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Peer-reviewedCC BY 4.0Frontiers in Public Health

The physical activity paradox and all-cause mortality: an umbrella review of systematic reviews and meta-analyses

  • Huachang Lin1
  • Hong Zhao1
  1. 1School of Physical Education and Health, Guilin College
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Abstract

Background: With over 2.8 billion adults engaged in occupational physical activity globally and physical inactivity remaining the fourth leading mortality risk factor, understanding domain-specific PA effects is a public health priority.

Evidence suggests domain-divergent effects: LTPA is protective; OPA may confer adverse effects. No umbrella review has compared evidence across all three PA domains for all-cause mortality.

Methods: Umbrella review of systematic reviews with meta-analyses examining domain-specific PA (LTPA, OPA, transport) and all-cause mortality (PROSPERO: CRD42026142431). Five databases and Epistemonikos were searched to June 2026. Four Chinese-language databases were additionally searched. Quality was assessed via AMSTAR 2; evidence credibility was classified using the Ioannidis framework. Primary study overlap was quantified via Corrected Covered Area (CCA) analysis. CCA-informed descriptive synthesis with correlated-effects sensitivity analysis was complemented by leave-one-out and AMSTAR 2 quality-stratified sensitivity analyses.

Results: Twelve systematic reviews (>300 cohort studies, >32 million participants) were included. A consistent descriptive domain-gradient emerged: LTPA showed strong protective associations (HR/RR 0.50–0.81, Ioannidis Class II, GRADE Moderate); transport PA showed moderate protection (RR 0.77–0.92, Ioannidis Class III, GRADE Moderate); OPA showed null-to-elevated-risk associations after LTPA adjustment (pooled HR 1.12, 95% CI 1.05–1.19, Ioannidis Class IV, GRADE Low), from one evidence cluster (pairwise CCA = 89%, very high study-level overlap; this does not mean 89% of participants derive from one source, but rather that the two reviews share approximately 89% of their included primary studies). CCA analysis confirmed largely independent evidence bases between domains (cross-domain CCA = 6.3%). Illustrative population attributable fraction analyses estimated that insufficient LTPA accounts for 10.2% of all-cause mortality globally, assuming causality.

Conclusions: This first multi-domain umbrella review reveals a consistent descriptive domain-gradient: LTPA is protective, transport PA moderately protective, and OPA shows null-to-elevated-risk after LTPA adjustment, though this derives from a single evidence cluster (CCA = 89%) and requires independent replication. Large Chinese cohorts (~0.9 million [CKB evidence reported in, n ~ 512,000 overlapping]; post-hoc exploratory finding, not from the 12 included reviews) report protective OPA associations, suggesting context-dependence. Current evidence suggests that PA domains may differ in mortality risk associations and warrant domain-specific consideration, though OPA evidence remains preliminary and requires independent replication.

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Cite

BibTeXRIS
BibTeX
@article{lin2026physical,
  title = {{The physical activity paradox and all-cause mortality: an umbrella review of systematic reviews and meta-analyses}},
  author = {Huachang Lin and Hong Zhao},
  journal = {Frontiers in Public Health},
  year = {2026},
  month = oct,
  doi = {10.3389/fpubh.2026.1934173},
  url = {https://www.frontiersin.org/articles/10.3389/fpubh.2026.1934173/full},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - The physical activity paradox and all-cause mortality: an umbrella review of systematic reviews and meta-analyses
AU  - Huachang Lin
AU  - Hong Zhao
PY  - 2026
DA  - 2026/10/28
JO  - Frontiers in Public Health
DO  - 10.3389/fpubh.2026.1934173
UR  - https://www.frontiersin.org/articles/10.3389/fpubh.2026.1934173/full
AB  - Background: With over 2.8 billion adults engaged in occupational physical activity globally and physical inactivity remaining the fourth leading mortality risk factor, understanding domain-specific PA effects is a public health priority.  Evidence suggests domain-divergent effects: LTPA is protective; OPA may confer adverse effects. No umbrella review has compared evidence across all three PA domains for all-cause mortality.  Methods: Umbrella review of systematic reviews with meta-analyses examining domain-specific PA (LTPA, OPA, transport) and all-cause mortality (PROSPERO: CRD42026142431). Five databases and Epistemonikos were searched to June 2026. Four Chinese-language databases were additionally searched. Quality was assessed via AMSTAR 2; evidence credibility was classified using the Ioannidis framework. Primary study overlap was quantified via Corrected Covered Area (CCA) analysis. CCA-informed descriptive synthesis with correlated-effects sensitivity analysis was complemented by leave-one-out and AMSTAR 2 quality-stratified sensitivity analyses.  Results: Twelve systematic reviews (>300 cohort studies, >32 million participants) were included. A consistent descriptive domain-gradient emerged: LTPA showed strong protective associations (HR/RR 0.50–0.81, Ioannidis Class II, GRADE Moderate); transport PA showed moderate protection (RR 0.77–0.92, Ioannidis Class III, GRADE Moderate); OPA showed null-to-elevated-risk associations after LTPA adjustment (pooled HR 1.12, 95% CI 1.05–1.19, Ioannidis Class IV, GRADE Low), from one evidence cluster (pairwise CCA = 89%, very high study-level overlap; this does not mean 89% of participants derive from one source, but rather that the two reviews share approximately 89% of their included primary studies). CCA analysis confirmed largely independent evidence bases between domains (cross-domain CCA = 6.3%). Illustrative population attributable fraction analyses estimated that insufficient LTPA accounts for 10.2% of all-cause mortality globally, assuming causality.  Conclusions: This first multi-domain umbrella review reveals a consistent descriptive domain-gradient: LTPA is protective, transport PA moderately protective, and OPA shows null-to-elevated-risk after LTPA adjustment, though this derives from a single evidence cluster (CCA = 89%) and requires independent replication. Large Chinese cohorts (~0.9 million [CKB evidence reported in, n ~ 512,000 overlapping]; post-hoc exploratory finding, not from the 12 included reviews) report protective OPA associations, suggesting context-dependence. Current evidence suggests that PA domains may differ in mortality risk associations and warrant domain-specific consideration, though OPA evidence remains preliminary and requires independent replication.
SN  - 2296-2565
ER  -