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Population attributable fraction of leading non-communicable cardiovascular diseases due to leisure-time physical inactivity: a systematic review
  1. Hashel Al Tunaiji1,2,
  2. Jennifer C Davis1,
  3. Mohammad Ali Mansournia3,
  4. Karim M Khan1
  1. 1Centre for Hip Health and Mobility, University of British Columbia, Vancouver Coastal Health Research Institute (VCHRI), Vancouver, British Columbia, Canada
  2. 2Sport Medicine & Sciences Unit, Zayed Military Hospital, Abu Dhabi, United Arab Emirates
  3. 3Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
  1. Correspondence to Dr Hashel Al Tunaiji; dr.tunaiji{at}


Objective The aim of this systematic review was to investigate the methods used for estimating the population attributable fraction (PAF) to leisure-time physical inactivity (PI) of coronary artery diseases, hypertension and stroke in order to provide the best available estimate for PAF.

Design Systematic review.

Data sources Four electronic databases (MEDLINE/PubMed, EMBASE, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature) were searched from inception to August 2018.

Eligibility criteria for selecting studies This review included prospective cohort studies, with men and women aged ≥18 years old, investigating the PAF attributable to leisure-time PI related to coronary artery diseases, hypertension and stroke.

Results The PAF estimates of the three studies included were 13% (3%–22%) for ‘stage-1 hypertension’ subtype incidence due to ‘non-regular exercise’; 25% (10.4%–35.8%) for ‘stage-2 hypertension’ subtype incidence due to ‘activity of daily living’ and ‘vigorous-intensity sports’; and 8.5% (1.7%–16.7%) for ‘total: fatal and non-fatal’ cardiovascular events of ‘incidence and mortality’ endpoints due to non-accumulation of 550 kcal/week (subsets not specified).

Conclusions The PAF estimate exhibited a protective dose–response relationship between hypertension and an increased amount of energy expenditure of leisure-time PI. In order to enhance accuracy of PAF estimates, the following steps are recommended: (1) to clearly define and state the working definition of leisure-time PI and dose using a reliable and valid objective measurement tool; (2) use a clear definition of outcome subtypes and endpoints using reliable and valid objective measures; and (3) estimate PAF using modelling techniques based on prospective data and ensuring to report 95% CI.

  • exercise
  • evaluation
  • chronic

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  • Contributors HAT and JCD searched for relevant literature and wrote the manuscript. HAT, JCD and KMK conceived the study idea. KMK helped with drafting and revisions. KMK has given the final approval of the version to be published. All the authors read and approved the final manuscript.

  • Funding This work was supported by the Canadian Institutes of Health Research (CIHR) Emerging Teams grant (KMK) - Mobility in Aging (Institute of Aging). JCD is funded by CIHR and Michael Smith Foundation for Health Research (MSFHR) Postdoctoral Fellowships.

  • Competing interests None declared.

  • Patient consent for publication Not required.

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

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