Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries
Identifieur interne : 000892 ( Pmc/Corpus ); précédent : 000891; suivant : 000893Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries
Auteurs : Davy Vancampfort ; Brendon Stubbs ; Ai KoyanagiSource :
- The International Journal of Behavioral Nutrition and Physical Activity [ 1479-5868 ] ; 2017.
Abstract
Sedentary behavior (SB) is, irrespective of a person’s physical activity levels, associated with a wide range of deleterious outcomes such as diabetes, stroke and associated premature mortality. There are no nationally representative, multi-national, population-based studies investigating the relationship between SB, chronic conditions, and physical multimorbidity (i.e., two or more chronic physical conditions). Thus, this cross-sectional study aimed to assess the association between chronic conditions, physical multimorbidity and SB among community-dwelling adults in six low- and middle-income countries (LMICs). We also explored the influential factors of these relationships.
The Study on Global Ageing and Adult Health (SAGE) survey included 34,129 adults aged ≥50 years. SB was self-reported and expressed as a categorical variable [<8 or ≥8 h per day (high SB)]. Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Multivariable logistic regression and mediation analyses were conducted.
The prevalence of physical multimorbidity and high SB (≥8 h/day) were 45.5% (43.7%–47.4%) and 10.8% (9.7%–12.1%), respectively. The prevalence of high SB increased in a linear fashion from 7.1% in people with no chronic condition to 24.1% in those with ≥4 chronic conditions. In the multivariable analysis, visual impairment (OR = 2.62), stroke (OR = 2.02), chronic back pain (OR = 1.70) hearing problems (OR = 1.58), chronic lung disease (OR = 1.48), asthma (OR = 1.39), arthritis (OR = 1.22) and multimorbidity (OR = 1.41) were significantly associated with high SB. Disability explained more than 50% of the association for all chronic conditions with particularly high percentages (>80%) for arthritis, asthma, and multimorbdity. Mobility problems explained 88.1% and 85.1% of the association of SB with arthritis and physical multimorbidiy, respectively. Pain was highly influential in the SB-arthritis relationship (85.6%). Sleep/energy problems explained between 9.3% (stroke) to 49.1% (arthritis) of the association, and cognitive problems from 21.5% (stroke) to 33.4% (hearing problems). Findings for anxiety and depression were mixed.
In LMICs, those with chronic conditions and physical multimorbidity are significantly more sedentary. Targeted messages to reduce time spent sedentary among individuals with chronic conditions may ameliorate associated disability, mobility difficulties and pain that are themselves the most important risk factors for SB.
The online version of this article (10.1186/s12966-017-0602-z) contains supplementary material, which is available to authorized users.
Url:
DOI: 10.1186/s12966-017-0602-z
PubMed: 29078781
PubMed Central: 5658996
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PMC:5658996Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries</title><author><name sortKey="Vancampfort, Davy" sort="Vancampfort, Davy" uniqKey="Vancampfort D" first="Davy" last="Vancampfort">Davy Vancampfort</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven Department of Rehabilitation Sciences,</institution></institution-wrap>Tervuursevest 101, 3001 Leuven, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven, University Psychiatric Center KU Leuven,</institution></institution-wrap>Leuvensesteenweg 517, 3070 Kortenberg, Belgium</nlm:aff></affiliation></author><author><name sortKey="Stubbs, Brendon" sort="Stubbs, Brendon" uniqKey="Stubbs B" first="Brendon" last="Stubbs">Brendon Stubbs</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 9439 0839</institution-id><institution-id institution-id-type="GRID">grid.37640.36</institution-id><institution>Physiotherapy Department, South London and Maudsley NHS Foundation Trust,</institution></institution-wrap>Denmark Hill, London, SE5 8AZ UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2322 6764</institution-id><institution-id institution-id-type="GRID">grid.13097.3c</institution-id><institution>Health Service and Population Research Department,</institution><institution>Institute of Psychiatry, Psychology and Neuroscience, King’s College London,</institution></institution-wrap>De Crespigny Park, London, Box SE5 8AF UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2299 5510</institution-id><institution-id institution-id-type="GRID">grid.5115.0</institution-id><institution>Faculty of Health, Social Care and Education, Anglia Ruskin University,</institution></institution-wrap>Chelmsford, UK</nlm:aff></affiliation></author><author><name sortKey="Koyanagi, Ai" sort="Koyanagi, Ai" uniqKey="Koyanagi A" first="Ai" last="Koyanagi">Ai Koyanagi</name><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 0247</institution-id><institution-id institution-id-type="GRID">grid.5841.8</institution-id><institution>Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu,</institution></institution-wrap>Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, 0883 Barcelona, Spain</nlm:aff></affiliation><affiliation><nlm:aff id="Aff7"><institution-wrap><institution-id institution-id-type="GRID">grid.469673.9</institution-id><institution>Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM,</institution></institution-wrap>Monforte de Lemos 3-5 Pabellón 11, 28029 Madrid, Spain</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">29078781</idno><idno type="pmc">5658996</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5658996</idno><idno type="RBID">PMC:5658996</idno><idno type="doi">10.1186/s12966-017-0602-z</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">000892</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000892</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries</title><author><name sortKey="Vancampfort, Davy" sort="Vancampfort, Davy" uniqKey="Vancampfort D" first="Davy" last="Vancampfort">Davy Vancampfort</name><affiliation><nlm:aff id="Aff1"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven Department of Rehabilitation Sciences,</institution></institution-wrap>Tervuursevest 101, 3001 Leuven, Belgium</nlm:aff></affiliation><affiliation><nlm:aff id="Aff2"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven, University Psychiatric Center KU Leuven,</institution></institution-wrap>Leuvensesteenweg 517, 3070 Kortenberg, Belgium</nlm:aff></affiliation></author><author><name sortKey="Stubbs, Brendon" sort="Stubbs, Brendon" uniqKey="Stubbs B" first="Brendon" last="Stubbs">Brendon Stubbs</name><affiliation><nlm:aff id="Aff3"><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 9439 0839</institution-id><institution-id institution-id-type="GRID">grid.37640.36</institution-id><institution>Physiotherapy Department, South London and Maudsley NHS Foundation Trust,</institution></institution-wrap>Denmark Hill, London, SE5 8AZ UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff4"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2322 6764</institution-id><institution-id institution-id-type="GRID">grid.13097.3c</institution-id><institution>Health Service and Population Research Department,</institution><institution>Institute of Psychiatry, Psychology and Neuroscience, King’s College London,</institution></institution-wrap>De Crespigny Park, London, Box SE5 8AF UK</nlm:aff></affiliation><affiliation><nlm:aff id="Aff5"><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2299 5510</institution-id><institution-id institution-id-type="GRID">grid.5115.0</institution-id><institution>Faculty of Health, Social Care and Education, Anglia Ruskin University,</institution></institution-wrap>Chelmsford, UK</nlm:aff></affiliation></author><author><name sortKey="Koyanagi, Ai" sort="Koyanagi, Ai" uniqKey="Koyanagi A" first="Ai" last="Koyanagi">Ai Koyanagi</name><affiliation><nlm:aff id="Aff6"><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 0247</institution-id><institution-id institution-id-type="GRID">grid.5841.8</institution-id><institution>Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu,</institution></institution-wrap>Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, 0883 Barcelona, Spain</nlm:aff></affiliation><affiliation><nlm:aff id="Aff7"><institution-wrap><institution-id institution-id-type="GRID">grid.469673.9</institution-id><institution>Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM,</institution></institution-wrap>Monforte de Lemos 3-5 Pabellón 11, 28029 Madrid, Spain</nlm:aff></affiliation></author></analytic><series><title level="j">The International Journal of Behavioral Nutrition and Physical Activity</title><idno type="eISSN">1479-5868</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p id="Par1">Sedentary behavior (SB) is, irrespective of a person’s physical activity levels, associated with a wide range of deleterious outcomes such as diabetes, stroke and associated premature mortality. There are no nationally representative, multi-national, population-based studies investigating the relationship between SB, chronic conditions, and physical multimorbidity (i.e., two or more chronic physical conditions). Thus, this cross-sectional study aimed to assess the association between chronic conditions, physical multimorbidity and SB among community-dwelling adults in six low- and middle-income countries (LMICs). We also explored the influential factors of these relationships.</p></sec><sec><title>Method</title><p id="Par2">The Study on Global Ageing and Adult Health (SAGE) survey included 34,129 adults aged ≥50 years. SB was self-reported and expressed as a categorical variable [<8 or ≥8 h per day (high SB)]. Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Multivariable logistic regression and mediation analyses were conducted.</p></sec><sec><title>Results</title><p id="Par3">The prevalence of physical multimorbidity and high SB (≥8 h/day) were 45.5% (43.7%–47.4%) and 10.8% (9.7%–12.1%), respectively. The prevalence of high SB increased in a linear fashion from 7.1% in people with no chronic condition to 24.1% in those with ≥4 chronic conditions. In the multivariable analysis, visual impairment (OR = 2.62), stroke (OR = 2.02), chronic back pain (OR = 1.70) hearing problems (OR = 1.58), chronic lung disease (OR = 1.48), asthma (OR = 1.39), arthritis (OR = 1.22) and multimorbidity (OR = 1.41) were significantly associated with high SB. Disability explained more than 50% of the association for all chronic conditions with particularly high percentages (>80%) for arthritis, asthma, and multimorbdity. Mobility problems explained 88.1% and 85.1% of the association of SB with arthritis and physical multimorbidiy, respectively. Pain was highly influential in the SB-arthritis relationship (85.6%). Sleep/energy problems explained between 9.3% (stroke) to 49.1% (arthritis) of the association, and cognitive problems from 21.5% (stroke) to 33.4% (hearing problems). Findings for anxiety and depression were mixed.</p></sec><sec><title>Conclusion</title><p id="Par4">In LMICs, those with chronic conditions and physical multimorbidity are significantly more sedentary. Targeted messages to reduce time spent sedentary among individuals with chronic conditions may ameliorate associated disability, mobility difficulties and pain that are themselves the most important risk factors for SB.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s12966-017-0602-z) contains supplementary material, which is available to authorized users.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Beard, Hpjr" uniqKey="Beard H">HPJR Beard</name></author><author><name sortKey="Bloom, De" uniqKey="Bloom D">DE Bloom</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fortin, M" uniqKey="Fortin M">M Fortin</name></author><author><name sortKey="Stewart, M" uniqKey="Stewart M">M Stewart</name></author><author><name sortKey="Poitras, M E" uniqKey="Poitras M">M-E Poitras</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Int J Behav Nutr Phys Act</journal-id><journal-id journal-id-type="iso-abbrev">Int J Behav Nutr Phys Act</journal-id><journal-title-group><journal-title>The International Journal of Behavioral Nutrition and Physical Activity</journal-title></journal-title-group><issn pub-type="epub">1479-5868</issn><publisher><publisher-name>BioMed Central</publisher-name><publisher-loc>London</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">29078781</article-id><article-id pub-id-type="pmc">5658996</article-id><article-id pub-id-type="publisher-id">602</article-id><article-id pub-id-type="doi">10.1186/s12966-017-0602-z</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Physical chronic conditions, multimorbidity and sedentary behavior amongst middle-aged and older adults in six low- and middle-income countries</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><contrib-id contrib-id-type="orcid">http://orcid.org/0000-0002-4592-8625</contrib-id><name><surname>Vancampfort</surname><given-names>Davy</given-names></name><address><phone>+32 2 758 05 11</phone><email>davy.vancampfort@kuleuven.be</email></address><xref ref-type="aff" rid="Aff1">1</xref><xref ref-type="aff" rid="Aff2">2</xref></contrib><contrib contrib-type="author"><name><surname>Stubbs</surname><given-names>Brendon</given-names></name><address><email>brendon.stubbs@kcl.ac.uk</email></address><xref ref-type="aff" rid="Aff3">3</xref><xref ref-type="aff" rid="Aff4">4</xref><xref ref-type="aff" rid="Aff5">5</xref></contrib><contrib contrib-type="author"><name><surname>Koyanagi</surname><given-names>Ai</given-names></name><address><email>a.koyanagi@pssjd.org</email></address><xref ref-type="aff" rid="Aff6">6</xref><xref ref-type="aff" rid="Aff7">7</xref></contrib><aff id="Aff1"><label>1</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven Department of Rehabilitation Sciences,</institution></institution-wrap>Tervuursevest 101, 3001 Leuven, Belgium</aff><aff id="Aff2"><label>2</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 0668 7884</institution-id><institution-id institution-id-type="GRID">grid.5596.f</institution-id><institution>KU Leuven, University Psychiatric Center KU Leuven,</institution></institution-wrap>Leuvensesteenweg 517, 3070 Kortenberg, Belgium</aff><aff id="Aff3"><label>3</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0000 9439 0839</institution-id><institution-id institution-id-type="GRID">grid.37640.36</institution-id><institution>Physiotherapy Department, South London and Maudsley NHS Foundation Trust,</institution></institution-wrap>Denmark Hill, London, SE5 8AZ UK</aff><aff id="Aff4"><label>4</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2322 6764</institution-id><institution-id institution-id-type="GRID">grid.13097.3c</institution-id><institution>Health Service and Population Research Department,</institution><institution>Institute of Psychiatry, Psychology and Neuroscience, King’s College London,</institution></institution-wrap>De Crespigny Park, London, Box SE5 8AF UK</aff><aff id="Aff5"><label>5</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0001 2299 5510</institution-id><institution-id institution-id-type="GRID">grid.5115.0</institution-id><institution>Faculty of Health, Social Care and Education, Anglia Ruskin University,</institution></institution-wrap>Chelmsford, UK</aff><aff id="Aff6"><label>6</label><institution-wrap><institution-id institution-id-type="ISNI">0000 0004 1937 0247</institution-id><institution-id institution-id-type="GRID">grid.5841.8</institution-id><institution>Research and Development Unit, Parc Sanitari Sant Joan de Déu, Universitat de Barcelona, Fundació Sant Joan de Déu,</institution></institution-wrap>Dr. Antoni Pujadas, 42, Sant Boi de Llobregat, 0883 Barcelona, Spain</aff><aff id="Aff7"><label>7</label><institution-wrap><institution-id institution-id-type="GRID">grid.469673.9</institution-id><institution>Instituto de Salud Carlos III, Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM,</institution></institution-wrap>Monforte de Lemos 3-5 Pabellón 11, 28029 Madrid, Spain</aff></contrib-group><pub-date pub-type="epub"><day>27</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="pmc-release"><day>27</day><month>10</month><year>2017</year></pub-date><pub-date pub-type="collection"><year>2017</year></pub-date><volume>14</volume><elocation-id>147</elocation-id><history><date date-type="received"><day>31</day><month>7</month><year>2017</year></date><date date-type="accepted"><day>19</day><month>10</month><year>2017</year></date></history><permissions><copyright-statement>© The Author(s). 2017</copyright-statement><license license-type="OpenAccess"><license-p><bold>Open Access</bold>This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/publicdomain/zero/1.0/">http://creativecommons.org/publicdomain/zero/1.0/</ext-link>) applies to the data made available in this article, unless otherwise stated.</license-p></license></permissions><abstract id="Abs1"><sec><title>Background</title><p id="Par1">Sedentary behavior (SB) is, irrespective of a person’s physical activity levels, associated with a wide range of deleterious outcomes such as diabetes, stroke and associated premature mortality. There are no nationally representative, multi-national, population-based studies investigating the relationship between SB, chronic conditions, and physical multimorbidity (i.e., two or more chronic physical conditions). Thus, this cross-sectional study aimed to assess the association between chronic conditions, physical multimorbidity and SB among community-dwelling adults in six low- and middle-income countries (LMICs). We also explored the influential factors of these relationships.</p></sec><sec><title>Method</title><p id="Par2">The Study on Global Ageing and Adult Health (SAGE) survey included 34,129 adults aged ≥50 years. SB was self-reported and expressed as a categorical variable [<8 or ≥8 h per day (high SB)]. Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Multivariable logistic regression and mediation analyses were conducted.</p></sec><sec><title>Results</title><p id="Par3">The prevalence of physical multimorbidity and high SB (≥8 h/day) were 45.5% (43.7%–47.4%) and 10.8% (9.7%–12.1%), respectively. The prevalence of high SB increased in a linear fashion from 7.1% in people with no chronic condition to 24.1% in those with ≥4 chronic conditions. In the multivariable analysis, visual impairment (OR = 2.62), stroke (OR = 2.02), chronic back pain (OR = 1.70) hearing problems (OR = 1.58), chronic lung disease (OR = 1.48), asthma (OR = 1.39), arthritis (OR = 1.22) and multimorbidity (OR = 1.41) were significantly associated with high SB. Disability explained more than 50% of the association for all chronic conditions with particularly high percentages (>80%) for arthritis, asthma, and multimorbdity. Mobility problems explained 88.1% and 85.1% of the association of SB with arthritis and physical multimorbidiy, respectively. Pain was highly influential in the SB-arthritis relationship (85.6%). Sleep/energy problems explained between 9.3% (stroke) to 49.1% (arthritis) of the association, and cognitive problems from 21.5% (stroke) to 33.4% (hearing problems). Findings for anxiety and depression were mixed.</p></sec><sec><title>Conclusion</title><p id="Par4">In LMICs, those with chronic conditions and physical multimorbidity are significantly more sedentary. Targeted messages to reduce time spent sedentary among individuals with chronic conditions may ameliorate associated disability, mobility difficulties and pain that are themselves the most important risk factors for SB.</p></sec><sec><title>Electronic supplementary material</title><p>The online version of this article (10.1186/s12966-017-0602-z) contains supplementary material, which is available to authorized users.</p></sec></abstract><kwd-group xml:lang="en"><title>Keywords</title><kwd>Multimorbidity</kwd><kwd>Pain</kwd><kwd>Mobility limitation</kwd><kwd>Sitting</kwd><kwd>Sedentary time</kwd></kwd-group><custom-meta-group><custom-meta><meta-name>issue-copyright-statement</meta-name><meta-value>© The Author(s) 2017</meta-value></custom-meta></custom-meta-group></article-meta></front><body><sec id="Sec1"><title>Background</title><p id="Par11">The average life expectancy is increasing worldwide [<xref ref-type="bibr" rid="CR1">1</xref>]. Irrespective of the socioeconomic development of a country, the main causes of death and disability in middle-aged to older adults (i.e. 50 years or older) are non-communicable diseases (NCDs), many of which often occur in combination [<xref ref-type="bibr" rid="CR2">2</xref>]. The co-occurrence of two or more chronic physical conditions is known as physical multimorbidity [<xref ref-type="bibr" rid="CR3">3</xref>]. With increasing population and life expectancy, the disease burden of physical multimorbidity to both individuals and societies are increasing [<xref ref-type="bibr" rid="CR4">4</xref>]. Although data are scarce, in low- and middle-income countries (LMICs) about half of middle-aged to older adults experience physical multimorbidity (i.e. 2 or more chronic conditions), about 25% have at least three, and about 10% four or more chronic conditions [<xref ref-type="bibr" rid="CR5">5</xref>]. Physical multimorbidity is an important risk concept as it is associated with a lower quality of life [<xref ref-type="bibr" rid="CR6">6</xref>], increased health-care utilization and costs [<xref ref-type="bibr" rid="CR7">7</xref>], and ultimately, higher risk for premature mortality [<xref ref-type="bibr" rid="CR8">8</xref>]. There is a consensus that in the years to come, this disease burden will be greatest in LMICs [<xref ref-type="bibr" rid="CR9">9</xref>], but knowledge on physical multimorbidity from LMICs is limited compared with HICs (95% of the available studies are from HICs), despite the fact that nearly 80% of NCD related deaths occur in LMICs [<xref ref-type="bibr" rid="CR10">10</xref>].</p><p id="Par12">The promotion of physical activity is an essential strategy within the multifaceted care of middle-aged to older adults for the prevention and management of chronic disease and physical multimorbidity [<xref ref-type="bibr" rid="CR11">11</xref>]. Regular physical activity contributes to the primary and secondary prevention of a wide range of chronic diseases [<xref ref-type="bibr" rid="CR12">12</xref>], improves quality of life [<xref ref-type="bibr" rid="CR13">13</xref>], and is associated with reduced risk of premature death [<xref ref-type="bibr" rid="CR14">14</xref>]. There is also increasing evidence demonstrating that sedentary behavior (SB) should be considered in this multifaceted care as it is, irrespective of a person’s physical activity levels, associated with a wide range of deleterious outcomes such as diabetes, stroke and associated premature mortality [<xref ref-type="bibr" rid="CR15">15</xref>]. SB refers to any waking behavior characterized by an energy expenditure ≤1.5 metabolic equivalents (METs), while in a sitting, reclining or lying posture [<xref ref-type="bibr" rid="CR16">16</xref>]. SB is highly prevalent and pervasive in societies across the world [<xref ref-type="bibr" rid="CR17">17</xref>, <xref ref-type="bibr" rid="CR18">18</xref>]. A recent systematic review, virtually exclusively among western societies, demonstrated that middle-aged to older adults spend 65–80% of their waking day being sedentary [<xref ref-type="bibr" rid="CR19">19</xref>].</p><p id="Par13">Research investigating the relationship between SB and chronic diseases has solely focused on high-income countries. In addition, there is a particular dearth of research on SB and physical multimorbidity. In the only study on this topic to date, among 2048 American adults (mean age = 42.7 years; 50.9% male), every 60 min/day increase in SB was associated with an 11% (adjusted OR =1.11; 95%CI = 1.01–1.21; <italic>P</italic> = 0.03) increased odds of being multimorbid (i.e. having ≥2 morbidities) [<xref ref-type="bibr" rid="CR20">20</xref>]. Moreover, the authors found that SB was associated with multimorbidity independent of light-intensity physical activity and adherence to moderate-to-vigorous physical activity guidelines, which underscores the importance of minimizing prolonged SB (in addition to promoting physical activity) in the treatment of multimorbidity.</p><p id="Par14">The lack of nationally representative population-based studies investigating the associations between SB, chronic conditions, and physical multimorbidity in LMICs is an important research gap given the rapid increase in chronic diseases in these countries, mainly due to changes in lifestyle [<xref ref-type="bibr" rid="CR21">21</xref>]. Furthermore, the association between chronic conditions or multimorbidity on SB may differ in LMICs due to different disease profiles [<xref ref-type="bibr" rid="CR22">22</xref>], suboptimal treatment of chronic conditions [<xref ref-type="bibr" rid="CR23">23</xref>, <xref ref-type="bibr" rid="CR24">24</xref>], and differences in knowledge regarding the risks of being sedentary [<xref ref-type="bibr" rid="CR25">25</xref>]. In addition, at the population level, there is a paucity of information on factors that might influence the relationship between SB, chronic diseases and physical multimorbidity. In this study we focused on physical (mobility, disability, pain and discomfort) and mental (cognition, sleep and energy, anxiety and depression) conditions as these variables have all been associated with SB [<xref ref-type="bibr" rid="CR26">26</xref>, <xref ref-type="bibr" rid="CR27">27</xref>] and the presence of chronic conditions [<xref ref-type="bibr" rid="CR5">5</xref>]. Given the aforementioned gaps within the literature, we aimed to assess the association between chronic conditions or physical multimorbidity and SB among community-dwelling adults aged 50 or older in six LMICs, and to assess the factors that might influence this relationship. We hypothesize that higher levels of SB are associated with the presence of chronic conditions and physical multimorbidity.</p></sec><sec id="Sec2"><title>Methods</title><sec id="Sec3"><title>The survey</title><p id="Par15">Data from the SAGE were analyzed. This survey was undertaken in China, Ghana, India, Mexico, Russia, and South Africa between 2007 and 2010. Based on the World Bank classification at the time of the survey, all of these countries were LMICs. Details of the survey methodology have been published elsewhere [<xref ref-type="bibr" rid="CR28">28</xref>]. In brief, in order to obtain nationally representative samples, a multistage clustered sampling design method was used. The sample consisted of adults aged ≥18 years with oversampling of those aged ≥50 years. Trained interviewers conducted face-to-face interviews using a standard questionnaire. Standard translation procedures were undertaken to ensure comparability between countries. If a respondent was unable to undertake the interview because of limited cognitive function, then a separate questionnaire was administered to a proxy respondent. These individuals were not included in the current study. The survey response rate ranged from 51% (Mexico) to 93% (China). Sampling weights were constructed to adjust for the population structure as reported by the United Nations Statistical Division. Ethical approval was obtained from the WHO Ethical Review Committee and local ethics research review boards. Written informed consent was obtained from all participants.</p></sec><sec id="Sec4"><title>Sedentary behaviour (outcome variable)</title><p id="Par16">In order to assess SB, participants were asked to state the total time they usually spent (expressed in minutes per day) sitting or reclining including at work, at home, getting to and from places, or with friends (e.g. sitting at a desk, sitting with friends, travelling in car, bus, train, reading, playing cards or watching television). This did not include time spent sleeping. The variable on SB was used in the analysis as a categorical [<8 (coded 0) or ≥8 h (coded 1) per day] variable. The eight-hour cut-off was chosen as previous research indicated that being sedentary for ≥8 h/day in the general population is associated with a higher risk for premature mortality [<xref ref-type="bibr" rid="CR29">29</xref>].</p></sec><sec id="Sec5"><title>Chronic conditions and physical multimorbidity (exposures)</title><p id="Par17">Eleven chronic physical conditions (angina, arthritis, asthma, chronic back pain, chronic lung disease, diabetes, edentulism, hearing problems, hypertension, stroke, visual impairment) were assessed. Chronic back pain was defined as having had back pain everyday during the last 30 days. Respondents who answered affirmatively to the question “Have you lost all of your natural teeth?” were considered to have edentulism. The participant was considered to have hearing problems if the interviewer observed this condition during the survey. Blood pressure was measured three times with a one-minute interval with the use of a wrist blood pressure monitor (Medistar Wrist Blood Pressure Model S) and the mean value of the three measurements was calculated. Hypertension was defined as having at least one of the following: systolic blood pressure ≥ 140 mmHg; diastolic blood pressure ≥ 90 mmHg; or self-reported diagnosis. Visual impairment was defined as having extreme difficulty in seeing and recognizing a person that the participant knows across the road [<xref ref-type="bibr" rid="CR30">30</xref>]. A validity study showed that this response likely corresponds to WHO definitions of visual impairment (20/60 or 0.48 logMAR) [<xref ref-type="bibr" rid="CR30">30</xref>]. Diabetes and stroke were solely based on lifetime self-reported diagnosis.</p><p id="Par18">For other conditions, the participant was considered to have the condition in the presence of either one of the following: self-reported diagnosis; or symptom-based diagnosis based on algorithms. We used these algorithms, which have been used in previous studies using the same dataset, to detect undiagnosed cases [<xref ref-type="bibr" rid="CR31">31</xref>, <xref ref-type="bibr" rid="CR32">32</xref>]. Specifically, the validated Rose questionnaire was used for angina [<xref ref-type="bibr" rid="CR33">33</xref>], and other previously validated symptom-based algorithms were used for arthritis, asthma, and chronic lung disease [<xref ref-type="bibr" rid="CR31">31</xref>, <xref ref-type="bibr" rid="CR34">34</xref>]. The questions used to assess self-reported diagnosis and the symptom-based algorithms are provided in Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Tables S1 and S2. The total number of chronic conditions was calculated and categorized as 0, 1, 2, 3, and ≥4. Multimorbidity was defined as ≥2 chronic conditions [<xref ref-type="bibr" rid="CR32">32</xref>].</p></sec><sec id="Sec6"><title>Mediators</title><sec id="Sec7"><title>Health status</title><p id="Par19">Health status was evaluated with eight health-related questions pertaining to four health domains including: (a) mobility; (b) pain and discomfort; (c) cognition; and (d) sleep and energy. Each of the four domains corresponds to those in common health related quality of life outcome measures such as the Short Form-12 (SF-12) [<xref ref-type="bibr" rid="CR35">35</xref>], the Health Utilities Index Mark-3 (HUI) [<xref ref-type="bibr" rid="CR36">36</xref>] and the EUROQOL-5D [<xref ref-type="bibr" rid="CR37">37</xref>]. Each domain consists of two questions that assessed health function in the past 30 days. The actual questions can be found in Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Table S3. Each item was scored on a five-point scale ranging from ‘none’ to ‘extreme/cannot do’. For each separate domain, we used factor analysis with polychoric correlations to obtain a factor score which was later converted to scores ranging from 0 to 100 with higher values representing worse health function [<xref ref-type="bibr" rid="CR38">38</xref>, <xref ref-type="bibr" rid="CR39">39</xref>].</p></sec><sec id="Sec8"><title>Anxiety</title><p id="Par20">In accordance with previous publications using a dataset with the identical question, those who claimed to have severe/extreme problems with worry or anxiety in the past 30 days were considered to have anxiety [<xref ref-type="bibr" rid="CR40">40</xref>, <xref ref-type="bibr" rid="CR41">41</xref>].</p></sec><sec id="Sec9"><title>Depression</title><p id="Par21">Questions based on the World Mental Health Survey version of the Composite International Diagnostic Interview [<xref ref-type="bibr" rid="CR42">42</xref>] were used for the endorsement of past 12-month DSM-IV depression using the same algorithm used in previous studies using the same dataset [<xref ref-type="bibr" rid="CR32">32</xref>, <xref ref-type="bibr" rid="CR43">43</xref>] (Details provided in Additional file <xref rid="MOESM1" ref-type="media">1</xref>: Table S4).</p></sec><sec id="Sec10"><title>Disability</title><p id="Par22">Disability was assessed by the use of the 12-item validated version of the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) [<xref ref-type="bibr" rid="CR44">44</xref>]. Item Response Theory analysis was used to create a scale ranging from 0 (no disability) to 100 (maximum disability) [<xref ref-type="bibr" rid="CR45">45</xref>].</p></sec></sec><sec id="Sec11"><title>Control variables</title><p id="Par23">These included sex, age, wealth, highest level of education achieved (≤primary, secondary, ≥tertiary), setting (urban or rural), living arrangement (alone or not), and employment status (engaged in paid work ≥2 days in last 7 days: Y/N). Wealth quintiles were created based on country-specific income.</p></sec><sec id="Sec12"><title>Statistical analysis</title><p id="Par24">The statistical analysis was performed with Stata 14.1 (Stata Corp LP, College station, Texas). The analysis was restricted to those aged ≥50 years given the high prevalence of chronic physical conditions in this age group. We conducted multivariable logistic regression analysis to assess the association between the number of chronic conditions including physical multimorbidity (≥2 chronic physical conditions) or each of the 11 chronic conditions (exposure variables) and sedentary behavior (outcome). Analyses using the overall sample and by age groups (50–64, ≥65 years) was done. Next, in order to gain an understanding of the extent to which various factors may explain the relation of individual chronic conditions and physical multimorbidity with SB, we conducted mediation analysis using the overall sample. We did not conduct this analysis for angina, diabetes, edentulism, and hypertension as these conditions were not significantly associated with SB in the overall sample. We focused on anxiety, cognition, depression, disability, mobility, pain/discomfort, and sleep/energy for their previously reported association with the exposure (chronic physical conditions) and the outcome (sedentary behavior). We used the <italic>khb</italic> (Karlson Holm Breen) command in Stata [<xref ref-type="bibr" rid="CR46">46</xref>] for this purpose. This method can be applied in logistic regression models and decomposes the total effect (i.e., unadjusted for the influential factor) of a variable into direct (i.e. the effect of chronic conditions or multimorbidity on SB adjusted for the factor) and indirect effects (i.e. the mediational effect). Using this method, the percentage of the main association explained by the mediator can also be calculated. Each potential mediator was included in the model individually. All regression analyses were adjusted for sex, age, education, wealth, setting, unemployment, living arrangement, and country. Country adjustment was done by including dummy variables for each country. When the individual chronic conditions were the exposure variable, the models were also adjusted for the presence of other chronic illness to account for comorbid chronic conditions. This variable included information on whether the individual had any of the other ten chronic conditions (Y/N). All variables were included in the models as categorical variables with the exception of age, pain/discomfort, cognition, sleep/energy, and disability (continuous variables). Under 5% of the data were missing for the variables used in the analysis. Complete-case analysis was done. The sample weighting and the complex study design were taken into account in the analyses. Results from the regression analyses are presented as odds ratios (ORs) with 95% confidence intervals (CIs). The level of statistical significance was set at <italic>P</italic> < 0.05.</p></sec></sec><sec id="Sec13"><title>Results</title><p id="Par25">The final analytical sample consisted of 34,129 individuals (China <italic>n</italic> = 13,175; Ghana <italic>n</italic> = 4305; India <italic>n</italic> = 6560; Mexico <italic>n</italic> = 2313; Russia <italic>n</italic> = 3938; South Africa <italic>n</italic> = 3838) aged ≥50 years. The median (IQR) age was 62 (55–70) years and 47.9% were males. The prevalence of physical multimorbidity and high SB (i.e. ≥8 h/day) were 45.5% (43.7%–47.4%) and 10.8% (9.7%–12.1%), respectively (Table <xref rid="Tab1" ref-type="table">1</xref>).<table-wrap id="Tab1"><label>Table 1</label><caption><p>Sample characteristics (overall and by highly sedentary behavior)</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th></th><th></th><th colspan="2">Highly sedentary behavior<sup>a</sup></th></tr><tr><th>Characteristic</th><th>Category</th><th>N</th><th>Overall</th><th>No</th><th>Yes</th></tr></thead><tbody><tr><td rowspan="5">Number of chronic conditions</td><td>0</td><td>6624</td><td>22.2</td><td>23.2</td><td>14.6</td></tr><tr><td>1</td><td>11,437</td><td>32.3</td><td>33.3</td><td>24.1</td></tr><tr><td>2</td><td>7430</td><td>22.4</td><td>22.6</td><td>20.7</td></tr><tr><td>3</td><td>3880</td><td>12.2</td><td>11.7</td><td>16.4</td></tr><tr><td>≥4</td><td>3214</td><td>10.9</td><td>9.2</td><td>24.1</td></tr><tr><td colspan="6">Sociodemographics</td></tr><tr><td> Age (years)</td><td>Median (IQR)</td><td></td><td>62 (55–70)</td><td>61 (55–70)</td><td>67 (58–75)</td></tr><tr><td> Sex</td><td>Male</td><td>15,666</td><td>47.9</td><td>48.4</td><td>45.1</td></tr><tr><td rowspan="3"> Education</td><td>≤Primary</td><td>21,264</td><td>57.4</td><td>58.8</td><td>47.7</td></tr><tr><td>Secondary</td><td>9943</td><td>35.2</td><td>34.1</td><td>41.8</td></tr><tr><td>≥Tertiary</td><td>2189</td><td>7.4</td><td>7.1</td><td>10.5</td></tr><tr><td rowspan="5"> Wealth</td><td>Poorest</td><td>6496</td><td>17.1</td><td>16.6</td><td>20.7</td></tr><tr><td>Poorer</td><td>6697</td><td>19.0</td><td>18.5</td><td>21.7</td></tr><tr><td>Middle</td><td>6648</td><td>19.5</td><td>19.6</td><td>19.1</td></tr><tr><td>Richer</td><td>7009</td><td>21.3</td><td>21.8</td><td>18.0</td></tr><tr><td>Richest</td><td>7147</td><td>23.1</td><td>23.5</td><td>20.5</td></tr><tr><td> Setting</td><td>Urban</td><td>17,115</td><td>46.2</td><td>45.4</td><td>51.5</td></tr><tr><td> Unemployed</td><td>Yes</td><td>20,134</td><td>57.3</td><td>55.7</td><td>70.9</td></tr><tr><td> Living arrangement</td><td>Alone</td><td>3608</td><td>10.0</td><td>8.8</td><td>18.8</td></tr><tr><td colspan="6">Chronic physical conditions</td></tr><tr><td> Angina</td><td>Yes</td><td>4921</td><td>17.6</td><td>16.4</td><td>25.5</td></tr><tr><td> Arthritis</td><td>Yes</td><td>9514</td><td>29.5</td><td>28.5</td><td>37.3</td></tr><tr><td> Asthma</td><td>Yes</td><td>2390</td><td>7.9</td><td>7.5</td><td>10.7</td></tr><tr><td> Chronic back pain</td><td>Yes</td><td>2543</td><td>8.6</td><td>7.7</td><td>15.9</td></tr><tr><td> Chronic lung disease</td><td>Yes</td><td>4477</td><td>15.8</td><td>14.5</td><td>25.2</td></tr><tr><td> Diabetes</td><td>Yes</td><td>2647</td><td>6.8</td><td>6.7</td><td>8.4</td></tr><tr><td> Edentulism</td><td>Yes</td><td>4124</td><td>12.9</td><td>12.1</td><td>19.7</td></tr><tr><td> Hearing problems</td><td>Yes</td><td>2075</td><td>5.6</td><td>4.9</td><td>11.1</td></tr><tr><td> Hypertension</td><td>Yes</td><td>20,141</td><td>55.0</td><td>54.0</td><td>61.9</td></tr><tr><td> Stroke</td><td>Yes</td><td>1190</td><td>3.0</td><td>2.6</td><td>7.0</td></tr><tr><td> Visual impairment</td><td>Yes</td><td>353</td><td>1.3</td><td>1.0</td><td>3.3</td></tr><tr><td colspan="6">Health status</td></tr><tr><td> Mobility</td><td>Median (IQR)</td><td></td><td>27 (0–58)</td><td>27 (0–51)</td><td>51 (27–73)</td></tr><tr><td> Pain/discomfort</td><td>Median (IQR)</td><td></td><td>36 (0–56)</td><td>36 (0–46)</td><td>36 (18–56)</td></tr><tr><td> Cognition</td><td>Median (IQR)</td><td></td><td>50 (40–69)</td><td>31 (0–50)</td><td>41 (20–60)</td></tr><tr><td> Sleep/energy</td><td>Median (IQR)</td><td></td><td>20 (0–49)</td><td>20 (0–40)</td><td>40 (0–59)</td></tr><tr><td colspan="6">Other variables</td></tr><tr><td> Disability</td><td>Median (IQR)</td><td></td><td>11 (3–31)</td><td>11 (3–28)</td><td>25 (8–47)</td></tr><tr><td> Anxiety</td><td>Yes</td><td>2046</td><td>8.1</td><td>7.5</td><td>13.6</td></tr><tr><td> Depression</td><td>Yes</td><td>1692</td><td>6.0</td><td>5.8</td><td>8.7</td></tr></tbody></table><table-wrap-foot><p><italic>Abbreviation: IQR</italic> Interquartile range</p><p>Data are column percentages unless otherwise stated</p><p>Estimates are based on weighted sample</p><p><sup>a</sup>Highly sedentary behavior referred to being sedentary for ≥8 h/day</p></table-wrap-foot></table-wrap></p><p id="Par26">The prevalence of high SB increased in a linear fashion with an increasing number of chronic conditions ranging from 7.1% in people with no chronic condition to 24.1% in those with 4 or more chronic conditions (Fig. <xref rid="Fig1" ref-type="fig">1</xref>).<fig id="Fig1"><label>Fig. 1</label><caption><p>Prevalence of highly sedentary behavior by number of chronic physical conditions. Estimates are based on weighted sample. Bars denote 95% confidence intervals. Highly sedentary behavior referred to being sedentary for ≥8 hours/day.</p></caption><graphic xlink:href="12966_2017_602_Fig1_HTML" id="MO1"></graphic></fig></p><p id="Par27">The results of the multivariable logistic regression analysis assessing the association between chronic conditions or physical multimorbidity and high SB are presented in Table <xref rid="Tab2" ref-type="table">2</xref>. In the overall sample, visual impairment (OR = 2.62), stroke (OR = 2.02), chronic back pain (OR = 1.70) hearing problems (OR = 1.58), chronic lung disease (OR = 1.48), asthma (OR = 1.39), arthritis (OR = 1.22), and physical multimorbidity (OR = 1.41) were significantly associated with high SB. When the analysis was stratified by age groups, arthritis, chronic back pain, hearing problems, and visual impairment, and physical multimorbidity were only significantly associated with high SB in the older age group, while asthma was only associated with high SB in the middle-aged group (<italic>P</italic> < 0.05). In terms of the number of chronic conditions, in the overall sample, compared to those who no chronic conditions, the presence of one or 2 chronic conditions was not significantly associated with high SB but the presence of 3 (OR = 1.55; <italic>p</italic> < 0.001) and 4 or more (OR = 2.22; p < 0.001) was associated with high SB. When stratified by age groups, in those aged 65 years or older, having 2 chronic conditions was significantly associated with higher odds (OR = 1.67) for high SB, while this odds increased to 2.36 and 2.98 for the presence of 3 and 4 or more chronic conditions, respectively (<italic>P</italic> < 0.001).<table-wrap id="Tab2"><label>Table 2</label><caption><p>Associations of chronic conditions, multimorbidity, and number of chronic conditions with highly sedentary behavior (outcome) estimated by multivariable logistic regression</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th>Overall</th><th>50–64 years</th><th>≥65 years</th></tr></thead><tbody><tr><td>Angina</td><td>Yes vs. No</td><td>1.04 [0.83,1.31]</td><td>1.00 [0.71,1.41]</td><td>1.10 [0.84,1.45]</td></tr><tr><td>Arthritis</td><td>Yes vs. No</td><td>1.22* [1.03,1.44]</td><td>1.17 [0.92,1.49]</td><td>1.33* [1.07,1.67]</td></tr><tr><td>Asthma</td><td>Yes vs. No</td><td>1.39* [1.07,1.80]</td><td>1.59* [1.02,2.47]</td><td>1.24 [0.95,1.61]</td></tr><tr><td>Chronic back pain</td><td>Yes vs. No</td><td>1.70*** [1.37,2.11]</td><td>1.38 [0.98,1.95]</td><td>1.87*** [1.43,2.44]</td></tr><tr><td>Chronic lung disease</td><td>Yes vs. No</td><td>1.48*** [1.19,1.85]</td><td>1.69*** [1.26,2.26]</td><td>1.38* [1.05,1.82]</td></tr><tr><td>Diabetes</td><td>Yes vs. No</td><td>1.15 [0.93,1.44]</td><td>1.24 [0.89,1.72]</td><td>1.15 [0.88,1.49]</td></tr><tr><td>Edentulism</td><td>Yes vs. No</td><td>1.11 [0.86,1.43]</td><td>0.87 [0.61,1.26]</td><td>1.14 [0.84,1.54]</td></tr><tr><td>Hearing problems</td><td>Yes vs. No</td><td>1.58*** [1.23,2.02]</td><td>1.20 [0.68,2.11]</td><td>1.54** [1.16,2.03]</td></tr><tr><td>Hypertension</td><td>Yes vs. No</td><td>0.98 [0.85,1.14]</td><td>0.98 [0.79,1.22]</td><td>1.03 [0.85,1.26]</td></tr><tr><td>Stroke</td><td>Yes vs. No</td><td>2.02*** [1.53,2.67]</td><td>2.20*** [1.46,3.32]</td><td>2.09*** [1.46,3.00]</td></tr><tr><td>Visual impairment</td><td>Yes vs. No</td><td>2.62*** [1.75,3.93]</td><td>2.11 [0.86,5.19]</td><td>2.45*** [1.52,3.95]</td></tr><tr><td>Multimorbidity<sup>a</sup></td><td>Yes vs. No</td><td>1.41*** [1.19,1.66]</td><td>1.17 [0.93,1.48]</td><td>1.81*** [1.39,2.36]</td></tr><tr><td rowspan="5">Number of chronic conditions</td><td>0</td><td>1.00</td><td>1.00</td><td>1.00</td></tr><tr><td>1</td><td>1.09 [0.88,1.37]</td><td>1.07 [0.82,1.40]</td><td>1.35 [0.97,1.88]</td></tr><tr><td>2</td><td>1.16 [0.93,1.46]</td><td>1.01 [0.75,1.36]</td><td>1.67* [1.07,2.61]</td></tr><tr><td>3</td><td>1.55*** [1.21,1.98]</td><td>1.10 [0.69,1.74]</td><td>2.36*** [1.58,3.52]</td></tr><tr><td>≥4</td><td>2.22*** [1.68,2.94]</td><td>2.26*** [1.44,3.53]</td><td>2.98*** [1.96,4.51]</td></tr></tbody></table><table-wrap-foot><p>Data are odds ratio [95% confidence interval]</p><p>Highly sedentary behavior referred to being sedentary for ≥8 h/day</p><p>Models are adjusted for sex, age, education, wealth, setting, unemployment, living arrangement, and country. For individual chronic conditions, the models were also adjusted for the presence of other chronic conditions</p><p>* <italic>p</italic> < 0.05, ** <italic>p</italic> < 0.01, *** <italic>p</italic> < 0.001</p><p><sup>a</sup>Multimorbidity was defined as ≥2 chronic conditions</p></table-wrap-foot></table-wrap></p><p id="Par28">The results of the mediation analysis among those aged ≥50 years are shown in Tables <xref rid="Tab3" ref-type="table">3</xref> and <xref rid="Tab4" ref-type="table">4</xref>.<table-wrap id="Tab3"><label>Table 3</label><caption><p>Mental health (anxiety, cognition, depression, sleep/energy) variables as mediators in the association between chronic conditions (multimorbidity) and highly sedentary behavior among adults aged ≥50 years</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th colspan="2">Total effect</th><th colspan="2">Direct effect</th><th colspan="2">Indirect effect</th><th></th></tr><tr><th>Exposure</th><th>Mediator</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>% Mediated</th></tr></thead><tbody><tr><td rowspan="4">Arthritis</td><td>Anxiety</td><td>1.22 [1.04,1.45]</td><td>0.017</td><td>1.21 [1.03,1.43]</td><td>0.023</td><td>1.01 [1.00,1.02]</td><td>0.064</td><td>NA</td></tr><tr><td>Cognition</td><td>1.23 [1.04,1.46]</td><td>0.014</td><td>1.15 [0.97,1.37]</td><td>0.108</td><td>1.07 [1.04,1.10]</td><td><0.001</td><td>32.8</td></tr><tr><td>Depression</td><td>1.22 [1.04,1.45]</td><td>0.018</td><td>1.21 [1.02,1.43]</td><td>0.030</td><td>1.02 [1.01,1.03]</td><td>0.003</td><td>7.7</td></tr><tr><td>Sleep/energy</td><td>1.23 [1.04,1.45]</td><td>0.017</td><td>1.11 [0.94,1.31]</td><td>0.225</td><td>1.11 [1.07,1.14]</td><td><0.001</td><td>49.1</td></tr><tr><td rowspan="4">Asthma</td><td>Anxiety</td><td>1.38 [1.06,1.81]</td><td>0.017</td><td>1.30 [0.99,1.70]</td><td>0.059</td><td>1.06 [1.03,1.10]</td><td><0.001</td><td>19.3</td></tr><tr><td>Cognition</td><td>1.40 [1.07,1.83]</td><td>0.014</td><td>1.27 [0.97,1.66]</td><td>0.082</td><td>1.10 [1.06,1.14]</td><td><0.001</td><td>28.7</td></tr><tr><td>Depression</td><td>1.39 [1.06,1.81]</td><td>0.016</td><td>1.33 [1.02,1.74]</td><td>0.036</td><td>1.04 [1.02,1.07]</td><td>0.003</td><td>13.2</td></tr><tr><td>Sleep/energy</td><td>1.38 [1.07,1.79]</td><td>0.014</td><td>1.21 [0.93,1.56]</td><td>0.155</td><td>1.15 [1.10,1.20]</td><td><0.001</td><td>42.3</td></tr><tr><td rowspan="4">Chronic back pain</td><td>Anxiety</td><td>1.71 [1.36,2.14]</td><td><0.001</td><td>1.61 [1.28,2.03]</td><td><0.001</td><td>1.06 [1.03,1.09]</td><td><0.001</td><td>10.6</td></tr><tr><td>Cognition</td><td>1.74 [1.38,2.18]</td><td><0.001</td><td>1.48 [1.18,1.86]</td><td>0.001</td><td>1.17 [1.12,1.23]</td><td><0.001</td><td>28.7</td></tr><tr><td>Depression</td><td>1.71 [1.37,2.14]</td><td><0.001</td><td>1.65 [1.32,2.07]</td><td><0.001</td><td>1.03 [1.01,1.06]</td><td>0.003</td><td>6.2</td></tr><tr><td>Sleep/energy</td><td>1.70 [1.36,2.13]</td><td><0.001</td><td>1.50 [1.19,1.89]</td><td>0.001</td><td>1.13 [1.08,1.18]</td><td><0.001</td><td>23.6</td></tr><tr><td rowspan="4">Chronic lung disease</td><td>Anxiety</td><td>1.48 [1.18,1.85]</td><td>0.001</td><td>1.39 [1.11,1.74]</td><td>0.005</td><td>1.07 [1.04,1.10]</td><td><0.001</td><td>16.4</td></tr><tr><td>Cognition</td><td>1.48 [1.19,1.84]</td><td><0.001</td><td>1.33 [1.07,1.66]</td><td>0.011</td><td>1.11 [1.08,1.15]</td><td><0.001</td><td>27.6</td></tr><tr><td>Depression</td><td>1.48 [1.19,1.85]</td><td>0.001</td><td>1.43 [1.15,1.79]</td><td>0.001</td><td>1.03 [1.01,1.05]</td><td>0.002</td><td>8.2</td></tr><tr><td>Sleep/energy</td><td>1.49 [1.19,1.85]</td><td><0.001</td><td>1.32 [1.06,1.65]</td><td>0.013</td><td>1.13 [1.08,1.17]</td><td><0.001</td><td>29.9</td></tr><tr><td rowspan="4">Hearing problems</td><td>Anxiety</td><td>1.58 [1.24,2.03]</td><td><0.001</td><td>1.54 [1.21,1.97]</td><td>0.001</td><td>1.03 [1.00,1.05]</td><td>0.036</td><td>6.0</td></tr><tr><td>Cognition</td><td>1.60 [1.24,2.05]</td><td><0.001</td><td>1.36 [1.06,1.75]</td><td>0.015</td><td>1.17 [1.12,1.22]</td><td><0.001</td><td>33.4</td></tr><tr><td>Depression</td><td>1.57 [1.22,2.02]</td><td>0.001</td><td>1.57 [1.21,2.02]</td><td>0.001</td><td>1.00 [0.99,1.02]</td><td>0.842</td><td>NA</td></tr><tr><td>Sleep/energy</td><td>1.59 [1.24,2.05]</td><td><0.001</td><td>1.50 [1.17,1.94]</td><td>0.002</td><td>1.06 [1.03,1.09]</td><td><0.001</td><td>12.2</td></tr><tr><td rowspan="4">Stroke</td><td>Anxiety</td><td>2.02 [1.52,2.69]</td><td><0.001</td><td>1.97 [1.48,2.61]</td><td><0.001</td><td>1.03 [1.00,1.06]</td><td>0.054</td><td>NA</td></tr><tr><td>Cognition</td><td>2.03 [1.56,2.66]</td><td><0.001</td><td>1.75 [1.33,2.29]</td><td><0.001</td><td>1.16 [1.11,1.23]</td><td><0.001</td><td>21.5</td></tr><tr><td>Depression</td><td>2.03 [1.54,2.66]</td><td><0.001</td><td>2.00 [1.52,2.63]</td><td><0.001</td><td>1.01 [1.00,1.03]</td><td>0.112</td><td>NA</td></tr><tr><td>Sleep/energy</td><td>2.03 [1.56,2.64]</td><td><0.001</td><td>1.90 [1.46,2.48]</td><td><0.001</td><td>1.07 [1.03,1.11]</td><td><0.001</td><td>9.3</td></tr><tr><td rowspan="4">Visual impairment</td><td>Anxiety</td><td>2.64 [1.75,3.99]</td><td><0.001</td><td>2.10 [1.38,3.21]</td><td>0.001</td><td>1.26 [1.13,1.39]</td><td><0.001</td><td>23.5</td></tr><tr><td>Cognition</td><td>2.66 [1.73,4.10]</td><td><0.001</td><td>1.97 [1.27,3.06]</td><td>0.002</td><td>1.35 [1.23,1.48]</td><td><0.001</td><td>30.7</td></tr><tr><td>Depression</td><td>2.60 [1.73,3.91]</td><td><0.001</td><td>2.43 [1.62,3.65]</td><td><0.001</td><td>1.07 [1.02,1.12]</td><td>0.009</td><td>6.9</td></tr><tr><td>Sleep/energy</td><td>2.64 [1.75,3.99]</td><td><0.001</td><td>2.29 [1.51,3.47]</td><td><0.001</td><td>1.15 [1.08,1.23]</td><td><0.001</td><td>14.6</td></tr><tr><td rowspan="4">Multimorbidity<sup>a</sup></td><td>Anxiety</td><td>1.41 [1.20,1.67]</td><td><0.001</td><td>1.36 [1.15,1.60]</td><td><0.001</td><td>1.04 [1.02,1.06]</td><td><0.001</td><td>11.5</td></tr><tr><td>Cognition</td><td>1.40 [1.19,1.65]</td><td><0.001</td><td>1.24 [1.05,1.47]</td><td>0.012</td><td>1.12 [1.09,1.16]</td><td><0.001</td><td>35.0</td></tr><tr><td>Depression</td><td>1.41 [1.19,1.66]</td><td><0.001</td><td>1.37 [1.16,1.62]</td><td><0.001</td><td>1.03 [1.01,1.04]</td><td>0.001</td><td>7.5</td></tr><tr><td>Sleep/energy</td><td>1.40 [1.19,1.66]</td><td><0.001</td><td>1.23 [1.05,1.45]</td><td>0.012</td><td>1.14 [1.09,1.19]</td><td><0.001</td><td>38.1</td></tr></tbody></table><table-wrap-foot><p><italic>Abbreviation</italic>: <italic>OR</italic> Odds ratio, <italic>CI</italic> Confidence interval</p><p>Highly sedentary behavior referred to being sedentary for ≥8 h/day</p><p>Models are adjusted for sex, age, education, wealth, setting, unemployment, living arrangement, and country. For individual chronic conditions, the models were also adjusted for the presence of other chronic conditions</p><p>The mediated percentage was only calculated in the presence of a significant indirect effect (<italic>P</italic> < 0.05)</p><p><sup>a</sup>Multimorbidity was defined as ≥2 chronic conditions</p></table-wrap-foot></table-wrap><table-wrap id="Tab4"><label>Table 4</label><caption><p>Disability, mobility, and pain/discomfort as mediators in the association between chronic conditions (multimorbidity) and highly sedentary behavior among adults aged ≥50 years</p></caption><table frame="hsides" rules="groups"><thead><tr><th></th><th></th><th colspan="2">Total effect</th><th colspan="2">Direct effect</th><th colspan="2">Indirect effect</th><th></th></tr><tr><th>Exposure</th><th>Mediator</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>OR [95% CI]</th><th><italic>P</italic>-value</th><th>% Mediated</th></tr></thead><tbody><tr><td rowspan="3">Arthritis</td><td>Disability</td><td>1.23 [1.04,1.46]</td><td>0.017</td><td>1.04 [0.87,1.24]</td><td>0.670</td><td>1.18 [1.14,1.23]</td><td><0.001</td><td>81.6</td></tr><tr><td>Mobility</td><td>1.23 [1.04,1.45]</td><td>0.015</td><td>1.02 [0.86,1.22]</td><td>0.780</td><td>1.20 [1.15,1.25]</td><td><0.001</td><td>88.1</td></tr><tr><td>Pain/discomfort</td><td>1.23 [1.04,1.46]</td><td>0.016</td><td>1.03 [0.87,1.22]</td><td>0.732</td><td>1.19 [1.14,1.25]</td><td><0.001</td><td>85.6</td></tr><tr><td rowspan="3">Asthma</td><td>Disability</td><td>1.41 [1.07,1.85]</td><td>0.014</td><td>1.07 [0.81,1.41]</td><td>0.638</td><td>1.32 [1.24,1.40]</td><td><0.001</td><td>80.6</td></tr><tr><td>Mobility</td><td>1.41 [1.08,1.84]</td><td>0.011</td><td>1.12 [0.86,1.45]</td><td>0.413</td><td>1.27 [1.20,1.33]</td><td><0.001</td><td>68.4</td></tr><tr><td>Pain/discomfort</td><td>1.41 [1.08,1.84]</td><td>0.011</td><td>1.21 [0.93,1.58]</td><td>0.158</td><td>1.17 [1.11,1.22]</td><td><0.001</td><td>44.5</td></tr><tr><td rowspan="3">Chronic back pain</td><td>Disability</td><td>1.71 [1.35,2.17]</td><td><0.001</td><td>1.28 [1.02,1.60]</td><td>0.035</td><td>1.34 [1.26,1.43]</td><td><0.001</td><td>54.7</td></tr><tr><td>Mobility</td><td>1.75 [1.38,2.22]</td><td><0.001</td><td>1.36 [1.08,1.72]</td><td>0.009</td><td>1.29 [1.22,1.36]</td><td><0.001</td><td>44.9</td></tr><tr><td>Pain/discomfort</td><td>1.73 [1.37,2.17]</td><td><0.001</td><td>1.36 [1.09,1.69]</td><td>0.007</td><td>1.27 [1.19,1.36]</td><td><0.001</td><td>43.8</td></tr><tr><td rowspan="3">Chronic lung disease</td><td>Disability</td><td>1.49 [1.19,1.86]</td><td><0.001</td><td>1.16 [0.93,1.45]</td><td>0.191</td><td>1.28 [1.22,1.35]</td><td><0.001</td><td>62.5</td></tr><tr><td>Mobility</td><td>1.50 [1.21,1.87]</td><td><0.001</td><td>1.19 [0.96,1.46]</td><td>0.110</td><td>1.27 [1.21,1.33]</td><td><0.001</td><td>58.1</td></tr><tr><td>Pain/discomfort</td><td>1.49 [1.20,1.85]</td><td><0.001</td><td>1.27 [1.02,1.58]</td><td>0.032</td><td>1.18 [1.12,1.23]</td><td><0.001</td><td>40.4</td></tr><tr><td rowspan="3">Hearing problems</td><td>Disability</td><td>1.58 [1.21,2.05]</td><td>0.001</td><td>1.19 [0.91,1.55]</td><td>0.194</td><td>1.32 [1.24,1.42]</td><td><0.001</td><td>61.4</td></tr><tr><td>Mobility</td><td>1.60 [1.23,2.07]</td><td><0.001</td><td>1.35 [1.04,1.75]</td><td>0.024</td><td>1.18 [1.13,1.24]</td><td><0.001</td><td>35.8</td></tr><tr><td>Pain/discomfort</td><td>1.59 [1.23,2.05]</td><td><0.001</td><td>1.46 [1.13,1.87]</td><td>0.003</td><td>1.09 [1.05,1.13]</td><td><0.001</td><td>18.6</td></tr><tr><td rowspan="3">Stroke</td><td>Disability</td><td>2.01 [1.52,2.67]</td><td><0.001</td><td>1.40 [1.04,1.87]</td><td>0.026</td><td>1.44 [1.32,1.58]</td><td><0.001</td><td>52.3</td></tr><tr><td>Mobility</td><td>2.02 [1.54,2.65]</td><td><0.001</td><td>1.48 [1.12,1.98]</td><td>0.007</td><td>1.36 [1.27,1.46]</td><td><0.001</td><td>43.8</td></tr><tr><td>Pain/discomfort</td><td>2.04 [1.57,2.66]</td><td><0.001</td><td>1.83 [1.41,2.39]</td><td><0.001</td><td>1.11 [1.07,1.17]</td><td><0.001</td><td>15.2</td></tr><tr><td rowspan="3">Visual impairment</td><td>Disability</td><td>2.79 [1.85,4.22]</td><td><0.001</td><td>1.35 [0.88,2.05]</td><td>0.165</td><td>2.08 [1.77,2.43]</td><td><0.001</td><td>71.1</td></tr><tr><td>Mobility</td><td>2.76 [1.80,4.25]</td><td><0.001</td><td>1.79 [1.16,2.74]</td><td>0.008</td><td>1.55 [1.40,1.71]</td><td><0.001</td><td>43.0</td></tr><tr><td>Pain/discomfort</td><td>2.68 [1.77,4.06]</td><td><0.001</td><td>2.09 [1.38,3.17]</td><td>0.001</td><td>1.28 [1.19,1.39]</td><td><0.001</td><td>25.4</td></tr><tr><td rowspan="3">Multimorbidity<sup>a</sup></td><td>Disability</td><td>1.36 [1.15,1.61]</td><td><0.001</td><td>1.03 [0.87,1.23]</td><td>0.705</td><td>1.32 [1.25,1.39]</td><td><0.001</td><td>89.1</td></tr><tr><td>Mobility</td><td>1.39 [1.18,1.64]</td><td><0.001</td><td>1.05 [0.89,1.24]</td><td>0.570</td><td>1.32 [1.26,1.40]</td><td><0.001</td><td>85.1</td></tr><tr><td>Pain/discomfort</td><td>1.40 [1.18,1.66]</td><td><0.001</td><td>1.14 [0.97,1.35]</td><td>0.119</td><td>1.22 [1.16,1.30]</td><td><0.001</td><td>60.2</td></tr></tbody></table><table-wrap-foot><p><italic>Abbreviation</italic>: <italic>OR</italic> Odds ratio, <italic>CI</italic> Confidence interval</p><p>Highly sedentary behavior referred to being sedentary for ≥8 h/day</p><p>Models are adjusted for sex, age, education, wealth, setting, unemployment, living arrangement, and country. For individual chronic conditions, the models were also adjusted for the presence of other chronic conditions</p><p>The mediated percentage was only calculated in the presence of a significant indirect effect (<italic>P</italic> < 0.05)</p><p><sup>a</sup>Multimorbidity was defined as ≥2 chronic conditions</p></table-wrap-foot></table-wrap></p><p id="Par29">For the individual chronic conditions, anxiety did not explain the association of high SB with arthritis and stroke while for other conditions it explained from 6.0% (hearing problems) to 23.5% (visual impairment) of the association. Cognitive problems explained the relationship from 21.5% (stroke) to 33.4% (hearing problems). Depression was not an influential factor in the association of high SB with hearing problems and stroke, while it explained between 6.2% (chronic back pain) to 13.2% (asthma) of the association for the other conditions. Sleep/energy problems explained 9.3% (stroke) to 49.1% (arthritis) of the relationship. Disability explained more than 50% of the association for all chronic conditions with particularly high mediated percentages observed for arthritis (81.6%) and asthma (80.6%). Mobility difficulties also explained more than 35% of the association for all chronic conditions with particularly high mediated percentages observed for arthritis (88.1%). Pain was a major influential factor for the association between SB and arthritis (85.6%) and explained between 15.2% (stroke) to 44.5% (asthma) of the association with other conditions.</p><p id="Par30">As for the SB - physical multimorbidity relationship, the most important influential factor was disability (89.1%), followed by mobility (85.1%), pain/discomfort (60.2%), sleep/energy (38.1%), cognition (35.0%), anxiety (11.5%), and depression (7.5%).</p></sec><sec id="Sec14"><title>Discussion</title><sec id="Sec15"><title>General findings</title><p id="Par31">To the best of our knowledge, the current study is the first large-scale (<italic>n</italic> = 34,129), multinational (6 LMICs) analysis investigating associations of SB with chronic conditions and physical multimorbidity. The current data confirm the findings from a previous study conducted in a high-income country showing that SB is associated with a higher risk for physical multimorbidity [<xref ref-type="bibr" rid="CR20">20</xref>]. We found that most chronic conditions were associated with a high SB status (i.e. eight or more hours per day) in the overall sample, although this relationship was most notable among the oldest population (i.e. 65 years or older). Our mediation analysis showed that disability and mobility difficulties were important factors for most of the chronic conditions studied, while pain was a central factor for arthritis. As for physical multimorbidity, disability, mobility difficulties and pain were also important factors mediating high SB. Sleep/energy and cognitive problems explained the relation between SB and each chronic condition to a lesser extent while findings for anxiety, and depression were mixed. The factors identified in our study, which may explain the relationship between chronic conditions and physical multimorbidity with SB, should however be confirmed in prospective studies.</p><p id="Par32">In the overall sample, those with arthritis (OR = 1.22) and chronic back pain (OR = 1.70) were more likely to be sedentary for eight or more hours per day. These relationships appear to be mainly explained by disability, mobility difficulties, and pain while cognitive problems, depressive feelings, and sleep problems may also play a role. In both conditions, pain might cause mobility and sleep problems and ultimately feelings of depression, which in turn can all result in people being more sedentary. Previous literature in Western populations has demonstrated that pain can result in mobility limitations, higher levels of SB [<xref ref-type="bibr" rid="CR47">47</xref>], and depression [<xref ref-type="bibr" rid="CR48">48</xref>]. Clearly, such an interplay of pain, mobility limitations and depression among people with physical multimorbidity could play an even more pronounced role. Next to this, some SBs such as TV viewing, have been linked previously to poorer cognitive function in middle-aged to older adults [<xref ref-type="bibr" rid="CR49">49</xref>], although this is largely drawn from high-income populations. The reason why adults with cognitive problems are more likely to be sedentary is largely unknown, but clearly this warrants further exploration. One possible explanation is that cognitive problems, such as impairments in executive functioning can result in difficulties in planning complex behaviors and consequently there might be an increased risk of falls [<xref ref-type="bibr" rid="CR50">50</xref>]. Falls are on its turn associated with a fear of falling again and avoidance of activities due to this fear, which is also associated with grey matter volume loss [<xref ref-type="bibr" rid="CR51">51</xref>, <xref ref-type="bibr" rid="CR52">52</xref>]. In the case of arthritis, cognitive problems may be linked to SB via comorbid cardiovascular risk factors or systemic inflammatory processes [<xref ref-type="bibr" rid="CR53">53</xref>, <xref ref-type="bibr" rid="CR54">54</xref>]. Sedentary time and the number of sedentary bouts per day (i.e. ≥20 min) are associated with an increased 10-year cardiovascular disease (CVD) risk in people with arthritis, independent of engagement in moderate to vigorous physical activity [<xref ref-type="bibr" rid="CR55">55</xref>].</p><p id="Par33">Our data also suggest that people with asthma were more sedentary (OR = 1.39). It is known that many individuals with asthma avoid physical activities for fear of exacerbating symptoms or triggering physical activity-induced bronchoconstriction [<xref ref-type="bibr" rid="CR56">56</xref>]. Studies have shown that replacing SB with light intensity physical activity can however improve asthma control and asthma-related quality of life [<xref ref-type="bibr" rid="CR56">56</xref>], and is a possible protective factor against asthma development [<xref ref-type="bibr" rid="CR57">57</xref>]. As people with asthma are at an increased risk for mobility problems and musculoskeletal pain [<xref ref-type="bibr" rid="CR58">58</xref>], interventions focusing on reducing this pain, discomfort and mobility problems are probably essential as well to reduce the time spent sedentary. Not only asthma, but also other chronic lung diseases such as chronic obstructive pulmonary disease (COPD) may induce mobility difficulties, pain, or disability. These factors may predispose an individual to be more socially isolated due to their restrictions in ability to conduct activities of daily living or stigmatized as respiratory symptoms are often associated with tuberculosis in LMICs [<xref ref-type="bibr" rid="CR59">59</xref>].</p><p id="Par34">For over a decade, targeting increases in moderate to vigorous physical activity has been the emphasis of a large number of exercise training and behavior change interventions in people with COPD [<xref ref-type="bibr" rid="CR60">60</xref>], but with limited success [<xref ref-type="bibr" rid="CR61">61</xref>]. The lower levels of physical activity coupled with the often fragile physical and psychological health among patients with COPD may make reducing SB a more suitable conduit for behavior change [<xref ref-type="bibr" rid="CR62">62</xref>, <xref ref-type="bibr" rid="CR63">63</xref>]. In our study, people with COPD had 1.48 times higher odds for being sedentary eight or more hours. Recent evidence showed as well that SB is an independent predictor of mortality in subjects with COPD, even adjusting for moderate-to-vigorous physical activity and a number of other variables. Mortality was four times higher in subjects with COPD who spend ≥8.5 h/d in activities requiring <1.5 MET [<xref ref-type="bibr" rid="CR64">64</xref>]. Therefore, there is an urgent need to test interventions to reduce SB including the provision of information about the health consequences of SB [<xref ref-type="bibr" rid="CR65">65</xref>].</p><p id="Par35">Stroke was associated with a 2.0 times higher odds for high SB in our study. A previous qualitative study in Canadian stroke survivors [<xref ref-type="bibr" rid="CR66">66</xref>] demonstrated that there is also limited awareness of health risks of SB among stroke survivors.</p><p id="Par36">Finally, we also found significant associations between highly sedentary status and hearing problems and visual impairments. Hearing problems [<xref ref-type="bibr" rid="CR67">67</xref>] and visual impairments [<xref ref-type="bibr" rid="CR68">68</xref>] should therefore be considered as important risk conditions for SB in LMICs. Stigma and discrimination associated with these chronic conditions and a lack of social support may complicate daily life participation in these populations.</p></sec><sec id="Sec16"><title>Practical implications and future research</title><p id="Par37">Our analyses provide further evidence for the need to develop strategies to deal with a sedentary lifestyle in LMICs, and offer important hypotheses for testing in future prospective cohort studies. Our data add to the need to increase awareness among care providers at all levels of care in LMICs of the risks of SB of their patients. Given the evidence in the general population of the benefits of reducing SB, we propose that it is important to test the efficacy and effectiveness of a dual strategy in low resource settings by developing both a smaller group of master trainers/supervisors (e.g. exercise physiologists and physiotherapists) and researchers and a larger group of practitioners (e.g. nurses) who are responsible for minimizing SB in high risk groups. This method has been successfully employed for cognitive behavioral therapy in trials in LMICs [<xref ref-type="bibr" rid="CR69">69</xref>, <xref ref-type="bibr" rid="CR70">70</xref>]. A stepped-care approach, where patients start with self-management in order to reduce their SB, may be a feasible strategy in LMIC settings. Such self-management strategies could, for example, include regular interruptions in sedentary time, such as standing or walking frequently throughout waking hours, during television commercial breaks or while using the phone. Then, if patients do not achieve significant reductions, they could continue with a manualized approach under the supervision of a non-specialist worker (e.g. nurses, occupational therapists). Patients would only be referred to a specialist supervisor (e.g. exercise physiologists and physiotherapists) if no significant reductions occur, for example due to pain, sleep and cognitive problems or mobility problems or associated anxiety and depression. It is known from physical activity research that inclusion of exercise physiologists or physiotherapists reduces dropout rates from lifestyle interventions and consequently improves outcomes [<xref ref-type="bibr" rid="CR71">71</xref>]. Careful consideration of which strategies would be most efficacious, and evaluation of this stepped-care approach, is essential. The current available evidence is, however, mainly based on evidence from high-income countries and showed that lifestyle interventions focusing on light physical activity participation reduced SB by 24 min/day (95%CI = 8 to 41 min/day, <italic>n</italic> = 3981) while in interventions focusing on reducing time spent sedentary only, SB was reduced by 42 min/day (95% CI = 5 to 79 min/day, <italic>n</italic> = 62) [<xref ref-type="bibr" rid="CR72">72</xref>].</p><p id="Par38">Although application of self-monitoring devices and alarms are not easy implementable in low resource settings, a recent International mobile-health Intervention on physical activity, sitting, and weight in adult employees using light-weight, low-cost, non-interactive pedometers as a self-monitoring and motivational tool demonstrated reduction in sedentary time. In a 100-day program, participants were encouraged to increase incidental activity such as using stairs and avoidance of sitting. After 100 days, the time spent sedentary reduced in low-income countries by 0.73 h per day (95% CI = −0.75 to −0.70 h) and by 0.59 h per day 95% CI = −1.08 to −0.10 h) in middle-income countries [<xref ref-type="bibr" rid="CR73">73</xref>].</p><p id="Par39">Efficacy trials of interventions focusing on SB among people with chronic conditions in different cultural settings across LMICs are however urgently needed. If the efficacy and effectiveness of these SB interventions are well established in better equipped scientific settings with trained research staff, the final step will be to fund interventions and initiatives to translate research findings into “real-world” settings while exploring its cost-effectiveness. In order to justify the inclusion of programs focusing on SB reductions as a routine component in the treatment of chronic diseases and multimorbidity in LMICs, cost-benefit analyses should be conducted in order to quantify the financial implications of diverting resources or investing funds into such initiatives. Therefore, next to intervention studies exploring the efficacy of these programs, effectiveness research capable of driving practice change, along with policy-level research, is urgently required. Ministries of health and education will play a critical role in this governance and policy development step. If research shows that reducing SB is efficacious and effective in the prevention and management of chronic diseases and multimorbidity in middle-aged to older adults in LMICs, interventions should be mainstreamed in existing health systems at all levels of care. Finally, since visual impairments and hearing problems are associated with higher levels of SB, future research could explore whether programs providing hearing aids and glasses might assist those in need to become more physically active.</p></sec><sec id="Sec17"><title>Limitations and strengths</title><p id="Par40">The current findings should be interpreted in light of some limitations. First, the study is cross-sectional, and cause and effect cannot be deduced. Therefore, it remains unclear whether SB was caused by chronic conditions or vice versa. For example, SB is known to be a risk factor for cardiovascular diseases, while pain caused by arthritis may cause people to be more sedentary. Second, whilst we included all physical health conditions which were assessed within the SAGE, other physical conditions such as tuberculosis, cancer and HIV may have been present and not identified in the study. Therefore, the prevalence of physical multimorbidity is likely to be an underestimation and it is possible that the association between multimorbidity and SB could have differed if data on more chronic physical conditions were available. Third, since the information on chronic conditions and SB was based on self-report, reporting biases may exist. Future research should utilize objective measures of SB. Accelerometers-inclinometers are available that allow for valid and reliable SB behavior. Fourth, by separating the sample into dichotomous SB categories, we were not able to examine how different quantities of SB may affect morbidity. Finally, the present study did not include institutionalized people, which may limit generalizability at a national level. Nonetheless, the strengths of the study include the multi-national scope focused on LMICs, countries which are not investigated yet in the prior research literature. Additionally, we investigated numerous potentially modifiable factors that can be targeted for future interventions aiming to reduce SB.</p></sec></sec><sec id="Sec18"><title>Conclusions</title><p id="Par41">The current study demonstrates that middle-aged to older adults with chronic conditions and physical multimorbidity are significantly more sedentary. Future longitudinal research is required to confirm the directionality of our results and explore influential factors. In addition, research on the efficacy and effectiveness of reducing SB in the management of chronic diseases and physical multimorbidity in LMICs should be a priority for funding bodies. Clinicians should consider in particular mobility problems, disability and pain as potential barriers but also other mental health issues such as sleep problems and poor cognition.</p></sec></body><back><app-group><app id="App1"><sec id="Sec19"><title>Additional file</title><p id="Par48"><media position="anchor" xlink:href="12966_2017_602_MOESM1_ESM.docx" id="MOESM1"><label>Additional file 1: Table S1.</label><caption><p>Questions used to assess self-reported diagnosis. <bold>Table S2.</bold> Questions and answer options used for symptoms-based diagnosis. <bold>Table S3.</bold> Questions used to assess health status. <bold>Table S4.</bold> Questions and answer options used for endorsement of DSM-IV depression. (DOCX 15 kb)</p></caption></media></p></sec></app></app-group><glossary><title>Abbreviations</title><def-list><def-item><term>CI</term><def><p id="Par5">Confidence interval</p></def></def-item><def-item><term>HICs</term><def><p id="Par6">High-income countries</p></def></def-item><def-item><term>LMICs</term><def><p id="Par7">Low- and middle-income countries</p></def></def-item><def-item><term>OR</term><def><p id="Par8">Odds ratio</p></def></def-item><def-item><term>SAGE</term><def><p id="Par9">Study on Global Ageing and Adult Health</p></def></def-item><def-item><term>SB</term><def><p id="Par10">Sedentary behavior</p></def></def-item></def-list></glossary><fn-group><fn><p><bold>Electronic supplementary material</bold></p><p>The online version of this article (10.1186/s12966-017-0602-z) contains supplementary material, which is available to authorized users.</p></fn></fn-group><ack><title>Acknowledgements</title><p>None.</p><sec id="FPar1"><title>Funding</title><p id="Par42">Brendon Stubbs receives funding from the National Institute for Health Research Collaboration for Leadership in Applied Health Research & Care Funding scheme. Ai Koyanagi’s work is supported by the Miguel Servet contract financed by the CP13/00150 and PI15/00862 projects, integrated into the National R + D + I and funded by the ISCIII - General Branch Evaluation and Promotion of Health Research - and the European Regional Development Fund (ERDF-FEDER). The views expressed in this publication are those of the authors and not necessarily those of the any funding agencies.</p></sec><sec id="FPar2"><title>Availability of data and materials</title><p id="Par43">The datasets generated during and/or analyzed during the current study are available in the Global Ageing and Adult Health Survey repository, available at <ext-link ext-link-type="uri" xlink:href="http://www.who.int/healthinfo/sage/en">http://www.who.int/healthinfo/sage/en</ext-link></p></sec></ack><notes notes-type="author-contribution"><title>Authors’ contributions</title><p>Access to the Study on Global Ageing and Adult Health Survey data collection was obtained by AK and DV. Analyses were performed by AK and BS. DV wrote a first draft which was reviewed and revised in several rounds by the other co-authors. All authors approved the final version and all authors certify that they have participated sufficiently in the work to believe in its overall validity and to take public responsibility for appropriate portions of its content.</p></notes><notes notes-type="COI-statement"><sec id="FPar3"><title>Ethics approval and consent to participate</title><p id="Par44">Ethical approval was obtained from ethical boards at each study site. Participants give written informed consent. Details are available at <ext-link ext-link-type="uri" xlink:href="http://www.who.int/healthinfo/sage/en/">http://www.who.int/healthinfo/sage/en/</ext-link> .</p></sec><sec id="FPar4"><title>Consent for publication</title><p id="Par45">Not applicable.</p></sec><sec id="FPar5"><title>Competing interests</title><p id="Par46">The authors declare that they have no competing interests.</p></sec><sec id="FPar6"><title>Publisher’s Note</title><p id="Par47">Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p></sec></notes><ref-list id="Bib1"><title>References</title><ref id="CR1"><label>1.</label><mixed-citation publication-type="other">World Health Organization: World Health Statistics 2016. Monitoring health for the SDGs sustainable development goals. 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