Global, regional, and national burden of major diabetes-related complications attributable to physical inactivity

• No meta-analysis of population-based observational studies has estimated the burden of diabetes-related complications due to physical inactivity. • Globally, one in ten cases of macrovascular complications and retinopathy in people with diabetes is due to physical inactivity. • Regional disparities exist, with more cases in high-income Asia-Pacific, Central Asia, and North Africa-Middle East countries, Latin America, and the Caribbean. • Women and those with low education showed a higher burden of diabetes-related complications due to physical inactivity. • Healthcare providers and policymakers could prioritize physical activity in region-specific diabetes management protocols. Studies investigating the global, regional, and national impact of physical inactivity on diabetes complications are scarce. We aimed to estimate the population attributable fractions (PAF) of macrovascular complications and retinopathy in people with diabetes at the national, regional, and global levels. We conducted a pooled analysis of population-based cohort studies and cross-sectional surveys to identify the prevalence of physical inactivity and its association with macrovascular complications and retinopathy in adults with diabetes. Diabetes-related complications included macrovascular (i.e., cardiovascular diseases, stroke, coronary heart disease (CHD), heart failure) complications and retinopathy. PAFs were estimated using the adjusted relative risks, the proportion of physical inactivity in cases, and the available prevalence of physical inactivity from countries and territories worldwide. We pooled data from 2,374,714 adults from representative prospective cohorts and cross-sectional surveys. We included data from high-income Western Countries ( n (number of studies) = 11), Latin America and Caribbean ( n = 4), high-income Asia Pacific ( n = 3), East and South-East Asia ( n = 3), Sub-Saharan Africa ( n = 3), South Asia ( n = 2), and Central and Eastern Europe ( n = 1). The highest PAFs were observed for stroke (10.2%; 95% uncertainty interval (UI): 5.1%–16.6%), retinopathy (9.7%; 95%UI: 4.1%–16.5%), and heart failure (7.3%; 95%UI: 3.1%– 12.5%). High-income Asia Pacific, Latin America and Caribbean, and the Central Asia, North Africa–Middle East regions showed the largest PAF to physical inactivity for macrovascular and retinopathy. The largest sex disparity was observed in retinopathy. A higher country income was associated with a higher PAF across all investigated complications. Oppositely, adults with low educational attainment showed higher PAFs for all analyzed complications, especially in cardiovascular disease and CHD. The global burden of diabetes-related complications is significantly influenced by physical inactivity. Tailoring interventions to reduce physical inactivity in this population may contribute to mitigating the health impacts of diabetes complications.