Life in chairs is at least a little bit hazardous to your general health, above and beyond the effect of poor physical fitness. We suspect this today thanks to some good science. During my decade working as a massage therapist, I learned of the musculoskeletal dangers of chairs from watching my clients suffer through their desk jobs. It seemed obvious that lots of time in chairs was likely to cause some back pain at least.
I was wrong, though, and it became the ultimate example of destroying an “obvious” fact with actual science. This article explores the health effects of a sedentary lifestyle more objectively than I did in my career in massage therapy, starting with the debunking one of the big myths in musculoskeletal medicine …
What were the bodies like on the beach? Ugly and white and ruined by offices.
Leonard Cohen, The Favourite Game
Sitting a lot is not — repeat, not — a risk factor for low back pain
This is a correction of a major old error of mine, reversing a opinion I held strongly for more than a decade, until 2017. Chairs may be unhealthy in some ways — much more on this below — but they are not the back torture devices I once believed. There’s not much wiggle room on this point: many studies have shown that people who sit a lot simply do not get more back pain than more active people. There is no link. It’s just not a thing.
This was already established as early as 2000 when Hartvigsen et al. looked at thirty-five different relevant experiments,1 14 of them about sitting at work, 21 with otherwise physically “lazy” jobs, and 8 that had “a representative sample, a clear definition of LBP and a clear statistical analysis”:
Regardless of quality, all but one of the studies failed to find a positive association between sitting-while-working and low back pain. High quality studies found a marginally negative association for sitting compared to diverse workplace exposures, e.g. standing, driving, lifting, bending, and compared to diverse occupations. One low quality study associated sitting in a poor posture with low back pain. The extensive recent epidemiological literature does not support the popular opinion that sitting-while-at-work is associated with low back pain.
That was published at about the same time that I was still forming my own “professional” opinion that sitting a lot probably causes low back pain.
Seven years and several studies later, Lis et al. reviewed fifteen suitable studies.2 Although they noted evidence of a link between back pain and awkward sitting postures and vibration — so helicopter pilots get a lot of back pain, apparently — they otherwise just confirmed Hartvigsen et al.’s findings, concluding that “sedentary lifestyle by itself is not associated with LBP.” This was then backed up again by two more reviews in 2009,34 which were the most recent as of 2017 when I finally caught up to the evidence, realized my mistake, and updated this article and others.
How did I go so wrong? Easy enough: I just never checked.5 I probably also carelessly assumed that “primitive” people who squat a lot have fewer back problems — which is also not a safe assumption.6 And I probably underestimated the role of genetics, which is a major risk factor for degenerative disc disease that probably drowns out any relatively minor modifiable risk factors.7
It remains remotely possible that back pain is more common in certain kinds of serious sitters. But if there is any link at all, it cannot possibly be a strong one.
So what’s left? If not cause low back pain, what other kinds of harm could sitting a lot do?
The still life: what is so bad about sitting exactly? (If not back pain?)
In the classic science fiction novel, Ringworld, Larry Niven paints a future full of delicate and sensitive people. Pain and effort are virtually eliminated, and fitness and pain tolerance along with them. But so what? It’s no great loss, as long as no one has to do any physical work or suffer. Right?
Niven probably didn’t know just how unhealthy it might be to live a life without effort.
We’re already half way to that future. Almost everything our great grandparents did was more work. The population of agricultural workers is less than a third what it was fifty years ago, let alone a century ago.8 The most trivial tasks required more physical effort then than now, and most things that are hard work have been automated: transportation, agriculture, manufacturing. The Information Age has created legions of workers who lift only their fingers for hours every day … and then we go home to even more screen time! From PowerPoint to Netflix, from spreadsheets to games. Americans are sitting about an hour more per day in 2018 than they were in 2008: 8 per day for teens and 6 for adults.9 Yikes.
It’s not the longevity lifestyle: a national Geographic article examining three unusually long-lived groups of people found that regular activity was a major common denominator, among other things.10 None of them were programmers. We’re certainly soft.1112 Musculoskeletal problems, at least, seem to be steadily on the rise. (That’s hard to prove, but there is evidence.13)
The basic problem is that biology is a use-it-or-lose-it business. Everything in the human body works on feedback. Nothing works (or heals) without stimulus. For instance, tendons degenerate with both too much or too little use.14 Tissue can literally die without stimulation. A bed sore is a rotting patch of stagnant tissue, and it’s a real and serious problem for anyone who actually can’t move. (This is how Christopher Reeve died in 2004: an infected pressure ulcer.) Simply failing to move isn’t much better.
Chair-bound workers are suffering from sub-clinical bed sores: tissues start to howl for the physical and neurological stimulation they need to survive and thrive and contribute to our metabolic fitness, but we only move just enough and just in time to stop tissue from actually starting to become necrotic (dead).15 But they certainly get “sick,” especially in the shoulders, back and hips — which tend to remain relatively immobile even when we get up and go to the water cooler.
What do we lose?
I’m preaching to the choir: everyone already knows that exercise is healthy and we’ve got to “use it or lose it.” It’s the details that so many people are sketchy on. What exactly do we lose, and how does using it help?
Research has shown that chronic inactivity causes marked degeneration of virtually every measure of physical fitness,1617 such as relatively obvious problems like the degeneration of reflexes,18 interesting examples like the tendon “rot” from disuse mentioned above, and — ack! — vulnerability to chronic pain.19
Research like this began a long time ago,20 the better part of a century21 — a litany of bad news for chair warriors, connecting inactivity to cardiovascular disease, diabetes, and cancer.22232425
Sitting around is actually exhausting. Fun fact: if you’re on the sedentary side, you will feel less fatigued if you get more activity.26
There are many mechanisms for all this, but one of the most interesting is that muscle tissue may actually be a wellspring of health-sustaining, regulatory chemicals — like big, beefy glands that you can flex — but they do this mainly when they are working. They are like glands you have to pump yourself. When resting for too long, muscles cells stop producing these substances that we need for normal biological operations.2728
[Author takes a break to lift some weights for five minutes. Aaah! Refreshing!]
That’s all pretty grim, but it gets worse: activity may not reverse that effect, or not easily. The effect just described, for instance, was not easily reversed by exercise.29
Are you an “active couch potato”?
I certainly am: I exercise a lot, but I sit even more. An active couch potato30 describes exercisers who sit most of their day, but still get in plenty of exercise: like a weekend warrior that doesn’t wait for the weekend.31 It aptly describes nearly everyone who sits at work but is otherwise active.
Despite our activity, active couch potatoes may have similar health risks to entirely inactive ones.
Not only is there a correlation between inactivity and certain kinds of cancer, but it may not be possible to compensate for that with exercise breaks. Studying dozens of cancer studies, Schmid et al found that the cancer risk was the same if the chair time was the same, whether subjects were otherwise active or not.
“[The results] indicate that the increased risk of cancer seen in individuals with prolonged time spent sedentary is not explained by the mere absence of physical activity in those persons,” the researchers say.
A 2014 experiment put accelerometers on a couple thousand people for a while and then checked their aerobic fitness, finding that a couple of hours of sitting was just as harmful as 20 minutes of exercise was beneficial.32 Which suggests that it may be difficult to exercise enough to compensate for sitting all day. Just like it’s much easier to eat calories than to spend them, it’s easier to lose fitness to the chair than it is to boost it by getting up and running around.
Sit around long enough — four days of serious laziness — and you may become relatively immune to the death-delaying benefits of exercise.33 Doubtless you can eventually work your way back to benefitting from exercise after a laziness binge, but it might be an inefficient, uphill battle.
How many days of laziness are needed to sabotage the effectiveness of your exercise? Research continues, and a 2022 study by Dos Santos et al. is less pessimistic.34 Their results give some comfort to weekend warriors, and seem to show that clearly all is not lost if your exercise is concentrated in just a day or two each week.
So maybe you can afford to put exercise off to the weekend after all? Maybe. But I’d err on the side of fewer lazy days per week.
So you may have heard that “sitting is the new smoking”
This all seems like really bad news for sitting. Could sitting be as bad as … smoking?
It’s a bit like smoking. Smoking is bad for you even if you get lots of exercise. So is sitting too much.
Travis Saunders, quoted in Sitting is the New Smoking — Even for Runners
This analogy is everywhere, starting circa 2011, with no clear single origin.35 NBC News made it news. Runner’s World ran with it. Science writer Alex Hutchinson covered it well for The Globe & Mail, but the headline (which Alex didn’t write) trumpeted the analogy like it’s The Truth, already well-established.
But sitting is like smoking? Really? Isn’t that just a bit hyperbolic?
Well, yes, of course it is. Smoking is insanely bad for you; it’s hard to believe sitting is anywhere near as dangerous, probably “only a fifth or a sixth as bad as smoking,” specifically (according to the editors of British Journal of Sports Medicine, and somewhat tongue-in-cheek, I think36). Many people seem to have become annoyed by the analogy, and some bright people scoff at it … with good reason.37 A 2018 paper tackled the claim directly, concluding that smoking is a lot riskier than excessive sitting.38 Author Dr. Terry Boyle:
“The simple fact is, smoking is one of the greatest public health disasters of the past century. Sitting is not, and you can’t really compare the two.”
And it’s just an analogy, which serves to suggest two things:
- Like smoking, sitting is something previously thought to be almost completely harmless that may turn out to be harmful. This in itself is quite plausible.
- The more recent and much more speculative twist: like smoking, sitting may be harmful even if we are otherwise healthy and active.
If the second bit is true — if — then we would want to reduce the total chair time to nullify its negative effects … and not just try to exercise to compensate for it. Maybe in the future people will marvel at how a few generations of people ruined themselves because they didn’t know better than to sit down all day?
The paralysis perspective
If sitting is anywhere near as dangerous as smoking, then paraplegics and quadraplegics would be dropping like flies. So how dangerous is paralysis? It is dangerous …
Paraplegia actually is roughly as bad as smoking — it has about the same impact on life expectancy.39 But these people can’t get out of chair … and their inactivity does not account for all their problems, and perhaps not even most of them.40 People who aren’t literally stuck in their chairs are definitely going to see less — much less — of an impact on their health.
So on the one hand, yes, paralysis is actually is a general health hazard. On the other hand, the danger is only roughly equivalent to being a smoker, and not all of the risk comes from the forced sedentariness. So an ordinary lazy life is, at worst, significantly less dangerous than paralysis.
Therefore, “sitting is the new smoking” is definitely hyperbole.
More direct evidence that sitting is not the new smoking
The paralysis perspective is a bit of a slam dunk, but how about the direct evidence? It’s limited and contradictory so far. There’s good news and bad.
A 2015 study, Pulsford et al, was the first science to push back against the fear, uncertainty, and doubt of the “new smoking” idea — a FUD-fighter.41 There was never any good evidence that “sitting is the new smoking,” but this is good evidence that “sitting time was not associated with all-cause mortality risk” in over 5,000 subjects.42
That doesn’t mean that a sedentary lifestyle is safe or healthy, but it does strongly suggest that we aren’t doomed by it.
Like most of its kind until now, that study relied on people reporting their own activity levels, which is hardly the best way of going about it, especially in the age of fitness trackers. What if you stuck those gadgets on 8000 middle-aged people for four years? A 2017 paper reports on just such an experiment.43 — probably the biggest of its kind so far, but I’m sure much bigger ones are on the horizon as the tech gets ever cheaper.
Contradicting Pulsford et al, the results did affirm a link. Not a causal link!44 Some of the study subjects died — 340 of them — and those people spent more time overall not moving, and had longer periods of not moving.
That study also contradicts the other important implication of the smoking analogy: it showed that taking breaks did mitigate the risk.46
So that’s one less thing to be unreasonably concerned about! Which is great. Because if anything actually is “the new smoking,” it might be stress.47
One final reassuring citation: in 2017, the British Journal of Sports Medicine published more confirmation that there is no clear link between sitting and diabetes.48
Adaptation: You are your stresses, for better or worse
Babies look more similar to each other than adults because they have not yet been shaped by stress and trauma. Oh, sure, they have some distinguishing features, but nothing like adults. They are kind of larval looking, all of them.
Much of who you are as an adult is a modified — stress-adapted — version of an original template.49 Most of who you are and what you are physically capable of is the result of adaptation to stresses and stimuli.
All of biology is organized around adaptive reactions to stimuli: immediate reflex (neurological) responses, nearly immediate hormonal and behavioural responses, tissue change responses. Every response is about improving conditions for the organism. Starting to fall down? The organism reacts to stop it. Regular pounding impact on your legs? Make the bones stronger.
Take away the stresses, and the body stops investing energy in unnecessary adaptations. Adapting is “expensive.” You don’t do it if you don’t have to.
Wolff and Davis, bone and meat
The way some tissue adaptations work has been extremely well-described by science. Others, not so much. Bone adaptation is the best understood … and the most surprisingly fluid. Bone adapts well.
There are two “laws” of tissue adaptation, one each for hard and soft tissue. Wolff’s law is that bone will change and strengthen in response to loading. This was first noticed by Julius Wolff in the 19th Century, who got the naming rights. It was greatly refined in the mid 20th century by Dr. Harold Frost, an American surgeon who studied bone biology, and published scientific papers more often than I change my socks. The full details of how bone responds to stress are described in his Mechanostat model. The corollary in soft tissue is the obscure and much less developed Davis’ law. (No one even seems to know who Davis was.)
Although there’s no question soft tissue does adapt to stress, the responses of muscles, tendons, and ligaments are much more complex and less well understood. Many treatments are based on the idea of forcing adaptation or “toughening up” tissues by stressing the tissues. It has always been a reasonable idea, but the devil is in the details: what constitutes the “right” amount and kind of stress is difficult to know, and the results of such therapies have generally been highly inconsistent.
For more information, see Tissue Provocation Therapies in Musculoskeletal Medicine: Can healing be forced? The laws of tissue adaptation & therapies like Prolotherapy & Graston Technique.
One of the best use-it-or-lose it examples? Running
It has become strangely fashionable to deny the health benefits of running, and to assert that it actually makes you fatter and erodes muscle and bone! For example, these claims were actually made in John Kiefer’s extremely popular article, Why Women Should Not Run (and shredded in this great rebuttal, Sorry, but Science Says Running is Good for You, Not Bad).
Running can be hard on bodies, but it takes mental gymnastics and serious abuse of the evidence to believe that “cardio above a walk or below a sprint is bad for you (especially if you are a woman).” However, even the much milder assumption that running can be “hard on bodies” is not safe. For instance, the evidence actually shows that “running significantly reduced arthritis and hip replacement risk.”50
Say whaaat? Running is good for joints?
Well, at least not particularly bad for them. The results are probably due in large part to the fact that runners were typically skinnier. Nevertheless, the data flies in the face of the common assumption that running is much harder on the joints. Instead, what it clearly shows is that running is either neutral or helpful … . probably because using joints is healthier than not using them, on average.
Obviously overuse is another matter.
The Goldilocks Principle: use it or lose it, but not too much
Get more exercise, but don’t go overboard. Although the modern human tends to err on the side of “not enough” exercise, it’s also surprisingly easy to push too hard when you’re unconditioned. “Too much” is surprisingly little for tendons and joints that aren’t used to doing much. This may explain the plague of repetitive strain injuries in weekend warriors.
A fascinating 2007 study showed that tendons are harmed by both over and under use.51 Tendon cells adapt to the forces imparted on them, creating a tissue tolerance “set point” for your activity level. That can decrease with disuse, and increase with exercise — as long as there’s enough rest between challenges. Activity that is too frequent or intense might damage cells without giving them a chance to adapt.
For tendons at least (and probably much else), there is a need for some kind of in between exercise intensity, something not too easy, nor too hard, but a Goldilocks “juuuust right.” To avoid hurting yourself, take only small steps outside your comfort zone — especially at first, and especially with any activity that’s highly repetitive, and especially if you already know you're vulnerable in any general way, e.g. severely sleep deprived or diabetic or you smoke.
Obviously, if you don’t exercise at all, it is not good for you. Exercise improves your health. And a lot of exercise improves your health a lot. But that doesn’t mean that insanely large amounts of exercise are insanely good for your body. At some point, too much begins to damage various physiological systems. Everything in physiology follows the rule that too much can be as bad as too little. There are optimal points of allostatic balance.
Why Zebras Don’t Get Ulcers, by Robert M Sapolsky, 123
You’re not seizing up (not literally anyway)
There’s a popular notion that sitting shortens muscles, that you “freeze like that.” More specifically, a popular fear is that sitting causes your hip flexors to shorten, to cinch up and stay that way, to actually lose extensibility. There is some basis for this. For instance, a good quality 2012 study found that high heels cause adaptive shortening of the calf musculature by 13%.52 Here’s an example of this argument being made by a particularly credible and eloquent expert, evolutionary biologist Daniel Lieberman:
Paper after paper, study after study, have shown that chairs give us back problems because they shorten our hip flexors, give us weak backs, of course it makes us sedentary. We take years off our lives probably by sitting in chairs, but we like them because they’re comfortable. You go to an African village, you find me a chair with a back. That’s a rare thing out there.
Brains Plus Brawn, by Daniel E Lieberman
Unfortunately, it’s not quite as clear cut as that. Even when muscles do shorten, it doesn’t necessarily mean much. That calf muscle shortening I mentioned above? The authors of that paper also found that it had no measurable effect on ankle function.53 That seems like an important detail. Todd Hargrove of BetterMovement.org explained this very well:
It is well known that completely immobilizing a joint for an extended period of time can lead to loss of muscle sarcomeres and contracture and cross linking of connective tissue. However, it appears that one can fully prevent any negative effects of extended immobilization on tissue length with only short and infrequent bouts of movement. In one study, researchers kept the soleus muscle of a rat completely immobilized in a cast for 10 days. Every two days the cast was removed and the muscle was stretched for fifteen minutes. This was enough to preserve tissue length, but not enough to make the rat happy with the experiment.54
In another study, just half an hour of stretch a day preserved range of motion in a muscle that was immobilized in a shortened position for the rest of the day.55 These studies suggest that sitting in a chair almost all day every day would not cause loss of tissue length, provided you get up to go the refrigerator every once in a while.
It likely takes an ridiculous amount of abuse of your body to have any effect at all on muscle length, most of that loss probably doesn’t matter all that much, and it’s really not that hard to prevent. So while a lot of sitting is almost certainly problematic,56 but don’t think of it as “seizing up” — that’s a little too dramatic.
Don’t stretch: mobilize!
You do not need a stretching habit, per se, to keep your muscles from shrivelling up. Nearly any movement is sufficient to prevent that (see last section). Getting out of the chair to stretch a bit is the wrong tool for the job: it’s not a good way to “use it.” A little static elongation of muscle tissue simply does not constitute adequate stimulation to be an antidote for all the effects of four hours of sitting per day, let alone eight or twelve.
What you need is a similar-but-better concept I call “mobilizations”: repeated, rhythmic elongations and contraction of muscle tissue. For instance, when most people get up from a long sit, they will instinctively stretch their arms backwards, opening up the chest, and a few will then close the chest as well, flexing the same muscles they just stretched.
That’s the perfect thing, the right impulse — you just need to do a bit more of it. Repeat! Doing it once pulls your chest and upper back muscles away from the brink. Doing it ten times in a row a few times a day is mobilizing. Basically: light exercise, emphasizing the range of motion of the joints that need it the most after sitting in a chair.
I have a whole, large article about mobilizing:
What is it, exactly, that we have to “use” to avoid losing it?
Everything — but, above all, your heart and lungs, and your brains if you want to keep sharp into old age.
The evidence is overwhelming that moderate aerobic activity is probably the single most important kind of exercise … because there isn’t a single cell in your body that doesn’t depend on a constantly blood-borne supply of oxygen and nutrients. The delivery system must be constantly challenged. Aerobic exercise affects the entire system.
But you really have to use anything that you don’t want to lose.
There is a concept in athletics called “training specificity.” It’s one of the Laws of Exercise: you get good at what you do, and only what you do. If you jump up and down on one foot, you’ll get good at jumping up and down on one foot … but not the other foot. If you lift weights slowly, you’ll get good at lifting weights slowly … but not so good at lifting them quickly.
You kind of need a specific exercise for anything you want to keep in shape. This is why exercise experts tend to recommend a wide variety of exercises.
Should you get an awesome office chair?
My personal Balance Fit™ by Sissell, perched on a stool I have had for decades now. Do I use my BF as often as I should? Of course not, human nature being what it is. Do I still think I should use it? You betcha.
The medical value of ergonomically “advanced” chairs is greatly exaggerated. There is no such thing as a perfect chair: your body isn’t going to thrive if you are stuck in any position for hours at a time. The issue isn’t the precise positioning of your meat and bones, but the overall lack of motion, exertion, and variety of stimulation — and no chair can solve that.
Your best chair might just be two or three different chairs used in rotation, including or used in conjunction with an destabilizing cushion, such as a Disc-O-Sit or Balance Fit, or a fitness ball.
In my office, I have a standard office chair and a stool, both of which I use in combination with a Balance Fit for variety. Because I have a home office — something more and more of us have these days — there are plenty of other chairs I can sit in to work. This variety is more important than having one fancy chair.
But I do still have a fancy chair. 😜 If you’ve got the cash, by all means — get yourself a highly adjustable chair that you like. I worried about the cost of mine only until I sat in it. I’ve now been sitting in it regularly, without a trace of buyer’s remorse, for about 18 years.
This is my fancy chair. Yes, I like it. And I also regularly change up what I’m sitting on, because no chair is a substitute for variety & movement.
Should you consider getting rid of my chair, and standing on the job instead?
Standing to work has been gaining popularity as an answer to the presumed perils of sitting. For instance, according to a business blog, several Japanese companies have ditched desks entirely. Everyone stands to do their office work!
Was it a tough change? Yes. The first month, or even two, is apparently quite difficult as the body adjusts. But then you begin to feel healthier, perhaps lose a few pounds due to the activity resulting from constant balancing, and you realize you are more productive.
After keeping an eye on this trend for a decade, I have finally decided to (mildly) advise against it. I think you should probably not choose to stand on the job, unless it particularly appeals to you or fits your circumstances unusually well. Standing seems to be just another form of stagnancy, with its own dangers. The Cornell Human Factors and Ergonomics Research Group (which looks like an interesting resource) identifies a number of problems with standing to work:
Standing to work has long known to be problematic, it is more tiring, it dramatically increases the risks of carotid atherosclerosis (ninefold) because of the additional load on the circulatory system, and it also increases the risks of varicose veins…. The performance of many fine motor skills also is less good when people stand rather than sit.
They review a few other problems with sit-stand workstations, and conclude with the advice to mainly sit to work but get up and move regularly:
“The key is to build movement variety into the normal workday.”
In other words, variety and regular microbreaking for light exercises, mobilizing at the least, and perhaps quick bouts of resistance training.
Sounds an awful lot like the conclusion of the chair section above, doesn't it?
My “ergnomics schmergonomics” rant
Ergonomics professionals all over the world are busily working on the wrong thing, trying to get people into good positions so that their workstations are as efficient as possible and require as little movement as possible. The goal of this kind of ergonomics is to turn people into cyborg-like extensions of their cubicles. The goal is also damage control: how to minimize the consequences of an insane amount of sitting, while still actually keeping people in their chairs.
It’s all a sinister plot, obviously. Modern workplace ergonomics is a classic bit of corporate manipulation. It fails to solve the obvious problem in an obvious way. The obvious problem is the sheer volume of sitting, and the obvious solution is more movement variety — what more progressive ergonomics professionals call “micro-breaking” or “micro-exercise” or (more fun) “movement snacks.”
This is not to say that conventional ergonomics is entirely useless or trivial — even if you get up fifty times a day, a bad mouse position is still going to torment you. But let’s get it in perspective!
This perfectly illustrates what I’m trying to say: that conventional ergonomics solutions may be missing the point & often get out of hand.
Microbreaks are regular, small, meaningful breaks from being stuck in one position at work. This dynamic ergonomics concept has gradually begun to eclipse more familiar, conventional ergonomic priorities. The idea is simple: no chair or efficiently arranged computer workstation, no matter how comfortable, can protect you from the danger of hours of sitting every day. The only truly ergonomic workstation “arrangement” is to break free of it frequently.
It’s not good enough to get up regularly for meetings, going to the printer, etc?
Yes and no. Any kind of getting up is much better than being glued to your seat. But it really isn’t enough, either.
The key point that usually gets overlooked is that walking around the office does not — and I know this will come as a big shock — actually give your biology all that much to do. Photocopying isn’t really a workout. Going to the bathroom isn’t exercise. Walking delivers health benefits astonishingly efficiently,57 but it’s not that good.
How much micro exercise is enough?
A couple minutes of mobilizing per hour is probably enough of an antidote to the worst consequences of excessive sitting, and it’s a practical amount — although even just five minutes per hour can be weirdly hard for busy people to pull off. If you can, double the dose to ten minutes per hour, if your work situation allows, if you have the discipline for overdoing this a bit.
The high end of this range is inspired by all that “sitting is the new smoking” evidence. It may not be necessary to do very much. Or then again it may. But ten minutes per hour is roughly the most the average person is going to be willing or able to invest in preventative exercise. That’s 16% of your time!
How can a few minutes be enough? Simple: sitting wouldn’t be particularly harmful, except that we do so much of it. It’s probably not hard to counteract the effects of an hour of sitting with a few well-chosen exercises. If you make a point of flexing and using the muscles that are most needful — efficiency! — it probably undoes most of the damage.
Getting up and bending over to touch your toes thirty times every half hour may seem forced, contrived or arbitrary — but it’s the only cure for a forced, contrived and arbitrary amount of sitting.
Here’s more about the how-to of microbreaking:
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
- If you are having serious back pain, please see When to Worry About Low Back Pain: And when not to! What’s bark and what’s bite? Checklists and red flags for the scary causes of back pain.
- “Sitting is the New Smoking — Even for Runners,” Selene Yeager, RunnersWorld.com.
- Todd Hargrove wrote a nice analysis of a classic claim: Does Excessive Sitting Shorten the Hip Flexors?
- Mobilize! — Dynamic joint mobility drills are an alternative to stretching, a way to “massage with movement” reviews the essentials of this life-saving alternative to conventional stretching.
- Many people are (pointlessly) worried about their posture. For some perspective on the subject, see Does Posture Matter? — A detailed guide to posture and postural correction strategies (especially why none of it matters very much).
- For a reality check about the value stretch, see Quite a Stretch.
- The Art of Rest — The finer points of resting strategy when recovering from injury and chronic pain (hint: it’s a bit trickier than you might think)
What’s new in this article?
Ten updates have been logged for this article since publication (2005). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more
When’s the last time you read a blog post and found a list of many changes made to that page since publication? Like good footnotes, this sets PainScience.com apart from other health websites and blogs. Although footnotes are more useful, the update logs are important. They are “fine print,” but more meaningful than most of the comments that most Internet pages waste pixels on.
I log any change to articles that might be of interest to a keen reader. Complete update logging of all noteworthy improvements to all articles started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.
See the What’s New? page for updates to all recent site updates.
Jun 5, 2023 — Editing. Top-to-bottom content tidying and tuning. It’s uncomfortably rare for me to just throughly re-read one of my own articles. It took two full hours just to go through it carefully fixing minor issues along the way and taking notes on more substantive updates I’d like to do.
2022 — Science update. Added a citation to Santos about weekend warriorism.
2021 — Science update. Added a citation to Sheng et al about the excellent fitness bang-for-buck delivered by walking.
2019 — Science update, added citation to Akins et al on the effect of mutiple days of laziness on exercise benefits (hint: it’s not good).
2018 — Science updated, added citation to Vallance et al on the risks of sitting versus smoking.
2017 — Science update, cited Stamatakis et al, showing no clear link between sitting and diabetes.
2017 — Major upgrade to my debunking of “sitting is the new smoking,” based on a beefier “paralysis perspective,” and on new evidence from Diaz.
2017 — Added a significant footnote about the (unclear) relationship between habitual squatters and back pain.
2017 — Major correction — New section explains my new position, which is the opposite of my old position: “Sitting a lot is not — repeat, not — a risk factor for low back pain.” Read more about the mistake.
2016 — Added “Why is exercise healthy?” sidebar.
2005 — Publication.
- Hartvigsen J, Leboeuf-Yde C, Lings S, Corder EH. Is sitting-while-at-work associated with low back pain? A systematic, critical literature review. Scand J Public Health. 2000 Sep;28(3):230–9. PubMed 11045756 ❐
- Lis AM, Black KM, Korn H, Nordin M. Association between sitting and occupational LBP. Eur Spine J. 2007 Feb;16(2):283–98. PubMed 16736200 ❐ PainSci Bibliography 53732 ❐
- Chen SM, Liu MF, Cook J, Bass S, Lo SK. Sedentary lifestyle as a risk factor for low back pain: a systematic review. Int Arch Occup Environ Health. 2009 Jul;82(7):797–806. PubMed 19301029 ❐
This systematic review of 15 studies, 8 classified as high quality, “confirms that sedentary lifestyle by itself is not associated with low back pain.” Only one of the high-quality studies reported a link.
- Bakker EWP, Verhagen AP, van Trijffel E, Lucas C, Koes BW. Spinal mechanical load as a risk factor for low back pain: a systematic review of prospective cohort studies. Spine (Phila Pa 1976). 2009 Apr;34(8):E281–93. PubMed 19365237 ❐
This review of 18 studies of risk factors for low back pain confirmed strong evidence of no link to sitting, standing, walking, or common amateur sports; “conflicting” evidence about leisure activitiues like gardening, whole body vibration, hard physical work, and even “working with ones trunk in a bent and/or twisted position”; and no evidence of any quality about sleeping.
- My assumption felt safe enough that I never got that sinking “citation needed” itch. I thought I had bigger research fish to fry. There are a lot of things to pay attention to in musculoskeletal medicine. I never even stumbled across the evidence, even though I have delved deep into many closely related topics, such as the absence of a clear link between posture and back pain.
- Fahrni WH, Trueman GE. Comparative Radiological Study of the Spines of a Primitive Population With North Americans and Northern Europeans. J Bone Joint Surg Br. 1965 Aug;47:552–5. PubMed 14341078 ❐ PainSci Bibliography 53604 ❐ This old study, and a couple related ones they discuss, showed that habitual squatters probably have lower rates of degenerative disc disease … which by no means necessarily correlates with back pain. One of the strongest themes in musculoskeletal medicine in the last 25 years has been the discovery that the correlation between structural features and actual pain is amazingly sloppy (see Brinjikji), and there are countless possible reasons why one group of people might suffer less (or more) from their DDD than another group of people. But even if we assume that more DDD equals more back pain, this data implicates lordosis specifically — the degeneration is associated with the low-back curve — which is eliminated by sitting in a chair just about as well as by squatting. If DDD is reduced in squatters, it probably is in sitters too!
- Battié MC, Videman T, Kaprio J, et al. The Twin Spine Study: contributions to a changing view of disc degeneration. Spine J. 2009;9(1):47–59. PubMed 19111259 ❐ “Disc degeneration is now considered a condition that is genetically determined in large part, with environmental factors, although elusive, also playing an important role. Most of the specific environmental factors once thought to be the primary risk factors for disc degeneration appear to have very modest effects, if any.”
- Food and Agriculture Organization of the United Nations, visited June 4, 2002, www.fao.org.
- Yang L, Cao C, Kantor ED, et al. Trends in Sedentary Behavior Among the US Population, 2001-2016. JAMA. 2019 Apr;321(16):1587–1597. PubMed 31012934 ❐
- Buettner D. New Wrinkles on Aging. National Geographic. 2005 Nov;208(5):2.
A classic National Geographic feature story (no longer available online). The article examines three long-lived groups of people, and what they all share: non-smoking, family-oriented and social, active daily, and a diet rich in fruits, veggies and whole grains.
An old friend of my family’s has been an outdoorsman for his whole life. He’s one of those people who doesn’t just go camping, he “goes into the bush” for a while. He tells me that he’s seen a trend in his Outward Bound students, even the ones who are superbly gym-fit:
“They’re wimps,” he says. “Pure and simple. Put them on a mountainside, they’re whipped in a few hours, if not a few minutes. I can go for days, forever practically. They ask me, ‘Aren’t you tired yet?’ I never am.”
This is a story a massage client once told me. Maybe it’s exaggerated, but I’ve known quite a few farmers and have no trouble believing it …
An aging farmer fell off a ladder and hurt his back. He refused to be taken to the doctor. “Not necessary,” he insisted. “Haven’t been to a doctor in thirty years, and I ain’t starting now!” But he was too crippled to resist, and his children took him to get help. The doctors soon discovered that he had broken his back — but not for the first time. He had, in fact, fractured his back twice previously, and healed, without ever getting help.
This anecdote strongly suggests that hard-working people are truly tougher — maybe a lot tougher — than us sedentary folk. We may be lot more prone to injuries and complications.
- Is pain really on the rise? It’s not certain that this is the case, nor clear why it would be, but there is plenty of suggestive evidence. A 2005 study in England (Harkness et al) examined then-and-now data, comparing with the 1950s, reporting a “much higher” prevalence of body pain. In 2010 (Jiménez-Sánchez et al), surveys of the Spanish population were mined for rates of serious musculoskeletal pain since the early 90s, finding that it “increased from 1993 to 2001.” A 2017 study (Wallace et al) found that knee arthritis doubled in the 20th Century compared to 19th and prehistoric humans, but not because we’re heavier and living longer — something else is doing it.
- Arampatzis A, Karamanidis K, Albracht K. Adaptational responses of the human Achilles tendon by modulation of the applied cyclic strain magnitude. J Exp Biol. 2007 Aug;210(Pt 15):2743–53. PubMed 17644689 ❐ More on this paper below.
It sounds like I’m exaggerating, but it’s probably literally true. Bed sores do not take all that long to form. Ask any nurse. They are underway within a couple hours, and people who log serious time in chairs are almost certainly flirting with pressure sores — it’s just that they are easily prevented with relatively little movement.
Wikipedia: “A simple example of a mild pressure sore may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within 2 hours, this shortage of blood supply, called ischemia, may lead to tissue damage and cell death. The sore will initially start as a red, painful area.”
- Blair SN. Physical inactivity: the biggest public health problem of the 21st century. Br J Sports Med. 2009 Jan;43(1):1–2. PubMed 19136507 ❐ PainSci Bibliography 55219 ❐
This article presents data on how healthful mild to moderate exercise is, and connects a lack of exercise with “killers” — obesity and smoking, for instance, are strongly correlated with inactivity.
- Bak EE, Hellénius ML, Ekblom B. Are we facing a new paradigm of inactivity physiology? Br J Sports Med. 2010 Feb. PubMed 20133325 ❐ PainSci Bibliography 54987 ❐
From the introduction:
Recent, observational studies have suggested that prolonged bouts of sitting time and lack of whole-body muscular movement are strongly associated with obesity, abnormal glucose metabolism, diabetes, metabolic syndrome, cardiovascular disease (CVD) risk and cancer, as well as total mortality independent of moderate to vigorous-intensity physical activity.
Accordingly, a possible new paradigm of inactivity physiology is suggested, separate from the established exercise physiology, that is, molecular and physiological responses to exercise.
This new way of thinking emphasises the distinction between the health consequences of sedentary behaviour, that is, limiting everyday life non-exercise activity and that of not exercising. Until now, the expression “sedentary behaviour” has misleadingly been used as a synonym for not exercising. Sedentary time should be defined as the muscular inactivity rather than the absence of exercise.
- Nakazawa K, Yano H, Suzuki Y, Gunji A, Fukunaga T. Effects of long term bed rest on stretch reflex responses of elbow flexor muscles. J Gravit Physiol. 1997 Jan;4(1):37–40. PubMed 11541174 ❐
From the abstract: “All subjects showed that both short and long latency stretch reflex FMG activities of muscle biceps brachii were reduced immediately after 20 days bed rest, and then recovered gradually to pre-bed rest levels at one- to two-months after bed rest ....” Note, however, that another muscle studied did not show reflex degeneration in the same conditions.
- Sluka KA, O’Donnell JM, Danielson J, Rasmussen LA. Regular physical activity prevents development of chronic pain and activation of central neurons. J Appl Physiol. 2013 Mar;114(6):725–33. PubMed 23271699 ❐
This elaborate test of mice showed that they were less sensitive to certain kinds of pain if they had gotten more exercise. Specifically, regular exercise protected them from pain caused by exercise (no surprise there), but also — a little more interesting — pain caused by injecting carageenan (which causes inflammation). So exercise probably protects mice from the pain of carageenan injections — does that mean it will protect humans from other kinds of pain? We can’t quite go that far based on the this research. Nevertheless, it’s suggestive, and I’m inclined to agree with the authors: “physical inactivity is a risk factor for development of chronic pain and may set the nervous system to respond in an exaggerated way to low-intensity muscle insults.”
- Livingston RB. Psychological and neuromuscular problems arising from prolonged inactivity. New York Academy of Science. 1967.
- In 1991 — a quarter century ago — Corcoran wrote, “Abundant scientific evidence in the past 50 years has demonstrated the specific damage done to each of the body’s organ systems by inactivity.”
- Ford ES, Caspersen CJ. Sedentary behaviour and cardiovascular disease: a review of prospective studies. Int J Epidemiol. 2012 Oct;41(5):1338–53. PubMed 22634869 ❐
- Schmid D, Leitzmann MF. Television viewing and time spent sedentary in relation to cancer risk: a meta-analysis. J Natl Cancer Inst. 2014 Jul;106(7). PubMed 24935969 ❐
- Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time and mortality from all causes, cardiovascular disease, and cancer. Med Sci Sports Exerc. 2009 May;41(5):998–1005. PubMed 19346988 ❐
- Hamilton MT, Hamilton DG, Zderic TW. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and cardiovascular disease. Diabetes. 2007 Nov;56(11):2655–67. PubMed 17827399 ❐
- Puetz TW, O'connor PJ, Dishman RK. Effects of chronic exercise on feelings of energy and fatigue: a quantitative synthesis. Psychol Bull. 2006 Nov;132(6):866–876. PubMed 17073524 ❐
This is study of other studies (meta-analysis) that concluded that exercising regularly reduces feelings of fatigue. Intriguingly, it also identified some clues that the effect might be induced by placebo.
- Bey L, Hamilton MT. Suppression of skeletal muscle lipoprotein lipase activity during physical inactivity: a molecular reason to maintain daily low-intensity activity. J Physiol. 2003 Sep;551(Pt 2):673–82. PubMed 12815182 ❐ PainSci Bibliography 53798 ❐
- Zderic TW, Hamilton MT. Identification of hemostatic genes expressed in human and rat leg muscles and a novel gene (LPP1/PAP2A) suppressed during prolonged physical inactivity (sitting). Lipids In Health and Disease. 2012;11:137. PubMed 23061662 ❐ PainSci Bibliography 53799 ❐
- Zderic et al: “ … a key gene … was suppressed locally in muscle tissue within hours after sitting in humans; this was also observed after acute and chronic physical inactivity conditions in rats, and exercise was relatively ineffective at counteracting this effect in both species.”
- The term was coined by Australian researcher Genevieve Healy, PhD, of the University of Queensland.
- Weekend warriorism refers specifically to overdoing it on the weekend — generally sedentary and perhaps out of shape, but exercising intensely at widely spaced intervals. Someone who ran every evening for an hour wouldn’t be a weekend warrior … but they could still be an active couch potato.
- Kulinski JP, Khera A, Ayers CR, et al. Association Between Cardiorespiratory Fitness and Accelerometer-Derived Physical Activity and Sedentary Time in the General Population. Mayo Clin Proc. 2014 Jul. PubMed 25012770 ❐
- Akins JD, Crawford CK, Burton HM, et al. Inactivity induces resistance to the metabolic benefits following acute exercise. J Appl Physiol (1985). 2019 Apr;126(4):1088–1094. PubMed 30763169 ❐
If you sit still long enough — lazy for four days in a row — this evidence shows that your body loses the ability to benefit from exercise. Ten volunteers sat for more than 13 hours and took fewer than 4000 steps per day, and then did a one-hour workout on a treadmill. A workout like that normally has measurable benefits for metabolism for twenty-four hours, but there was no such effect in these subjects.
- Dos Santos M, Ferrari G, Lee DH, et al. Association of the "Weekend Warrior" and Other Leisure-time Physical Activity Patterns With All-Cause and Cause-Specific Mortality: A Nationwide Cohort Study. JAMA Intern Med. 2022 Jul. PubMed 35788615 ❐
Dos Santos et al. compared mortality (over ten years) in people who exercised 150 minutes per week spread out over just a day or two per week … versus three or more. They found no difference, which suggests that weekend warriorism may not be so bad.
The fairly obvious weakness in the study is that many of the subjects were spreading their exercise out over only a single extra day (“long weekend warriorism”). A more stark comparison — between people who exercise only on Saturdays to people who exercise most days — might have a different result.
The study concluded that “individuals who engage in the recommended levels of physical activity may experience the same benefit whether the sessions are performed throughout the week or concentrated into fewer days.”
- Probably a headline writer, around the time the first data emerged showing a correlation between sitting and mortality. However, the analogy was probably mostly popularized by Nilofer Merchant’s Feb 2013 TED talk: at least a couple million people have watched her declare, “What you’re doing, right now, at this very moment, is killing you.” Gripping stuff! Maybe a little premature and extreme, too.
- Khan K, Davis J. A week of physical inactivity has similar health costs to smoking a packet of cigarettes. Br J Sports Med. 2010;44(6):396. PainSci Bibliography 53795 ❐
- When I asked for opinions on Twitter, David Colquhoun called it a “naive and evidence free catch phrase.” What he means, I believe, is that epidemiology is hard; it can be super tricky to figure out exactly what causes what. The research cited so far primarily establishes that sitting and lousy health outcomes are strongly associated — by no means is it established that sitting caused the trouble. Inactivity could well be an innocent bystander that just happens to correlate strongly with the real culprits.
- Vallance JK, Gardiner PA, Lynch BM, et al. Evaluating the Evidence on Sitting, Smoking, and Health: Is Sitting Really the New Smoking? Am J Public Health. 2018 Nov;108(11):1478–1482. PubMed 30252516 ❐ PainSci Bibliography 53105 ❐
- Smoking shortens lives by about ten years (Jha), or about 85% of a normal lifespan — which is almost exactly the same as the life expectancy of a paraplegic. According to Yeo, lifespan is 84% of normal for paraplegia (and 70% for quadraplegia). A 2010 study — the first to describe organ dysfunction and failure in these people, incredibly — found that “multiple organ failure occurred in the majority of patients” (Stein). Clearly, paralyzed people have many health challenges.
- Organs are mainly regulated by the autonomic nervous system and not via pathways through the spinal nerves. After complete loss of spinal nerve supply, organs continue to function quite well in the short term, even as movement and sensation are destroyed (paralysis). But the irritation to the spinal cord causes autonomic dysregulation over time, slowly wreaking havoc on organ function. The effects of inactivity may play a role, possibly even a large one, but it’s extremely likely that much of the organ failure is mainly a direct, slow-motion consequence of trauma.
- FUD stands for “fear, uncertainty, and doubt,” a common form of misinformation that provokes anxieties and pessimism, often for the sake of attention and marketing. There’s a lot of FUD in modern health care information. FUD-fighting is important work!
- Pulsford RM, Stamatakis E, Britton AR, Brunner EJ, Hillsdon M. Associations of sitting behaviours with all-cause mortality over a 16-year follow-up: the Whitehall II study. Int J Epidemiol. 2015 Oct. PubMed 26454871 ❐
- Diaz KM, Howard VJ, Hutto B, et al. Patterns of sedentary behavior and mortality in US middle-aged and older adults: a national cohort study. Ann Intern Med. 2017 Sep. PubMed 28892811 ❐
- Diaz et al (see previous note) did not prove that inactivity causes a shorter life expectancy. No one has yet proved that. It’s plausible, but not established. There are other good explanations for the link, as there always are in epidemiology.
Genetic pleiotropy is a classic, common confounding factor: in this case, the same genes that predispose people to be less active (by making exercise less rewarding) could also be a factor in health problems that shorten lives. So the reason that inactivity and death are linked might not be because inactivity causes health problems, but because health problems cause inactivity!
And that’s just one example of a potential confounding factor that no one has actually checked yet. Because it’s hard.
- The hazard ratio for greater total sedentary time was 1.6. A hazard ratio of 2 means “twice the chance.” Hazard ratios for smoking-related diseases are dramatically higher, and even higher still for not-so-obviously related problems like coronary heart disease. See the CDC’s Tobacco-Related Mortality fact sheet.
- More specifically: the link to mortality was stronger when people had both a higher total sedentary time and longer stretches of not moving. So the good news is just an inversion of that: shorter periods of not moving were linked to lower mortality, leading the authors to conclude: “physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death.”
- I’m joking to make a point … except that there’s actually a real possibility that stress is more dangerous than sitting. Professor Robert M. Sapolsky is incredibly persuasive about this (see his book, Why Zebras Don’t Get Ulcers, or video course, Stress and Your Body). Stress is probably not more dangerous than smoking, but it may be closer to it than any other common problem.
- Stamatakis E, Pulsford RM, Brunner EJ, et al. Sitting behaviour is not associated with incident diabetes over 13 years: the Whitehall II cohort study. Br J Sports Med. 2017 May;51(10):818–823. PubMed 28465446 ❐ There was a link without accounting for baseline adiposity. Heavy people also tend to sit more, so you have to factor that out. When these researchers did, the appearance of an association between sitting and diabetes dried up.
- Imagine what would you be like if you had never had anything but extremely mild physical stresses in your life. What if you grew up in a padded, zero-G room? You would literally be fragile. Your bones would be like Styrofoam. You would look different: your skin would be a different colour and texture, your joints a different shape. You wouldn’t be able to do much of anything in normal gravity.
- Williams PT. Effects of running and walking on osteoarthritis and hip replacement risk. Med Sci Sports Exerc. 2013 Jul;45(7):1292–7. PubMed 23377837 ❐
- Arampatzis 2007, op. cit.
- Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug;213(Pt 15):2582–8. PubMed 20639419 ❐ PainSci Bibliography 55265 ❐
- According to Csapo et al, Chronic high-heel wearers do have shortened calf muscles, stiffer Achilles tendons, and a smaller ankle range of motion, but these changes “seem to counteract each other since no significant differences in static or dynamic torques were observed.”
- Williams PE, Catanese T, Lucey EG, Goldspink G. The importance of stretch and contractile activity in the prevention of connective tissue accumulation in muscle. J Anat. 1988 Jun;158:109–14. PubMed 3225214 ❐ PainSci Bibliography 55291 ❐
“It was found that the connective tissue accumulation that occurs in inactive muscles can be prevented either by passive stretch or by active stimulation.” An important point here is that stretch isn’t doing anything that muscle contraction isn’t, so the evidence does not particularly support a stretching habit.
- Williams PE. Use of intermittent stretch in the prevention of serial sarcomere loss in immobilised muscle. Ann Rheum Dis. 1990 May;49(5):316–7. PubMed 2344211 ❐ PainSci Bibliography 55288 ❐
- Perhaps the flexors do not actually shorten, but may well still feel significantly shortened, stiff, tight. Indeed, that is my subjective experience. I do not believe, and never did, that my hip flexors “shorten” in any meaningful, literal way when I sit all day, but they certainly do become cranky and uncooperative feeling, in the same fashion that is associated with the phenomenon of so-called trigger points elsewhere in the body. That sensation can be quite stubborn, and I am really conscious of it, particularly when I transition from a day of sitting at work to full-power athletic activity in the evening (which I do at least weekly). And there is no question this sensory phenomenon is worse when I’m pulling longer days in the chair.
- Sheng M, Yang J, Bao M, et al. The relationship between step count and all-cause mortality and cardiovascular events: A dose-response meta-analysis. J Sport Health Sci. 2021 Sep. PubMed 34547483 ❐ PainSci Bibliography 52202 ❐
This study shows that the health benefits of walking are both amazingly large and also “non-linear”: that is, you get a lot of benefit up front, a huge reduction in health hazards by the time you’ve hit 5K steps/day… at least double what you get out of the next 5K. The ten-thousand-steps “rule” is overkill for a lot of people.
(See more detailed commentary on this paper.)