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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 …

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  • 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.