malaysia
  • 11 International Research Center, Hospital Alemão Oswaldo Cruz and UNISA, São Paulo, Brazil
  • 12 Faculty of Medicine, Department of Internal Medicine, Istanbul Medeniyet University, Istanbul, Turkey
  • 13 Department of Medicine, Queen's University, Kingston, Ontario, Canada
  • 14 Universidad de La Frontera, Temuco, Chile
  • 15 Department of Medicine, University of the Philippines, Manila, Philippines
  • 16 Division of Adult Medicine, Department of Medicine, Philippine General Hospital, Ermita, Manila, Philippines
  • 17 Hatta Hospital, Dubai Health Authority/Dubai Medical College, Dubai, United Arab Emirates
  • 18 Estudios Clínicos Latino América, Instituto Cardiovascular de Rosario, Rosario, Argentina
  • 19 Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia
  • 20 University of the Western Cape, Bellville, Cape Town, South Africa
  • 21 Department of Community Medicine and School of Public Health, PGIMER, Chandigarh, India
  • 22 Department of Social Medicine, Wrocław Medical University, Wrocław, Poland
  • 23 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan
  • 24 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 25 Department of Biomedical Sciences Physiology Unit, University of Zimbabwe, Harare, Zimbabwe
  • 26 Advocate Aurora Research Institute, Advocate Aurora Health, Downers Grove, Illinois
JAMA Cardiol, 2022 Aug 01;7(8):796-807.
PMID: 35704349 DOI: 10.1001/jamacardio.2022.1581

Abstract

IMPORTANCE: High amounts of sitting time are associated with increased risks of cardiovascular disease (CVD) and mortality in high-income countries, but it is unknown whether risks also increase in low- and middle-income countries.

OBJECTIVE: To investigate the association of sitting time with mortality and major CVD in countries at different economic levels using data from the Prospective Urban Rural Epidemiology study.

DESIGN, SETTING, AND PARTICIPANTS: This population-based cohort study included participants aged 35 to 70 years recruited from January 1, 2003, and followed up until August 31, 2021, in 21 high-income, middle-income, and low-income countries with a median follow-up of 11.1 years.

EXPOSURES: Daily sitting time measured using the International Physical Activity Questionnaire.

MAIN OUTCOMES AND MEASURES: The composite of all-cause mortality and major CVD (defined as cardiovascular death, myocardial infarction, stroke, or heart failure).

RESULTS: Of 105 677 participants, 61 925 (58.6%) were women, and the mean (SD) age was 50.4 (9.6) years. During a median follow-up of 11.1 (IQR, 8.6-12.2) years, 6233 deaths and 5696 major cardiovascular events (2349 myocardial infarctions, 2966 strokes, 671 heart failure, and 1792 cardiovascular deaths) were documented. Compared with the reference group (<4 hours per day of sitting), higher sitting time (≥8 hours per day) was associated with an increased risk of the composite outcome (hazard ratio [HR], 1.19; 95% CI, 1.11-1.28; Pfor trend < .001), all-cause mortality (HR, 1.20; 95% CI, 1.10-1.31; Pfor trend < .001), and major CVD (HR, 1.21; 95% CI, 1.10-1.34; Pfor trend < .001). When stratified by country income levels, the association of sitting time with the composite outcome was stronger in low-income and lower-middle-income countries (≥8 hours per day: HR, 1.29; 95% CI, 1.16-1.44) compared with high-income and upper-middle-income countries (HR, 1.08; 95% CI, 0.98-1.19; P for interaction = .02). Compared with those who reported sitting time less than 4 hours per day and high physical activity level, participants who sat for 8 or more hours per day experienced a 17% to 50% higher associated risk of the composite outcome across physical activity levels; and the risk was attenuated along with increased physical activity levels.

CONCLUSIONS AND RELEVANCE: High amounts of sitting time were associated with increased risk of all-cause mortality and CVD in economically diverse settings, especially in low-income and lower-middle-income countries. Reducing sedentary time along with increasing physical activity might be an important strategy for easing the global burden of premature deaths and CVD.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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