EPIDEMIOLOGY

The 24-Hour Activity Cycle: A New Paradigm

for Physical Activity
MARY E. ROSENBERGER1, JANET E. FULTON2, MATTHEW P. BUMAN3, RICHARD P. TROIANO4,
MICHAEL A. GRANDNER5, DAVID M. BUCHNER6, and WILLIAM L. HASKELL7
1
Stanford Center on Longevity, Stanford University, Stanford, CA; 2Division of Nutrition, Physical Activity, and Obesity,
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Centers for Disease Control and Prevention, Atlanta, GA; 3School of Nutrition and Health Promotion, Arizona State
University, Phoenix, AZ; 4National Cancer Institute, National Institutes of Health, Bethesda, MD; 5Behavioral Sleep
Medicine Clinic, University of Arizona, Tucson, AZ; 6Department of Kinesiology and Community Health, University of
Illinois Urbana-Champaign, Urbana, IL; and 7Stanford Prevention Research Center, Stanford University, Stanford, CA

ABSTRACT
ROSENBERGER, M. E., J. E. FULTON, M. P. BUMAN, R. P. TROIANO, M. A. GRANDNER, D. M. BUCHNER, and W. L.
HASKELL. The 24-Hour Activity Cycle: A New Paradigm for Physical Activity. Med. Sci. Sports Exerc., Vol. 51, No. 3, pp. 454–464,
2019. The physiologic mechanisms by which the four activities of sleep, sedentary behavior, light-intensity physical activity, and
moderate-to-vigorous physical activity (MVPA) affect health are related, but these relationships have not been well explored in adults.
Research studies have commonly evaluated how time spent in one activity affects health. Because one can only increase time in one
activity by decreasing time in another, such studies cannot determine the extent that a health benefit is due to one activity versus due to
reallocating time among the other activities. For example, interventions to improve sleep possibly also increase time spent in MVPA. If so, the
overall effect of such interventions on risk of premature mortality is due to both more MVPA and better sleep. Further, the potential for
interaction between activities to affect health outcomes is largely unexplored. For example, is there a threshold of MVPA minutes per day,
above which adverse health effects of sedentary behavior are eliminated? This article considers the 24-h Activity Cycle (24-HAC) model as a
paradigm for exploring inter-relatedness of health effects of the four activities. It discusses how to measure time spent in each of the four
activities, as well as the analytical and statistical challenges in analyzing data based on the model, including the inevitable challenge of
confounding among activities. The potential usefulness of this model is described by reviewing selected research findings that aided in the
creation of the model and discussing future applications of the 24-HAC model. Key Words: SEDENTARY BEHAVIOR, SLEEP,
WEARABLES, LIGHT PHYSICAL ACTIVITY, MODERATE PHYSICAL ACTIVITY, VIGOROUS PHYSICAL ACTIVITY

D
uring the past decade, evidence has continued to
accumulate that a person_s behaviors during both
sleep and awake time have important consequences
for health and quality of life. Robust evidence on the health
benefits of optimal patterns of sleep and moderate-to-vigorous
physical activity (MVPA) has led to specific, time-based
public health guidelines for both of these activities in adults
(1,2). Less evidence is available about optimal patterns of
sedentary behavior and light-intensity physical activity
Address for correspondence: Mary Rosenberger, Ph.D., Stanford Center on
Longevity, Littlefield Center, 365 Lasuen St, Stanford, CA 94305; E-mail:
maryr@stanford.edu.
Submitted for publication August 2018.
Accepted for publication October 2018.
0195-9131/19/5103-0454/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2018 by the American College of Sports Medicine
DOI: 10.1249/MSS.0000000000001811
(LIPA), so only general recommendations are possible to
guide time spent in these behaviors (3). In this article, we refer
to these four categories of behavior as ‘‘activities.’’ In this
context, ‘‘activity’’ is a term referring to any behavior that
consumes time during the day (as used in time-use surveys),
as opposed to a physically active endeavor (4).
Current public health recommendations in adults deal sepa-
rately with sleep, sedentary behavior, LIPA, and MVPA over a
24-h sleep and wake cycle. This reflects that fact that much of
the data published to date deals with the relationship of specific
health outcomes to time spent in only one activity during a daily
24-h cycle. Studies generally have not considered the potential
interrelationships of activities with each other. However, some
evidence suggests that time spent in each activity can modify
the health-related influence of time spent in any of the other
activities. For example, increasing time spent in MVPA sig-
nificantly reduces the negative cardiometabolic health conse-
quences of sedentary behavior (5). In youth, it seems as though
the relationships between MVPA and sedentary behavior

454

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might have a different effect on health compared to the same
relationship in adults (6). Several comprehensive 24-h guide-
lines for youth and early childhood have been published in
recent years (7,8).
The development of device-based measurement tools and
the need for more comprehensive behavior recommendations
have spurred the creation of a new paradigm of daily activities
connected through time and physiology in a 24-h cycle (9).
This new paradigm—the 24-h Activity Cycle (24-HAC)
model—is intended to help characterize an optimal 24-h pattern
of physical activity for health and quality of life and aid in
creating future public health (or individualized) recommenda-
tions. Because of the volume and novelty of research in this area
in adults, this review will focus on this age group. Although
the youth are not the focus of this review. it is important to
acknowledge the application of 24-h cycle research to youth
and youth guidelines (10). The discussion that follows defines
the 24-HAC, reviews the relationship of each activity in the
cycle to disease prevention, outlines recent findings with be-
havioral synergies, and describes innovations from inves-
tigators who are already examining activity on a 24-h scale.
This article also discusses measurement of the activities of
the 24-HAC and the analytical and statistical challenges in
analyzing data based upon the model. The potential usefulness
of this model is described by reviewing selected research
findings that aided in the creation of the model and discussing
future applications of the 24-HAC model. This article reviews
the most recent evidence on sleep, sedentary behavior, phys-
ical activity, and health in the context of the 24-HAC, with a
focus on measurement and health promotion challenges and
opportunities. In addition, consideration has been given to
bring together studies representing a complete interdisciplin-
ary research cycle based on available tools.
METHODS
In April 2016, the Stanford Center on Longevity hosted a
workshop entitled ‘‘Wearable Devices & the 24-h Activity
Cycle: A Framework for Developing Daily Activity Recom-
mendations,’’ which convened researchers and industry leaders
to examine a new hypothesis, namely, that health recommen-
dations would be more effective if they could include all
established health-related activities (sleep, sedentary behavior,
LIPA, and MVPA) experienced in a daily cycle. This was a shift
in paradigm from traditional activity recommendations, which
have been created separately by individual research fields (11).
The Stanford workshop stimulated a symposium at the
2017 American College of Sports Medicine Annual Meeting
entitled ‘‘Wake up! Optimizing Physical Activity, Sedentary
Behavior, and Sleep for Better Health.’’ The symposium
presented the 24-HAC and the science supporting its de-
velopment. In collaboration, Stanford conference organizers
and American College of Sports Medicine symposium
speakers have refined the 24-HAC model, collated literature
relevant to the various aspects of the 24-HAC and presented
it in the form of this brief review.
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Introducing Component Activities of the 24-HAC
and Related Public Health Guidelines
The four basic activities of the 24-HAC model are sleep,
sedentary behavior, LIPA, and MVPA. Although this article
does not subdivide these activities, as seen in Table 1, LIPA
may be divided into very light and light activities, and MVPA
divided into moderate-intensity and vigorous-intensity activ-
ities. Thus, the 24-HAC is a comprehensive model of daily
activity. Other health-related behaviors also occur within the
24 h (e.g., diet, smoking). However, the 24-HAC focuses on
activities that are physical behaviors, primarily time-based, and
can be assessed with wearable technologies, as seen in Figure 1.
Definitions for these activities and the evidence of health
risks or benefits are included in Table 1. Evidence is lim-
ited, however, on the ideal daily balance of each of these
health-promoting activities to maintain optimal disease preven-
tion, weight maintenance, and physical function and perfor-
mance. The 24-HAC is intended to create new opportunities
to better examine daily activities, their interrelationships,
and how they may synergistically contribute to optimal health
and well-being.
Sleep
Human sleep is a naturally recurring and easily reversible
state that is characterized by reduced or absent consciousness,
perceptual disengagement, immobility, and the adoption of a
characteristic sleeping posture. Regulation of the sleep–wake
system includes homeostatic and circadian components (15)
and is modified by physiologic (16) and environmental fac-
EPIDEMIOLOGY
tors (17). The sleep–wake regulatory system is comprised of
two independent systems (sleep and wake) that originate in
the midbrain and project throughout the brain and body. Re-
views of this neurobiological system are described elsewhere
(16) but, in summary, sleep is regulated by a set of sleep–
wake switches that are at least partially controlled by the
neurotransmitter orexin (18). The circadian system is com-
prised of a central clock as well as many peripheral clocks
that work to maintain regular rhythms (19). A model of sleep
regulation that combines the sleep–wake and circadian pro-
cesses has been proposed by Borbely (20).
Sleep physiology affects health through total sleep time and
sleep quality (Table 2). Insufficient sleep is related to weight
gain and obesity (21), cardiometabolic disease (22), mor-
tality (23), and other negative health outcomes (17). About
one third of the US population reports averaging G7 h of
sleep per day, below the recommended amount of Q7 hIdj1
(1,24). Insufficient sleep also is related to deficits in cog-
nitive function, which can impair physical function (12). In
addition, poor sleep quality (defined in Table 2) is preva-
lent in the population and contributes to the sleep–health
relationship (17). Lastly, sleep exists in a social-ecological
context, such that a number of factors are known to be as-
sociated with the increased likelihood of insufficient or
poor-quality sleep (17).
Medicine & Science in Sports & Exercised 455
 TABLE 1. Definitions, MET levels, and evidence for the association with health outcomes for activities of the 24-HAC.
Activity Definition METs Health Outcomes
Sleep
Sleep A naturally recurring and easily reversible state that is characterized by ~0.9 Strong or moderate evidence for higher risk of:
reduced or absent consciousness, perceptual disengagement, immobility,  Weight gain and obesity
and the adoption of a characteristic sleeping posture  Diabetes
 Hypertension
 Heart disease and stroke
 Depression
 Death (1)
Sedentary behavior
Sedentary behavior Any waking behavior characterized by an energy expenditure e1.5 metabolic e1.5 Strong or moderate evidence for higher risk of:
equivalents (METs), while in a sitting, reclining, or lying posture (3).  Early death
Sitting A position in which one’s weight is supported by one’s buttocks rather than  CVD and CVD mortality
one’s feet, and in which one’s back is upright (3).  Type 2 diabetes
Passive sitting Any waking activity in a sitting posture characterized by an energy  Colon, endometrium, lung, cancers (12)
expenditure e1.5 METs (3).
Reclining A body position between sitting and lying (3).
Lying Being in a horizontal position on a supporting surface (3).
LIPA
Very light intensity Any voluntary movement produced by skeletal muscles that results in 1.5 to e2.0  Compared to sedentary behavior, lower risk
energy expenditure (4). of early death (13)
Active sitting Any waking activity in a sitting posture characterized by an energy
expenditure 91.5 METs (3).
Standing A position in which one has or is maintaining an upright position while
supported by one’s feet (3).
Passive standing Any waking activity in a standing posture characterized by an energy
expenditure e2.0 METs, while standing without ambulation, whether
supported or unsupported (3).
Light intensity Any voluntary movement produced by skeletal muscles that results in 1.5 to G3.0
energy expenditure (4).
Active standing Any waking activity in a standing posture characterized by an energy
expenditure 92.0 METs, while standing without ambulation, whether
supported or unsupported (3).
MVPA
Moderate intensity Any voluntary movement produced by skeletal muscles that results in 3.0 to 5.9 Strong or moderate evidence for lower risk of:
energy expenditure (4).  Early death
On an absolute scale, physical activity that is done at 3.0 to 5.9 times the  CVD and CVD mortality
intensity of rest (14).  High blood pressure
On a scale relative to an individual’s personal capacity, moderate-intensity  Adverse blood lipid profile
physical activity is usually a 5 or 6 on a scale of 0 to 10 (14).  Type 2 diabetes
Vigorous intensity Any voluntary movement produced by skeletal muscles that results in Q6.0  Metabolic syndrome
energy expenditure (4).  Bladder, breast, colon, endometrium,
EPIDEMIOLOGY

On an absolute scale, physical activity that is done at 6.0 or more esophagus, kidney, lung, stomach cancers
times the intensity of rest (14).  Weight loss (when combined with
On a scale relative to an individual’s personal capacity, vigorous-intensity reduced calorie intake)
physical activity is usually a 7 or 8 on a scale of 0 to 10 (14).  Prevention of weight regain
 Weight gain
 Dementia (including Alzheimer’s)
Strong evidence for:
 Improved cardiorespiratory and muscular fitness
 Improved cognition
 Improved quality of life
 Improved sleep
 Reduced anxiety
 Reduced depression
 Reduced risk of falls and fall-related
injuries (older adults) (12,14).
CVD, cardiovascular disease.

Sedentary Behavior
Sedentary behavior (Table 1) is related to health outcomes
independently of MVPA (13,25,26) and has an unknown
relationship with sleep. Several studies show time recalled in
sedentary behaviors, such as sitting and TV viewing, increase
the risk for all-cause mortality. A meta-analysis of six pro-
spective studies showed higher amounts of daily total sitting
time was associated with greater risk of all-cause mortality (27)
and a meta-analysis of 10 prospective studies showed prolonged
TV viewing time might increase the risk of all-cause mortality
(28). Similarly, studies using accelerometers to estimate sedentary
time show adults participating in less sedentary time (6 hIdj1
compared with 10 hIdj1) have lower risks of mortality (29).
Investigators have examined whether participation in MVPA
can eliminate the health risks of sedentary behavior, and the
answer may be yes, though very large amounts of MVPA (e.g.,
greatly exceeding guidelines) may be needed, and only in
highly sedentary individuals. Limited evidence exists on the
physiologic mechanisms of sedentary behaviors (30), but two
reviews (5,27) show the risks of sitting on mortality are atten-
uated when participants are physically active. A meta-analysis
of high levels of sitting (98 hIdj1) indicates that risks are

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FIGURE 1—Defining the activities (blue) and the research purposes
(orange) for creating a 24-HAC model for research.
attenuated when people engage in weekly moderate-intensity
activity of 60 to 75 minIdj1 (5). However, sleep and LIPA
were not considered in finding this balance. Results from
these studies may provide a starting point from which to
consider developing public health guidance for sedentary
behavior that take MVPA into account.
LIPA and Moderate-to-Vigorous Intensity
Physical Activity
Light-intensity physical activity is relatively undefined
and usually considered as ‘‘other’’ movement not described
as sleep, sedentary behavior, or MVPA. Housework, shop-
ping, cooking, easy gardening, and standing around are ex-
about a 20% lower risk of mortality, with most of the risk
reduction coming from the groups who are not participating
in large amounts of MVPA (29). A prospective study of older
adults showed, through self-report, that replacing sedentary
time with light-intensity activities such as household chores,
gardening, and walking were associated with longevity (32).
Finally, a study of a representative sample of Swedish adults
showed that replacing sedentary time with accelerometer-
measured LIPA was associated with decreased mortality (33).
Hundreds of studies have confirmed the relationship be-
tween MVPA and health and have linked MVPA to im-
provements in a wide range of conditions, including heart
disease, cancer, obesity, and diabetes (13,34). In recent years,
this research has expanded to include strong associations
with brain health, including reduction in dementia and
Alzheimer_s disease, as well as improvements in mood dis-
orders like depression. Newer analyses have shown that
MVPA is associated with reductions in the rate of 13 dif-
ferent cancers (35).
Public Health Guidelines for Sleep and
Physical Activity
Guidelines exist for healthy sleep targets for adults. The
American Academy of Sleep Medicine and Sleep Research
Society jointly recommend at least 7 hIdj1 of sleep for
healthy adults (1). National guidelines do not exist for sleep
quality, but considering known risk factors for sleep disor-
ders, healthy sleep should consist of a sleep latency that is
not too long (typically fewer than 30 min), fewer than four
awakenings during the night, and sleep that feels restorative
without leading to sleepiness during the day (36).

EPIDEMIOLOGY
amples of activities usually categorized as light intensity. The 2008 Physical Activity Guidelines for Americans
Participation in LIPA makes up much of individuals_ daily provides recommendations for the amount and intensity of
activity profiles (31). physical activity needed to obtain substantial health benefits
Several prospective cohort studies show participation in (2). For adult aerobic activity, the guidelines recommend a
LIPA is associated with improved survival or decreased weekly dose of at least 150 min of moderate-intensity phys-
mortality. An accelerometer-based study from the National ical activity, 75 min of vigorous-intensity physical activity,
Health and Nutrition Examination Survey 2003 to 2006 or an equivalent combination. The evidence supporting the
showed that adults participating in 5 or more hIdj1 of LIPA, Guidelines is taken largely from studies in which participants
compared with those participating in less than 3 hIdj1, had recalled their patterns of MVPA. At the time of the 2008
TABLE 2. Terms and descriptions of variables used to measure sleep.
Term Description
Sleep period The time of day typically reserved for sleep. This is usually characterized by a typical bedtime and wake time.
Sleep (onset) latency Length of time between going to bed and falling asleep.
Sleep duration or TST The total amount of time that a person is asleep. Currently, this is the main measure used in sleep epidemiology and sleep guidelines.
Sleep deprivation An acute reduction in sleep duration from baseline. This typically refers to an experimental manipulation, whereas ‘ sleep loss’’ more commonly
refers to real-world reductions in sleep duration. ‘ Total sleep deprivation’’ refers to a complete loss of sleep for a given sleep period. ‘ Partial sleep
deprivation’’ or ‘ sleep restriction’’ refers to when sleep duration is curtailed but not completely eliminated.
WASO Amount of time spent awake after sleep onset and before the final awakening, usually in the morning.
Sleep continuity Quantification of the timeline of sleep, including time into bed, sleep latency, number of awakenings during the night,
WASO, time awake in the morning, and time out of bed. These values can be used to compute sleep duration and sleep efficiency.
Sleep efficiency Percentage of time of actual sleep in a sleep period.
100  (TST/(sleep latency + TST + WASO)
Sleepiness The likelihood that an individual will experience difficulty maintaining wakefulness when sleep is not appropriate (e.g., during the day). This is also
referred to as ‘ sleep propensity’’ and is differentiated from ‘ tiredness’’ and ‘ fatigue’’ in that it is defined by a likelihood of falling asleep, irrespective
of subjective feelings of energy level.
Sleep quality A nonspecific term that describes how ‘ good’’ or ‘ poor’’ an experience of sleep was. This can be reflected in impaired sleep continuity or sleep
architecture, or daytime dysfunction, such as not feeling refreshed in the morning or experiencing daytime sleepiness.
WASO, wake time after sleep onset; TST, total sleep time.

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 guidelines, evidence for recommendations dealing with sed-
entary behavior and light-intensity activity was insufficient.
In the decade since the publication of the 2008 guidelines, a
substantial amount of research has been published, and the
2018 Physical Activity Guidelines Advisory Committee Sci-
entific Report (13) reflects these new findings, including sci-
entific evidence on physical activity and sleep, sedentary
behavior, and LIPA. The Committee_s report is being used as
the basis for the Physical Activity Guidelines for Americans,
second edition.
Introducing the 24-HAC
The 24-HAC uses a holistic approach to integrate the four
health-related activities described above (i.e., sleep, sedentary
behavior, LIPA, and MVPA) into a paradigm that compre-
hensively describes the activities of daily life for optimum
health (11) (Fig. 1). The 24-HAC is dynamic. Changes in
time spent in one activity will influence time spent in at least
one other activity. For example, reductions in sedentary be-
havior (e.g., watching TV), may lead to increases in LIPA
(e.g., taking a walk) and/or extensions in sleep duration (e.g.,
going to bed earlier). The model also assumes interrelation-
ships among the activities. For example, participation in
MVPA may promote better sleep (37), which may in turn
lead to better alertness during the day and more activity (11).
Several studies demonstrate these relationships. For example,
in a 16-wk study in which participants logged daily activities,
temporal associations were observed between physical ac-
tivity and improved sleep quality during the following night
(38). In another study, greater sleep efficiency among older
women was associated with increased activity counts and
EPIDEMIOLOGY
MVPA the following day (39).
A key goal for the 24-HAC model is to provide an inte-
grated paradigm for unifying current time- and quality-based
recommendations for sleep and MVPA with emerging evi-
dence around sedentary behavior and LIPA.
Challenges and Considerations in Using the 24-HAC
in Practice and Research
The 24-HAC model combines sleep, sedentary behavior,
LIPA and MVPA into a new, comprehensive paradigm for
describing the complex patterns of daily activities. Com-
bining these activity types requires applying research
methods and behavioral approaches from a variety of sources
to understand their independent yet interdependent associa-
tions. The following sections discuss five areas that illustrate
the challenges and considerations of using the 24-HAC: 1)
measuring the 24-HAC; 2) analytic methods applied to the
24-HAC; 3) associations between activities in the 24-HAC;
4) a combined approach to improve the 24-HAC activities
through behavioral interventions; and 5) an example of how
research could be enhanced with the 24-HAC approach.
Measuring Activities of the 24-HAC
The strength of the 24-HAC measurement model is its
ability to classify and link activities into health-related
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categories that are mutually exclusive. The model depends on
the ability to accurately measure the daily human activity
cycle for days at a time. Historically, the main source of in-
formation on how people in free-living environments spent
their time has been self-report and this tool was unable to
achieve the level of detail in data collection necessary to
support a 24-h model of activity. This has changed with
widespread use of device-based measures (i.e., wearables).
Data collected from wearable sensors, particularly from ac-
celerometers and heart rate sensors, provide useful informa-
tion for documenting time spent in each of the 24-HAC
activities. In practice though, measuring the 24-HAC is chal-
lenging because individuals are unable to accurately self-monitor
both sedentary time and MVPA with the same consumer
wearable because of limitations built into the devices (40) and
investigators are unable to comprehensively assess the com-
plete 24-HAC with available research-grade wearables (41,42).
Suggestions of additional needs are listed in Figure 2.
The rapidity with which wearable technologies are devel-
oping is exciting although it presents an additional challenge
for measuring the 24-HAC. The speed of technology devel-
opment in wearable devices and the algorithms and software
to support the devices is developing so rapidly that much of
the validation research by scientists is outdated by the time
the publishing cycle has been completed. In the future,
physical activity epidemiology research as it pertains to the
24-HAC may be largely influenced by the ability to accu-
rately measure the activities that make up the 24-HAC (10);
therefore, a discussion of measurement challenges for each
of the 24-HAC activities follows.
Sleep measurement. The most accepted measure of
sleep is polysomnography, a combination of electroencepha-
lography, electromyography, electrooculography, electro-
cardiography, oximetry, and measures of respiration (43).
Polysomnography assesses sleep at the level of cortical ac-
tivity and can be used to discern brainwave-defined ‘‘sleep
stages.’’ Although polysomnography is an indirect measure of
sleep, it is considered the gold standard even with its important
limitations. Most notably, it is typically expensive and burden-
some, and is usually conducted in a laboratory setting. Because
of this, polysomnography can interfere with sleep and because it
is rarely recorded over several nights, is not well suited to reflect
habitual sleep behavior (44). Therefore, measurement outside of
the laboratory is conducted using wearable devices, which esti-
mate sleep time through actigraphy, using movement-detection
apparatus to assess patterns of mobility and immobility to
estimate sleep and wake time. Although other measurement
paradigms exist for habitual sleep, movement is still the
most well characterized and most frequently used.
Actigraphy was developed as an alternative to polysom-
nography and is often validated with polysomnography. Using
research-grade wearable devices with algorithms developed by
sleep researchers, high rates of agreement (about 85% to 90%,
in diverse samples) are observed between wearable devices and
polysomnography (45). Commercial wearables for behavioral
monitoring have typically not shown the same agreement with
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FIGURE 2—Example research needs and directions for the 24-HAC Model.
polysomnography (41). Caution therefore should be taken with
these approaches. Guidelines for the conduct of actigraphy
have been recently published by the Society of Behavioral
Sleep Medicine (44). Given that actigraphy is the primary
measurement tool for sleep research in the field and is also
used to measure the other 24-HAC activities, combining these
measurements into a 24-h model may be achievable.
Sedentary behavior measurement. Sedentary be-
havior measurement should be consistent with the definition
of sedentary behavior provided in Table 1, as the definition
includes both a sitting or lying posture and low levels of
energy expenditure (46). However, most studies of seden-
tary behavior rely on devices placed in body locations where
they measure body movement, but not posture (e.g., a hip
accelerometer) (47). Despite less than optimal measurement,
strong associations between sedentary time and health out-
comes are observed (13,27) To date, two validated devices
accurately measure body posture, but neither have been used
in a large epidemiological study (48,49). Obtaining accurate
24-HAC measurement for posture, and therefore true sed-
entary behavior, from most wearables remains a challenge.
The promise of the 24-HAC is that as other activities, such
as LIPA, are measured more accurately with devices, the
associated algorithms will be able to more accurately isolate
sedentary time as defined in Table 1.
LIPA measurement. Time spent in LIPA is challeng-
ing to measure by self-report, and few consumer wearables
measure or report LIPA (31,50). LIPA can be measured with
accelerometry, with LIPA defined as above the threshold for
sedentary behavior and below the threshold for MVPA.
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Other sophisticated methods have been proposed for mea-
suring LIPA (51), but devices used in research studies often
do not measure posture, making the classification of seden-
tary behavior versus LIPA prone to classification error
(41,47). Additionally, many consumer device manufacturers
combine all activity into their movement score, making it
EPIDEMIOLOGY
difficult to distinguish between LIPA and MVPA (51,52).
To accurately measure LIPA in the 24-HAC, efforts will be
needed to standardize the hardware, software, and algo-
rithms of device-based measures.
MVPA measurement. Device-based measurement of
MVPA is associated with several health outcomes (13,53).
Many consumer wearable devices (e.g., Fitbit, Apple Watch)
focus on quantifying MVPA. Algorithms for wearable devices
from accelerometry and heart rate have been validated on
numerous devices since the 1990s (54). A simple model for
consumers using wearable devices is to measure MVPA and
use those numbers to create a goal for meeting physical ac-
tivity guidelines (e.g., the rings on the Apple watch).
Despite the extensive validation, the substantial health
outcome-related research, and translation to research and
consumer applications, a number of challenges remain in
measuring MVPA in the 24-HAC model. First, the measure-
ment of MVPA lacks consistency and precision. Although
research devices usually try to build algorithms and scoring
around the accepted 3 MET value as the threshold for mod-
erate-intensity physical activity, device-based metrics of this
intensity level vary across devices and consumer devices may
use a proprietary metric (e.g., Nike Fuel). Other challenges
with MVPA measurement include body placement (48) and
Medicine & Science in Sports & Exercised 459
 difficulties with specific activities such as cycling and swim-
ming (55) whose movement patterns do not reflect their in-
tensity. Additionally, validation of these devices outside of the
laboratory is challenging because of a lack of gold-standard
comparison (41,42).
As the interest in activities across the 24-h grow, and if a
unified 24-HAC becomes recognized, it will be important to
consider validity of a combination of device-based and self-
reported methods for understanding the full composition of
activities (both context and actual activities performed). The
level of validity will vary by the application and type of re-
search question; however, it should be noted that current con-
ceptions of most devices and self-report tools do not consider the
integrated nature of these behaviors, and steps will be required to
fully leverage their capabilities within this new 24-HAC context.
Applying Optimal Analytic Methods for the 24-HAC
The challenges inherent in balancing different time-based
components and their relationships to health mean that new
analytic methods for physical activity epidemiology research
need to be developed to make full use of the 24-HAC. Tra-
ditional regression techniques are inadequate because the
components of the 24-HAC add up to the 24 hIdj1, so the
durations of the components are fully interdependent. In re-
sponse to the increasing availability of 24-h data and interest
in examining the components together, methods from other
fields of research have been applied to data from the 24-HAC.
Isotemporal substitution modeling, used to model the
substitution of food components, such as macronutrient or
food groups while holding total energy intake constant (56),
is a promising method. For physical activity, this method uses
EPIDEMIOLOGY
linear regression to estimate the effect of substituting one type
of activity with the same time amount of another activity type.
The estimates are obtained by comparing models with all ac-
tivity types included to those with one activity type removed.
Mekary et al. (57) applied the isotemporal substitution ap-
proach to physical activity data from the Nurses Health
Study. The approach also has been applied to numerous other
data sets using both reported, as well as device-based mea-
sures of activities (29). In addition, isotemporal substitution
models have examined the effects of substituting unhealthy
behavior (such as sedentary time) with healthier alternatives
(sleep or physical activity) during the 24-h cycle (9).
Most studies using the isotemporal substitution technique
are limited by accurate measurement of some but not all of
the 24-HAC activities. In addition, research often only captures
behaviors of primary interest (e.g., physical activity researchers
capture waking hours, sleep researchers capture sleeping hours).
To address these limitations, 24-h accelerometer-based protocols
are emerging, particularly with wrist-worn protocols (58), and
these devices show promise for improving inclusive mea-
surement across the 24 h as well as participant compliance.
However, it is rare and challenging for researchers to apply
methods and algorithms that can accurately quantify sleep,
sedentary, and more active behaviors within a continuous re-
cording of accelerometer data, as described above.
460 Official Journal of the American College of Sports Medicine
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
A second analytic method being applied to 24-HAC research
is compositional analysis. This method is derived from research
based on topics such as geology and the composition of drugs
and is used to determine an optimal contribution from each
ingredient (59,60). For the 24-HAC, the ‘‘ingredients’’ are ac-
tivities, and the health outcome is disease prevention. Several
studies have used this approach (60,61), and Canadian 24-h
Movement Guidelines for Children and Youth (7) were created
using this type of analysis (62). A difference between
isotemporal substitution models and compositional analysis is
the assumption about how the covariates and outcomes are
related: isotemporal substitution assumes linear relationships,
whereas compositional analysis assumes nonlinear relation-
ships and transforms the covariates into composite variables of
a whole. Both rely on traditional forms of regression analyses.
Given that 24-HAC research is still relatively new and
unexplored, other approaches to 24-HAC data analyses, such
as machine learning and functional data analysis, are expected
to emerge in the coming years.
Understanding the Interrelationships among Sleep,
Sedentary Behavior, LIPA, and MVPA
The relationship between sleep and MVPA is well
established. Moderate-to-vigorous physical activity is associ-
ated with greater ease in falling asleep, greater depth of sleep,
greater morning alertness, and better perceived sleep quality
(37). Laboratory studies and randomized trials of exercise
show modest but consistent improvements in sleep. These
effects are observed for total sleep time, slow wave sleep,
sleep onset latency, and overall sleep quality, with the greatest
benefits among those with poorer baseline sleep quality and
older adults (63). Additional relationships, such as how LIPA
affects health outcomes separately from MVPA or sedentary
behavior, are largely unexplored.
Surprisingly little research has explored whether sedentary
behavior is linked to sleep quality independent of MVPA. In the
American Time Use Survey, common sedentary pursuits (i.e.,
work commute time, TV viewing) were associated with short-
ened sleep duration (64). In youth, video gaming and computer
use have been linked to shortened sleep duration (65). Delayed
sleep timing also appears to be associated with more self-
reported minutes of sedentary time and lower levels of free-
living physical activity (66,67). Individuals with delayed sleep
timing patterns report less routinized exercise patterns and more
difficulty making time for exercise. Excess sitting time (partic-
ularly TV viewing) is associated with poor sleep quality and
obstructive sleep apnea risk (68).
Using the 24-HAC in Health
Promotion Interventions
The 24-HAC has significant potential for use in health
promotion interventions, although continued work is needed
to identify the best strategies to apply it in these approaches.
To accomplish this, innovative research designs will be nec-
essary to parse out the unique and joint effects of changes in
behavioral activities across the 24 h (69). For example,
http://www.acsm-msse.org
effective strategies to optimize changes in multiple behavioral
activities are needed, such as perhaps identifying key motivating
behavioral activities among the 24-HAC. Sequential, multiple
assignment randomized trials can be conducted to clarify when
and for whom intervention strategies that target sleep, sedentary
time, LIPA, or MVPA may be most influential and effective.
Because the 24-HAC entails complex behaviors that are
influenced by diverse factors, effective interventions will need
to reflect a solid understanding of the multilevel individual,
social, and environmental determinants that operate across the
24 h. For example, experimental evidence suggests neigh-
borhood characteristics may contribute to obesity and diabetes
(70). The social (e.g., social connectivity, proximity to others)
and built (e.g., crime, street connectivity) environments are
key predictors of physical activity (70). Taken together, these
results suggest that the environment (both social and physical
features) plays a role in health across the 24 h. For sleep, this
includes the microenvironment (i.e., bedroom), where estab-
lished sleep hygiene recommendations exist for optimal sleep
conditions. However, macroenvironmental features beyond
the bedroom, such as ambient noise and temperature, actual
and perceived crime, and social capital, also should be
accounted for. Validated scales and objective measures of
these metrics within the sleep context have not been fully
developed. Furthermore, only a few studies have described
favorable environments to reduce sedentary behavior, such as
the use of height-adjustable desks in the workplace (71) and
TV and electronics restrictions in the home (72). Collectively,
a broader contextual view of health behaviors that accounts
for their interrelationships and dependence on environmental
factors is needed to harness the interplay of the behaviors
role of physical activity in fall prevention in older adults
through at least four pathways (Fig. 3). Strong evidence dem-
onstrates that fall prevention exercise programs substantially
reduce risk of falls and fall injuries in older adults (13). The
traditional framework of fall prevention emphasizes the bene-
ficial physiologic effects of exercise on fall risk factors—in
particular exercise effects on muscle weakness and impaired
balance (pathway 1 in Fig. 3). The 24-HAC model posits that
physical activity categories are inter-related, as shown in the
dashed box in Figure 3, and thereby emphasizes the possibility
of additional mechanisms. The separate arrows in the figure
support the plausibility of these mechanisms.
Pathway 2 occurs if the increased activity from partici-
pation in fall prevention exercise programs also causes a
shift in time spent in sedentary behavior outside of exercise.
National Health and Nutrition Examination Survey acceler-
ometer data show sufficiently active older adults engage in
less sedentary behavior (73), and a meta-analysis reported
higher fall risk in more sedentary older adults (74).
Pathway 3 occurs if the increased activity of fall preven-
tion exercise improves sleep quality. A randomized trial il-
lustrates research on the beneficial effects of exercise on
sleep quality (75), and fewer sleep problems are associated
with fewer falls in older adults (76).
Pathway 4 occurs if fall prevention exercise reduces poly-
pharmacy and use of sedative drugs, as it is well documented
that polypharmacy and sedatives are associated with fall risk in
older adults (14). Evidence exists that higher amounts of
physical activity are associated with lower rates of poly-
pharmacy (77), and higher sleep quality should decrease use of
sedative drugs, as these drugs are commonly prescribed to

across the 24 h and inform health promotion interventions.
Using the 24-HAC in Research
The 24-HAC has great potential to inform research. This
potential is illustrated by an example of its use in research on the
EPIDEMIOLOGY
improve sleep quality (78). Figure 3 also shows why it is po-
tentially important to study and understand pathways 2, 3, and
4. Fall prevention exercise programs historically have empha-
sized strength training and balance training (14). To the extent
that MVPA activates pathways 2, 3, and 4, research could lead
to more emphasis on MVPA in fall prevention.

FIGURE 3—Possible mechanisms by which fall prevention exercise programs reduce risk of falls, based upon the 24-HAC paradigm. Activities of the
paradigm are within the dashed box and possible mechanisms of fall prevention are labeled 1, 2, 3, and 4. Pathway 1 represents the traditional
framework that physiologic effects of exercise modify fall risk factors, for example, balance training improves balance. Modeling fall prevention with
the 24-HAC paradigm creates the possibility of pathways 2, 3, and 4. These pathways derive from the inter-relatedness of activity categories, with the
model proposing that fall prevention exercise program could also reduce falls by pathways involving less sedentary behavior (during nonexercise time)
and improved sleep quality. See text for discussion of evidence that pathways 2, 3, and 4 are plausible.

REVIEW OF DAILY ACTIVITIES AND HEALTH Medicine & Science in Sports & Exercised 461

Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 Potential limitations of the 24-HAC. The application
of the 24-HAC model to future public health guidelines may
have limitations. The 24-HAC model brings together several
scientific disciplines in different stages of development. For
example, sedentary physiology is a less well-established disci-
pline than is physical activity research. To advance the 24-HAC,
it will be important to continue to advance the science on
sedentary and LIPA. In addition, the 24-HAC model because
it combines different constructs (as compared with guidelines
such as for physical activity or sleep) may be challenging to
communicate clear recommendations. In the future, commu-
nications experts and researchers should consider working
together to develop strategies to communicate the 24-HAC
model to a variety of audiences to include policy makers and
health professionals.
Next steps for research with the 24-HAC. Device-
based measures (i.e., wearable devices), improved data col-
lection methods, increased data access, novel applied analytical
techniques, and additional intervention approaches are forming
a unique research environment for examining the relationships
between activity and health. In the previous sections we
discussed several issues in the use of wearable devices relevant
to assess the activities of the 24-HAC model. Below are com-
ments on the general issue of assessing intensity are relevant
broadly to all research with wearable devices.
First, accurate measurement of the 24-HAC components is
still elusive despite the promise of combining motion and
heart rate measurement in one wrist-worn device. The tradi-
tional threshold analysis of accelerometer data has challenges.
The health benefits of physical activity are likely to follow a
more continuous pattern; therefore, intensity effects might be
EPIDEMIOLOGY
better modeled as a continuous function. The same is true for
duration. Research on how to best model health effects from
activity intensity and duration is a priority for future studies in
the 24-HAC.
From a measurement perspective, the number of large da-
tabases being created using accelerometers worn for the full
24 hIdj1 is increasing, and with wrist measurement, compli-
ance is improved. However, this promising development for
24-HAC research cannot yet be realized because of a few key
issues in processing large datasets with 24-h wear. For ex-
ample, the timing of some activities is difficult to determine
because of the similar signals that are associated with inactivity
(sleep, sedentary behavior, and nonwear). Including accurate
heart rate measurement in these large studies will go a long
way to address the deficits in analytics with an accelerometer
alone. In addition, improvement in the output from the sen-
sors to identify sedentary behaviors (based on posture) as
compared to quiet but active behaviors is a key to improving
24-HAC research. Lastly, the creation of methods to assess
health-related activities with all types of sensors, whether they
were built for commercial use (and therefore ease data
collection issues), or research use (which may be more of a
burden to participants), and independent of the current
model of software and hardware will create a more open
research environment.
462 Official Journal of the American College of Sports Medicine
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Finally, assuming that accurate measurement of the 24-HAC
is close at hand, the true utility of the 24-HAC can be realized.
Using assessment of the 24-HAC in epidemiology research
can lead to more specific recommendations, which in turn will
inform interventions (10). In the future, these recommenda-
tions and interventions could also be personalized based on
the specific activity level of the individual. This is the true
value in creating a new paradigm for activity, sedentary be-
havior and sleep research.
CONCLUSIONS
The 24-HAC model is proposed as a paradigm for research,
intervention, and public health recommendations. The 24-
HAC model provides a paradigm for extending research into
how time should be divided among its four component ac-
tivities so as to improve health. Thus, the model has the po-
tential to extend public health guidance, beyond separate
MVPA and sleep guidelines, to integrated guidance for sleep,
sedentary behavior, LIPA, and MVPA. However, Figure 1
illustrates a research feedback loop that can be imagined with
the 24-HAC. Future iterations of the 24-HAC could include
metrics that occur as part of a daily cycle and affect disease
outcomes in a population. Examples of these disciplines
might include nutrition, circadian rhythms, timing of food
intake and activity, alertness, stress, fatigue, and a range of
other related state indicators. The 24-HAC may improve the
understanding of pathophysiological mechanisms underlying
the role of sleep, sedentary, and active behaviors and their
combined role in the disease process. This model represents a
new paradigm, but it is rooted in science developed in separate
academic disciplines. After initially optimizing the 24-HAC
for health outcomes, one could imagine a roadmap to better
health that could be specific to populations, and even poten-
tially to individuals. The promise of the 24-HAC model lies in
an interdisciplinary approach to sleep, sedentary behavior, and
physical activity research for optimal health in a way that
directly addresses people_s daily activity patterns. In the
future, the 24-HAC may be used to educate audiences, in-
cluding researchers, policymakers, and health professionals;
inform public health guidelines on how people can best
distribute their activity across the 24-h cycle for optimal
health and quality of life, and develop strategies to help in-
dividuals achieve this balance.
The authors would like to acknowledge and thank Dr. John
Staudenmeyer for his oral presentation at the International Confer-
ence on Ambulatory Monitoring of Physical Activity and Movement in
Bethesda, MD, 2017. Additionally, the authors also thank Dr. Charles
Matthews for his effort in organizing the 2017 ACSM symposium.
M. A. G. is supported by a grant from the National Institute on Minority
Health and Health Disparities (R01MD011600) and the Department of
Defense (W81XWH-17-0088). The results of this review are presented
clearly, honestly and without fabrication, falsification or inappropri-
ate data manipulation. This review does not constitute endorsement
by ACSM. The findings and conclusions of this report are those of
the authors and do not necessarily represent the official position of
the National Institutes of Health or the Centers for Disease Control
and Prevention.
http://www.acsm-msse.org
 REFERENCES
1. Watson NF, Badr MS, Belenky G, et al. Recommended amount of
sleep for a healthy adult: a joint consensus statement of the
American Academy of Sleep Medicine and Sleep Research Soci-
ety. J Clin Sleep Med. 2015;11(6):591–2.
2. Haskell WL, Lee IM, Pate RR, et al. Physical activity and public
health: updated recommendation for adults from the American
College of Sports Medicine and the American Heart Association.
Circulation. 2007;116(9):1081–93.
3. Tremblay MS, Aubert S, Barnes JD, et al. Sedentary behavior re-
search network (SBRN)—terminology consensus project process
and outcome. Int J Behav Nutr Phys Act. 2017;14(1):75–91.
4. Caspersen CJ, Powell KE, Christenson GM. Physical activity,
exercise, and physical fitness: definitions and distinctions for
health-related research. Public Health Rep. 1985;100(2):126–31.
5. Ekelund U, Steene-Johannessen J, Brown WJ, et al. Physical
activity attenuates the detrimental association of sitting time
with mortality: a harmonised meta-analysis of data from more
than one million men and women. Lancet. 2016;388(1051):
1302–10.
6. Janz KF, Boros P, Letuchy EM, Kwon S, Burns TL, Levy SM.
Physical activity, not sedentary time, predicts dual-energy X-ray
absorptiometry-measured adiposity age 5 to 19 years. Med Sci
Sports Exerc. 2017;49(10):2071–7.
7. Tremblay MS, Carson V, Chaput JP, et al. Canadian 24-hour
movement guidelines for children and youth: an integration of
physical activity, sedentary behaviour, and sleep. Appl Physiol
Nutr Metab. 2016;41(6 Suppl 3):311–27.
8. Okely AD, Ghersi D, Hesketh KD, et al. A collaborative approach
to adopting/adapting guidelines—the Australian 24-hour move-
ment guidelines for the early years (birth to 5 years): an integration
of physical activity, sedentary behavior, and sleep. BMC Public
Health. 2017;17(S5):869.
9. Buman MP, Winkler EA, Kurka JM, et al. Reallocating time to
sleep, sedentary Behaviors, or active Behaviors: associations with
cardiovascular disease risk biomarkers, NHANES 2005–2006. Am
J Epidemiol. 2014;179(3):323–34.
10. Chaput JP, Carson V, Gray CE, Tremblay MS. Importance of all
movement behaviors in a 24 hour period for overall health. Int J
Environ Res Public Health. 2014;11:12575–81.
11. Smith K, Rosenberger M. Keeping seniors active - a 24-hour approach.
2017; [cited 2017 Jul 22 ] Available from: http://longevity.stanford.
edu/blog/2017/08/11/keeping-seniors-active-a-24-hour-approach/.
12. Goel N, Basner M, Dinges DF. Phenotyping of neurobehavioral
vulnerability to circadian phase during sleep loss. Methods Enzymol.
2015;552:285–308.
13. 2018 Physical Activity Guidelines Advisory Committee, 2018
Physical Activity Guidelines Advisory Committee. 2018 Physi-
cal Activity Guidelines Advisory Committee Scientific Report.
Washington, DC; 2018.
14. Drootin M. Summary of the updated American Geriatrics
Society/British Geriatrics Society clinical practice guideline for
prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1):
148–57.
15. Borbély AA, Tobler I. Manifestations and functional implications
of sleep homeostasis. Handb Clin Neurol. 2011;98:205–13.
16. Saper CB, Fuller PM. Wake–sleep circuitry: an overview. Curr
Opin Neurobiol. 2017;44:186–92.
17. Grandner MA. Sleep, health, and society. Sleep Med Clin. 2017;
12(1):1–22.
18. Sakurai T, Pandi-Pamural SR, Monte JM. Orexin and Sleep:
Molecular, Functional and Clinical Aspects. 2015; pp. 181–202.
19. Albrecht U. Timing to perfection: the biology of central and pe-
ripheral circadian clocks. Neuron. 2012;74(2):246–60.
20. Borbély AA. A two process model of sleep regulation. Hum
Neurobiol. 1982;1(3):195–204.
REVIEW OF DAILY ACTIVITIES AND HEALTH
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
21. Grandner MA. Sleep and obesity risk in adults: possible mecha-
nisms; contextual factors; and implications for research, interven-
tion, and policy. Sleep Health. 2017;3(5):393–400.
22. Grandner MA, Seixas A, Shetty S, Shenoy S. Sleep duration and
diabetes risk: population trends and potential mechanisms. Curr
Diab Rep. 2016;16(11):106.
23. Grandner MA, Hale L, Moore M, Patel NP. Mortality associated
with short sleep duration: the evidence, the possible mechanisms,
and the future. Sleep Med Rev. 2010;14(3):191–203.
24. Liu Y, Wheaton AG, Chapman DP, Cunningham TJ, Lu H,
Croft JB. Prevalence of healthy sleep duration among adults —
United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65(6):
137–41.
25. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. Sitting time
and mortality from all causes, cardiovascular disease, and cancer.
Med Sci Sports Exerc. 2009;41(5):998–1005.
26. Thorp AA, Owen N, Neuhaus M, Dunstan DW. Sedentary be-
haviors and subsequent health outcomes in adults: a systematic
review of longitudinal studies, 1996-2011. Am J Prev Med.
2011;41(2):207–15.
27. Chau JY, Grunseit AC, Chey T, et al. Daily sitting time and all-
cause mortality: a meta-analysis. PLoS One. 2013;8(11):e80000.
28. Sun JW, Zhao LG, Yang Y, Ma X, Wang YY, Xiang YB. Associa-
tion between television viewing time and all-cause mortality: a meta-
analysis of cohort studies. Am J Epidemiol. 2015;182(11):908–16.
29. Matthews CE, Keadle SK, Troiano RP, et al. Accelerometer-
measured dose–response for physical activity, sedentary time, and
mortality in US adults. Am J Clin Nutr. 2016;104(5):1424–32.
30. Hamilton MT, Hamilton DG, Zderic TW. Exercise physiology
versus inactivity physiology: an essential concept for under-
standing lipoprotein lipase regulation. Exerc Sport Sci Rev. 2004;
32(4):161–6.
31. Loprinzi PD. Light-intensity physical activity and all-cause mor-
tality. Am J Health Promot. 2017;31(4):340–2.
32. Matthews CE, Moore SC, Sampson J, et al. Mortality benefits for
replacing sitting time with different physical activities. Med Sci
EPIDEMIOLOGY
Sports Exerc. 2015;47(9):1833–40.
33. Dohrn IM, Sjöström M, Kwak L, Oja P, Hagströmer M. Accelerometer-
measured sedentary time and physical activity—a 15 year follow-up
of mortality in a Swedish population-based cohort. J Sci Med Sport.
2018;21:702–7.
34. Committee PAGA. Physical Activity Guidelines Advisory Committee
report [Internet]. Washington, DC: US Dep Heal Hum Serv; 2008.
35. Moore SC, Lee IM, Weiderpass E, et al. Association of leisure-
time physical activity with risk of 26 types of cancer in 1.44 mil-
lion adults. JAMA Intern Med. 2016;176(6):816.
36. Taylor D, Gehrman P, Dautovich N, Lichstein K, McCrae C.
Handbook of Insomnia. Tarporley: Springer Healthcare Ltd.; 2014.
37. Buman MP, Youngstedt SD. Physical activity, sleep, and Biobe-
havioral synergies for health. Sleep and Affect Elsevier. 2015;321–37.
38. Dzierzewski JM, Buman MP, Giacobbi PR, et al. Exercise and
sleep in community-dwelling older adults: evidence for a recipro-
cal relationship. J Sleep Res. 2014;23(1):61–8.
39. Lambiase MJ, Gabriel KP, Kuller LH, Matthews KA. Temporal
relationships between physical activity and sleep in older women.
Med Sci Sports Exerc. 2013;45(12):2362–8.
40. Sanders JP, Loveday A, Pearson N, et al. Devices for self-monitoring
sedentary time or physical activity: a scoping review. J Med Internet
Res. 2016;18(5):e90.
41. Rosenberger ME, Buman MP, Haskell WL, McConnell MV,
Carstensen LL. Twenty-four hours of sleep, sedentary behavior,
and physical activity with nine wearable devices. Med Sci Sports
Exerc. 2016;48(3):457–65.
42. Ferguson T, Rowlands AV, Olds T, Maher C. The validity of
consumer-level, activity monitors in healthy adults worn in free-living
Medicine & Science in Sports & Exercised 463
 conditions: a cross-sectional study. Int J Behav Nutr Phys Act.
2015;12(1):42.
43. Keenan S. An overview of polysomnorgraphy. In: Barkoukis T,
Avidan A, editors. Review of Sleep Medicine. Philadelphia:
Butterworth Heinemann Elsevier; 2007. pp. 143–67.
44. Ancoli-Israel S, Martin JL, Blackwell T, et al. The SBSM guide to
actigraphy monitoring: clinical and research applications. Behav
Sleep Med. 2015;13(1 Suppl):S4–38.
45. Marino M, Li Y, Rueschman MN, et al. Measuring sleep: accu-
racy, sensitivity, and specificity of wrist actigraphy compared to
polysomnography. Sleep. 2013;36(11):1747–55.
46. Owen N, Healy GN, Matthews CE, Dunstan DW. Too much sit-
ting: the population health science of sedentary behavior. Exerc
Sport Sci Rev. 2010;38(3):105–13.
47. Kozey-Keadle S, Libertine A, Lyden K, Staudenmayer J, Freedson
PS. Validation of wearable monitors for assessing sedentary be-
havior. Med Sci Sports Exerc. 2011;43(8):1561–7.
48. Rosenberger ME, Haskell WL, Albinali F, Mota S, Nawyn J,
Intille S. Estimating activity and sedentary behavior from an acceler-
ometer on the hip or wrist. Med Sci Sports Exerc. 2013;45(5):964–75.
49. Lyden K, Kozey Keadle SL, Staudenmayer JW, Freedson PS.
Validity of two wearable monitors to estimate breaks from seden-
tary time. Med Sci Sports Exerc. 2012;44(11):2243–52.
50. Evenson KR, Goto MM, Furberg RD. Systematic review of the
validity and reliability of consumer-wearable activity trackers. Int J
Behav Nutr Phys Act. 2015;12(1):159.
51. Buman MP, Hekler EB, Haskell WL, et al. Objective light-intensity
physical activity associations with rated health in older adults. Am J
Epidemiol. 2010;172(10):1155–65.
52. Healy GN, Dunstan DW, Salmon JJ, et al. Objectively measured
light-intensity physical activity is independently associated with 2-h
plasma glucose. Diabetes Care. 2007;30(6):1384–9.
53. Fishman EI, Steeves JA, Zipunnikov V, et al. Association between
objectively measured physical activity and mortality in NHANES.
Med Sci Sports Exerc. 2016;48(7):1303–11.
54. Haskell WL, Yee MC, Evans A, Irby PJ. Simultaneous measure-
ment of heart rate and body motion to quantitate physical activity.
Med Sci Sports Exerc. 1993;25(1):109–15.
EPIDEMIOLOGY
55. Esliger DW, Rowlands AV, Hurst TL, Catt M, Murray P, Eston
RG. Validation of the GENEA accelerometer. Med Sci Sports
Exerc. 2011;43(6):1085–93.
56. Willett W, Stampfer MJ. Total energy intake: implications for
epidemiologic analyses. Am J Epidemiol. 1986;124(1):17–27.
57. Mekary RA, Lucas M, Pan A, et al. Isotemporal substitution
analysis for physical activity, television watching, and risk of de-
pression. Am J Epidemiol. 2013;178(3):474–83.
58. Doherty A, Jackson D, Hammerla N, et al. Large scale population
assessment of physical activity using wrist worn accelerometers:
the UK Biobank study. PLoS One. 2017;12(2):e0169649.
59. Aitchison J. The statistical analysis of compositional data. J R Stat
Soc Ser B. 1982;44:139–77.
60. Chastin SF, Palarea-Albaladejo J, Dontje ML, Skelton DA. Combined
effects of time spent in physical activity, sedentary behaviors and
sleep on obesity and cardio-metabolic health markers: a novel com-
positional data analysis approach. PLoS One. 2015;10(10):e0139984.
61. Winkler EA, Chastin S, Eakin EG, et al. Cardiometabolic impact
of changing sitting, standing, and stepping in the workplace. Med
Sci Sports Exerc. 2018;50(3):516–24.
464 Official Journal of the American College of Sports Medicine
Copyright © 2019 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
62. Carson V, Tremblay MS, Chaput JP, Chastin SF. Associations be-
tween sleep duration, sedentary time, physical activity, and health
indicators among Canadian children and youth using compositional
analyses. Appl Physiol Nutr Metab. 2016;41(6 Suppl 3):S294–302.
63. Buman MP, King AC. Exercise as a treatment to enhance sleep.
Am J Lifestyle Med. 2010;4(6):500–14.
64. Basner M, Fomberstein KM, Razavi FM, et al. American time use
survey: sleep time and its relationship to waking activities. Sleep.
2007;30(9):1085–95.
65. Foti KE, Eaton DK, Lowry R, McKnight-Ely LR. Sufficient sleep,
physical activity, and sedentary behaviors. Am J Prev Med.
2011;41(6):596–602.
66. Shechter A, St-Onge M-P. Delayed sleep timing is associated with
low levels of free-living physical activity in normal sleeping
adults. Sleep Med. 2014;15(12):1586–9.
67. Baron KG, Reid KJ, Zee PC. Exercise to improve sleep in in-
somnia: exploration of the bidirectional effects. J Clin Sleep Med.
2013;9(8):819–24.
68. Buman MP, Kline CE, Youngstedt SD, Phillips B, Tulio de Mello
M, Hirshkowitz M. Sitting and television viewing: novel risk fac-
tors for sleep disturbance and apnea risk? Results from the 2013
National Sleep Foundation sleep in America poll. Chest. 2015;
147(3):728–34.
69. Collins LM, Murphy SA, Strecher V. The multiphase optimization
strategy (MOST) and the sequential multiple assignment random-
ized trial (SMART): new methods for more potent eHealth in-
terventions. Am J Prev Med. 2007;32(5):S112–8.
70. King AC, Sallis JF, Frank LD, et al. Aging in neighborhoods dif-
fering in walkability and income: associations with physical activity
and obesity in older adults. Soc Sci Med. 2011;73(10):1525–33.
71. Alkhajah TA, Reeves MM, Eakin EG, Winkler EA, Owen N,
Healy GN. Sit–stand workstations: a pilot intervention to reduce
office sitting time. Am J Prev Med. 2012;43(3):298–303.
72. Otten JJ, Jones KE, Littenberg B, Harvey-Berino J. Effects of tele-
vision viewing reduction on energy intake and expenditure in
overweight and obese adults. Arch Intern Med. 2009;169(22):2109.
73. Gennuso KP, Gangnon RE, Matthews CE, Thraen-Borowski KM,
Colbert LH. Sedentary behavior, physical activity, and markers of
health in older adults. Med Sci Sports Exerc. 2013;45(8):1493–500.
74. Thibaud M, Bloch F, Tournoux-Facon C, et al. Impact of physical
activity and sedentary behaviour on fall risks in older people: a
systematic review and meta-analysis of observational studies. Eur
Rev Aging Phys Act. 2012;9(1):5–15.
75. King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL.
Moderate-intensity exercise and self-rated quality of sleep in
older adults: a randomized controlled trial. JAMA. 1997;277(1):
32–7.
76. Min Y, Nadpara PA, Slattum PW. The association between sleep
problems, sleep medication use, and falls in community-dwelling
older adults: results from the health and retirement study 2010. J Aging
Res. 2016;2016:1–10.
77. Volaklis KA, Thorand B, Peters A, et al. Physical activity, mus-
cular strength, and polypharmacy among older multimorbid per-
sons: results from the KORA-age study. Scand J Med Sci Sports.
2018;28(2):604–12.
78. Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE. Seda-
tive hypnotics in older people with insomnia: meta-analysis of
risks and benefits. BMJ. 2005;331(7526):1169–73.
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