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Sliding down the risk factor rankings: reasons for and consequences of the dramatic downgrading of physical activity in the Global Burden of Disease 2019
  1. Emmanuel Stamatakis1,
  2. Ding Ding2,
  3. Ulf Ekelund3,4,
  4. Adrian E Bauman2
  1. 1 Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
  2. 2 Prevention Research Collaboration, Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
  3. 3 Department of Sports Medicine, Norwegian School of Sports Sciences, Oslo, Norway
  4. 4 Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
  1. Correspondence to Professor Emmanuel Stamatakis, Charles Perkins Centre, Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2006, Australia; emmanuel.stamatakis{at}

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Published in the Lancet in 2020, the Global Burden of Disease (GBD) 2019 provided updated disease burden rankings for 87 risk factors including behavioural and metabolic risks. GBD 2019 ranked low physical activity 19th out of 20 risk factors in terms of disability-adjusted life years, down from 10th in the equivalent 2010 GBD publication.1 The number of attributable deaths has decreased from 3.2 million in 20101 to approximately 1.2 million in 20192; both estimates are substantially lower than the Lancet 2012 physical activity series estimates (5 million deaths/year).3 GBD authors2 do not comment on this remarkable demotion of physical activity’s ranking in 2019, despite the fact that it contradicts the significant progress in the field of physical activity over the last decade.4 Here, we explore this seemingly counterintuitive downgrade to alert policy makers, health professionals and researchers about the caveats of interpreting GBD data. We also offer suggestions on how to improve future physical activity GBD estimates.

The oversimplified risk factor

Physical activity is a complex multidimensional behaviour whose health effects are determined by its intensity, duration, type (eg, aerobic vs strength training) and domain.4 GBD considered a single physical activity indicator that captures only total volume. This provides a stark contrast with how GBD treated other behaviours such as diet, which was addressed by 15 different risk factor indicators, including a diet low in seafood omega-3 fatty acids intake and low milk intake.2 One immediate consequence of such contrasting approaches was that low physical activity appeared to be a relatively simple, yet unimportant, prevention indicator.

Incomplete capturing of health risks

GBD 2019 calculated low physical activity relative risks using a single and relatively outdated (covering literature to early 2016) internal GBD meta-analysis of 174 studies,5 which addressed only five outcomes: breast and colon cancers, diabetes, ischaemic heart disease and ischaemic stroke. This is also counterintuitive considering the large amount of literature accumulated over several decades consistently linking physical inactivity to dozens of health outcomes, including 13 cancer sites.6 Such a breadth of health outcomes was reviewed by the WHO’s physical activity Guidelines Development Group in 2020,4 and the equivalent US 20187 and UK 2019 initiatives. By contrast, GBD 2019 included 44 new dietary meta-analyses covering a very long list of health outcomes. Moreover, GBD 2019 did not consider the causal influence of physical activity on key intermediate risk factors (eg, elevated blood pressure, body mass index), an omission which may have weakened further the disease burden position of low physical activity.

Black box methods?

GBD 2019 used intense, yet not clearly explained, data curation and analytical methods which are described in nearly 9000 pages of appendices.2 Online supplemental figure 1 summarises the 14-stage physical activity data curation. Other scientists and media workers alike8 have voiced concerns about this ‘black box’ approach as being non-replicable. Methodological opacity is amplified by changes in GBD standards over time, for example, the new Summary Exposure Value (SEV) metric introduced in GBD 2019 which essentially determines the ranking of each factor. SEV takes into account the extent of exposure by risk level and the ‘severity of that risk’s contribution to disease burden’. Using an undocumented method2 and imputed data for an unknown number of countries/territories, GBD 2019 used machine learning to harmonise different questionnaires’ data producing an SEV estimate of 3.5% for low physical activity. Although SEV is not directly comparable with conventional prevalence estimates, the 3.5% SEV value is 1/8 of the global aerobic physical inactivity prevalence estimates (27.5%)9 and 1/24 of the prevalence of physical inactivity when strength exercise is also considered (85.0%).10 In comparison, the SEV for the composite 15 dietary risk factors was 47%, a striking 13 times higher than that of low physical activity.

Supplemental material

How realistic are the GBD relative risks?

The GBD estimates3 are based on the concept of population attributable fractions, which are determined by the prevalence of a risk factor and the risk factor-outcome association (eg, relative risk). Both metrics are determined by what analysts chose as the optimal reference category (eg, lowest-risk physical activity category).

The GBD use methods that deviate substantially from established thresholds for optimal and minimal physical activity: while it is not entirely clear from the published GBD methods, the optimal theoretical minimum-risk (reference) level of physical activity appears to have been set to 8000 MET-minutes per week (equivalent to 5.5 hours of moderate intensity physical activity per day). This amount is 10 times higher than the latest accelerometry-based data indicating that the optimal protection against all-cause mortality occurs at 800 MET-minutes per week.11 The GBD relative risk calculations involved comparisons of the 8000 MET-minutes per week reference level with the also GBD-defined low physical activity (<4000 MET-hours per week, equivalent to 2.7 hours of moderate intensity physical activity per day), which is nearly six times the WHO-defined minimum physical activity threshold4 for health benefits.

Potential consequences

The issues we outlined above collectively contribute to a significant, yet entirely implausible, downgrading of low physical activity as a risk factor in GBD 2019. Left undiscussed, such downgrading could weaken the well-established role physical activity plays in disease prevention,3 4 and decades of evidence building and translation efforts . We are particularity concerned that GBD 2019 may undermine WHO’s Global Action Plan on Physical Activity 2018–203012, by misleading clinicians and policy makers into trivialising physical inactivity as a health problem.

A way forward

We suggest that the GBD incorporate more recent evidence that acknowledges the multidimensional nature of physical activity, such as that considered by the 2018 US guidelines7 and the WHO 2020 guidelines on physical activity and sedentary behaviour.4 To be reproducible and replicable, the GBD methods would benefit from adopting established physical activity standards for categorising prevalence and estimating health effects and include the full range of physical activity-related health outcomes that are based on solid research evidence produced over several decades.4

GBD has tremendous potential for improving human health. By giving physical activity a methodologically fair and transparent treatment, GBD could realise its full potential as a leading data source for better global health policy, clinical practice and research.

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  • Twitter @M_Stamatakis, @DrMelodyDing

  • Contributors All authors conceived the idea jointly. ES drafted and revised the manuscript several times. DD, UE and AB reviewed critically and edited part of the manuscript several times.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.