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Physical activity, diet quality and all-cause cardiovascular disease and cancer mortality: a prospective study of 346 627 UK Biobank participants
  1. Ding Ding1,2,
  2. Joe Van Buskirk1,3,
  3. Binh Nguyen1,2,
  4. Emmanuel Stamatakis2,4,
  5. Mona Elbarbary1,
  6. Nicola Veronese5,
  7. Philip J Clare1,2,6,
  8. I-Min Lee7,
  9. Ulf Ekelund8,9,
  10. Luigi Fontana2,10,11
  1. 1 Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia
  2. 2 Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia
  3. 3 Sydney Local Health District, Camperdown, New South Wales, Australia
  4. 4 School of Health Sciences, Faculty of Medicine and Health, Camperdown, New South Wales, Australia
  5. 5 Department of Internal Medicine, Geriatrics Section, University of Palermo, Palermo, Italy
  6. 6 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
  7. 7 Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  8. 8 Norwegian School of Sports Sciences, Oslo, Norway
  9. 9 Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
  10. 10 Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
  11. 11 Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
  1. Correspondence to Dr Ding Ding, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia; melody.ding{at}


Objectives To examine independent and interactive associations of physical activity and diet with all-cause, cardiovascular disease (CVD) and physical activity, diet and adiposity-related (PDAR) cancer mortality.

Methods This population-based prospective cohort study (n=346 627) is based on the UK Biobank data with linkage to the National Health Service death records to 30 April 2020. A left-truncated Cox proportional hazards model was fitted to examine the associations between exposures (self-reported total moderate-to-vigorous intensity physical activity (MVPA), vigorous-intensity physical activity (VPA) and a diet quality index (score ranged 0–3)) and outcomes (all-cause, CVD and PDAR cancer mortality).

Results During a median follow-up of 11.2 years, 13 869 participants died from all causes, 2650 from CVD and 4522 from PDAR cancers. Compared with quartile 1 (Q1, 0–210 min/week), Q2–Q4 of MVPA were associated with lower risks of all-cause (HR ranged from 0.87 (95% CI: 0.83 to 0.91) to 0.91 (95% CI: 0.87 to 0.96)), CVD (HR ranged from 0.85 (95% CI: 0.76 to 0.95) to 0.90 (95% CI: 0.81 to 1.00)) and PDAR cancer mortality (HR ranged from 0.86 (95% CI: 0.79 to 0.93) to 0.94 (95% CI: 0.86 to 1.02)). Compared with no VPA, any VPA was associated with lower risk for all-cause and CVD mortality (HR ranged from 0.85 (95% CI: 0.80 to 0.89) to 0.88 (95% CI: 0.84 to 0.93) and from 0.75 (95% CI: 0.68 to 0.83) to 0.90 (95% CI: 0.80 to 1.02), respectively). Although not reaching statistical significance for all-cause and CVD mortality, being in the best dietary category (diet quality index=2–3) was associated with a reduction in PDAR cancer mortality (HR=0.86, 95% CI: 0.78 to 0.93). No additive or multiplicative interactions between physical activity categories and dietary quality was found. When comparing across physical activity and diet combinations, the lowest risk combinations consistently included the higher levels of physical activity and the highest diet quality score.

Conclusions Adhering to both quality diet and sufficient physical activity is important for optimally reducing the risk of mortality from all causes, CVD and PDAR cancers.

  • epidemiology
  • preventive medicine

Data availability statement

Data may be obtained from a third party upon approval and payment. UK Biobank data could be obtained on application from

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Data availability statement

Data may be obtained from a third party upon approval and payment. UK Biobank data could be obtained on application from

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  • IL, UE and LF are joint senior authors.

  • Twitter @DrMelodyDing, @M_Stamatakis, @pjclare, @LuigiFontana22

  • Contributors DD and LF conceptualised the research question. DD led the investigation and drafted the paper. JvB conducted data analysis, PC supported revision of data analysis, BN helped with literature searches, ME with data management and NV with dietary measures. All authors provided critical feedback on the paper at various stages and approved the final version of the paper. DD is the guarantor of the project and accepts full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.

  • Funding DD ES abd LF were each funded by an Investigator Grant from the National Health and Medical Research Council of Australia (APP 2009254, APP1194510, and APP1177797, respectively). DD was additionally funded by Heart Foundation Australia, and LF additionally funded by the Australian Youth and Health Foundation and Philip Bushell Foundation.

  • Disclaimer The funder played no role in any aspects of the research project.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • 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.