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Physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events: systematic review and dose-response meta-analysis for the Global Burden of Disease Study 2013

BMJ 2016; 354 doi: (Published 09 August 2016) Cite this as: BMJ 2016;354:i3857
  1. Hmwe H Kyu, acting assistant professor1,
  2. Victoria F Bachman, medical student2,
  3. Lily T Alexander, post bachelor fellow1,
  4. John Everett Mumford, post bachelor fellow1,
  5. Ashkan Afshin, acting assistant professor1,
  6. Kara Estep, project officer II1,
  7. J Lennert Veerman, senior lecturer3,
  8. Kristen Delwiche, medical student4,
  9. Marissa L Iannarone, project officer1,
  10. Madeline L Moyer, systematic reviewer1,
  11. Kelly Cercy, data analyst1,
  12. Theo Vos, professor1,
  13. Christopher J L Murray, professor1,
  14. Mohammad H Forouzanfar, assistant professor1
  1. 1Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle, WA 98121, USA
  2. 2School of Medicine, University of Washington, Seattle, WA 98105, USA
  3. 3School of Public Health, Faculty of Medicine and Biomedical Sciences, University of Queensland, Herston, QLD 4006, Australia
  4. 4Geisel School of Medicine, Dartmouth College, Hanover, NH 03755-1404, USA
  1. Correspondence to: M H Forouzanfar forouzan{at}
  • Accepted 1 July 2016


Objective To quantify the dose-response associations between total physical activity and risk of breast cancer, colon cancer, diabetes, ischemic heart disease, and ischemic stroke events.

Design Systematic review and Bayesian dose-response meta-analysis.

Data sources PubMed and Embase from 1980 to 27 February 2016, and references from relevant systematic reviews. Data from the Study on Global AGEing and Adult Health conducted in China, Ghana, India, Mexico, Russia, and South Africa from 2007 to 2010 and the US National Health and Nutrition Examination Surveys from 1999 to 2011 were used to map domain specific physical activity (reported in included studies) to total activity.

Eligibility criteria for selecting studies Prospective cohort studies examining the associations between physical activity (any domain) and at least one of the five diseases studied.

Results 174 articles were identified: 35 for breast cancer, 19 for colon cancer, 55 for diabetes, 43 for ischemic heart disease, and 26 for ischemic stroke (some articles included multiple outcomes). Although higher levels of total physical activity were significantly associated with lower risk for all outcomes, major gains occurred at lower levels of activity (up to 3000-4000 metabolic equivalent (MET) minutes/week). For example, individuals with a total activity level of 600 MET minutes/week (the minimum recommended level) had a 2% lower risk of diabetes compared with those reporting no physical activity. An increase from 600 to 3600 MET minutes/week reduced the risk by an additional 19%. The same amount of increase yielded much smaller returns at higher levels of activity: an increase of total activity from 9000 to 12 000 MET minutes/week reduced the risk of diabetes by only 0.6%. Compared with insufficiently active individuals (total activity <600 MET minutes/week), the risk reduction for those in the highly active category (≥8000 MET minutes/week) was 14% (relative risk 0.863, 95% uncertainty interval 0.829 to 0.900) for breast cancer; 21% (0.789, 0.735 to 0.850) for colon cancer; 28% (0.722, 0.678 to 0.768) for diabetes; 25% (0.754, 0.704 to 0.809) for ischemic heart disease; and 26% (0.736, 0.659 to 0.811) for ischemic stroke.

Conclusions People who achieve total physical activity levels several times higher than the current recommended minimum level have a significant reduction in the risk of the five diseases studied. More studies with detailed quantification of total physical activity will help to find more precise relative risk estimates for different levels of activity.


  • We thank Belén Zapata Diomedi for her helpful comments on the manuscript; Emmanuela Gakidou for her valuable contribution to the production of the manuscript; Erica L Slepak and Yesenia Roman for their help with the citations of included studies; and Brad Bell for his valuable insights about the DisMod-MR software and the documentation.

  • Contributors: HHK, TV, CJLM, and MHF conceived, designed, and supervised the study. HHK and MLI developed and implemented the literature search strategy. HHK, VFB, MLM, MLI, JEM, KC, TV, and MHF acquired the data, including review of literature search results and data abstraction. HHK, VFB, LTA, KD, JLV, TV, CJLM, and MHF analysed and interpreted the data. HHK, VFB, LTA, AA, TV, and MHF drafted the manuscript, which was critically revised for important intellectual content by all authors. HHK and MHF carried out statistical analysis. KE provided administrative, technical, and material support. TV, CJLM, and MHF are joint senior authors. HHK and MHF are guarantors.

  • Funding: The study was funded by the Bill and Melinda Gates Foundation. The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: The full dataset is available from the corresponding author.

  • Transparency: The lead author affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

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