Review Article

Physical Activity Benefits and Risks on the Gastrointestinal System

Authors: Donald Martin, MD


This review evaluates the current understanding of the benefits and risks of physical activity and exercise on the gastrointestinal system. A significant portion of endurance athletes are affected by gastrointestinal symptoms, but most symptoms are transient and do not have long-term consequences. Conversely, physical activity may have a protective effect on the gastrointestinal system. There is convincing evidence that physical activity reduces the risk of colon cancer. The evidence is less convincing for gastric and pancreatic cancers, gastroesophageal reflux disease, peptic ulcer disease, nonalcoholic fatty liver disease, cholelithiasis, diverticular disease, irritable bowel syndrome, and constipation. Physical activity may reduce the risk of gastrointestinal bleeding and inflammatory bowel disease, although this has not been proven unequivocally. This article provides a critical review of the evidence-based literature concerning exercise and physical activity effects on the gastrointestinal system and provides physicians with a better understanding of the evidence behind exercise prescriptions for patients with gastrointestinal disorders. Well-designed prospective randomized trials evaluating the risks and benefits of exercise and physical activity on gastrointestinal disorders are recommended for future research.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Rehrer NJ, Janssen GM, Brouns F, et al. Fluid intake and gastrointestinal problems in runners competing in a 25-km race and a marathon. Int J Sports Med 1989;10(1 suppl):S22–S25.
2. Moses FM, Brewer TG, Peura DA. Running-associated proximal hemorrhagic colitis. Ann Intern Med 1988;108:385–386.
3. Glade MJ. Food, nutrition, and the prevention of cancer: a global perspective. American Institute for Cancer Research/World Cancer Research Fund, American Institute for Cancer Research, 1997. Nutrition 1999;15:523–526.
4. Oliveria SA, Christos PJ. The epidemiology of physical activity and cancer. Ann N Y Acad Sci 1997;833:79–90.
5. Colditz GA, Cannuscio CC, Frazier AL. Physical activity and reduced risk of colon cancer: implications for prevention. Cancer Causes Control 1997;8:649–667.
6. Aldoori WH, Giovannucci EL, Rimm EB, et al. Prospective study of physical activity and the risk of symptomatic diverticular disease in men. Gut 1995;36:276–282.
7. Leitzmann MF, Rimm EB, Willett WC, et al. Recreational physical activity and the risk of cholecystectomy in women. N Engl J Med 1999;341:777–784.
8. Leitzmann MF, Giovannucci EL, Rimm EB, et al. The relation of physical activity to risk for symptomatic gallstone disease in men. Ann Intern Med 1998;128:417–425.
9. Everhart JE, Go VL, Johannes RS, et al. A longitudinal survey of self-reported bowel habits in the United States. Dig Dis Sci 1989;34:1153–1162.
10. Brouns F, Beckers E. Is the gut an athletic organ? Digestion, absorption and exercise. Sports Med 1993;15:242–257.
11. Øktedalen O, Lunde OC, Opstad PK, et al. Changes in the gastrointestinal mucosa after long-distance running. Scand J Gastroenterol 1992;27:270–274.
12. Peters HP, Zweers M, Backx FJ, et al. Gastrointestinal symptoms during long-distance walking. Med Sci Sports Exerc 1999;31:767–773.
13. Peters HP, Bos M, Seebregts L, et al. Gastrointestinal symptoms in long-distance runners, cyclists, and triathletes: prevalence, medication, and etiology. Am J Gastroenterol 1999;94:1570–1581.
14. ter Steege RW, Van der Palen J, Kolkman JJ. Prevalence of gastrointestinal complaints in runners competing in a long-distance run: an Internet-based observational study in 1281 subjects. Scand J Gastroenterol 2008;43:1477–1482.
15. Peters HP, Akkermans LM, Bol E, et al. Gastrointestinal symptoms during exercise. The effect of fluid supplementation. Sports Med 1995;20:65–76.
16. Von Duvillard SP, Braun WA, Markofski M, et al. Fluids and hydration in prolonged endurance performance. Nutrition 2004; 20: 651–656.
17. Van Nieuwenhoven MA, Brouns F, Brummer RJ. Gastrointestinal profile of symptomatic athletes are rest and during physical exercise. Eur J Appl Physiol 2004;91:429–434.
18. Moses FM. The effect of exercise on the gastrointestinal tract. Sports Med 1990;9:159–172.
19. Rowell LB, Blackmon JR, Bruce RA. Indocyanine green clearance and estimated hepatic blood flow during mild to maximal exercise in upright man. J Clin Invest 1964;43:1677–1690.
20. Jeukendrup AE, Vet-Joop K, Sturk A, et al. Relationship between gastro-intestinal complaints and endotoxaemia, cytokine release and the acute-phase reaction during and after a long-distance triathlon in highly trained men. Clin Sci (Lond) 2000;98:47–55.
21. Soffer EE, Summers RW, Gisolfi C. Effect of exercise on intestinal motility and transit in trained athletes. Am J Physiol 1991;260:G698–G702.
22. Soffer EE, Wilson J, Duethman G, et al.. Effect of graded exercise on esophageal motility and gastroesophageal reflux in nontrained subjects. Dig Dis Sci 1994; 39: 193–198.
23. Rudzki SJ, Hazard H, Collinson D. Gastrointestinal blood loss in triathletes: its etiology and relationship to sports anaemia. Aust J Sci Med Sport 1995;27:3–8.
24. Halvorsen FA, Lyng J, Ritland S. Gastrointestinal bleeding in runners. Can J Gastroenterol 1986;21:493–497.
25. Choi SC, Choi SJ, Kim JA, et al. The role of gastrointestinal endoscopy in long-distance runners with gastrointestinal symptoms. Eur J Gastroenterol Hepatol 2001;13:1089–1094.
26. Nielsen P, Nachtigall D. Iron supplementation in athletes. Current recommendations. Sports Med 1998;26:207–216.
27. Peters HP, Wiersma WC, Akkermans LM, et al. Gastrointestinal mucosal integrity after prolonged exercise with fluid supplementation. Med Sci Sports Exerc 2000;32:134–142.
28. Bosenberg AT, Brock-Utne JG, Gaffin SL, et al. Strenuous exercise causes systemic endotoxemia. J Appl Physiol 1988;65:106–108.
29. Ritland S, Foss NE, Gjone E. Physical activity in liver disease and liver function in sportsmen. Scand J Soc Med Suppl 1982;29:221–226.
30. Mauriz JL, Tabernero B, Garcia-Lopez J, et al. Physical exercise and improvement of liver oxidative metabolism in the elderly. Eur J Appl Physiol 2000;81:62–66.
31. Huerta JM, Navarro C, Chirlaque MD, et al. Prospective study of physical activity and risk of primary adenocarcinomas of the oesophagus and stomach in the EPIC(European Prospective Investigation into Cancer and nutrition) cohort. Cancer Causes Control 2010;21:657–669.
32. Pelucchi C, Zucchetto A, Tavani A, et al. Physical activity and pancreatic cancer risk. Int J Cancer 2011;128:2243–2245.
33. Harriss DJ, Atkinson G, George K, et al. CCLEAR group. Lifestyle factors and colorectal cancer risk (1): systematic review and meta-analysis of associations with body mass index. Colorectal Dis 2009;11:547–563.
34. Friedenreich C, Norat T, Steindorf K, et al. Physical activity and risk of colon and rectal cancers: the European prospective investigation into cancer and nutrition. Cancer Epidemiol Biomarkers Prev 2006;15:2398–2407.
35. Wertheim BC, Martínez ME, Ashbeck EL, et al. Physical activity as a determinant of fecal bile acid levels [published online ahead of print April 21, 2009]. Cancer Epidemiol Biomarkers Prev 2009;18:1591–1598.
36. O’Connor AM, Johnston CF, Buchanan KD, et al. Circulating gastrointestinal hormone changes in marathon running. Int J Sports Med 1995;16:283–287.
37. Demers LM, Harrison TS, Halbert DR, et al. Effect of prolonged exercise on plasma prostaglandin levels. Prostaglandins Med 1981;6:413–418.
38. Erpecum Van K, Van Berge-Henegouwen GP. Gallstones: an intestinal disease? Gut 1999;44:435–438.
39. Collings KL, Pierce Pratt F, Rodriguez-Stanley S, et al. Esophageal reflux in conditioned runners, cyclists, and weightlifters. Med Sci Sports Exerc 2003;35:730–735.
40. Pandolfino JE, Bianchi LK, Lee TJ, et al. Esophagogastric junction morphology predicts susceptibility to exercise-induced reflux. Am J Gastroenterol 2004;99:1430–1436.
41. Ravi N, Stuart RC, Byrne PJ, et al. Effect of physical exercise on esophageal motility in patients with esophageal disease. Dis Esophagus 2005;18:374–377.
42. Parmelee-Peters K, Moeller JL. Gastroesophageal reflux in athletes. Curr Sports Med Rep 2004;3:107–111.
43. Nandurkar S, Locke GR 3rd, Fett S, et al. Relationship between body mass index, diet, exercise and gastro-oesophageal reflux symptoms in a community. Aliment Pharmacol Ther 2004;20:497–505.
44. Schoeman MN, Tippett MD, Akkermans LM, et al. Mechanisms of gastroesophageal reflux in ambulant healthy human subjects. Gastroenterology 1995;108:83–91.
45. Jozkow P, Wasko-Czopnik D, Dunajska K, et al. The relationship between gastroesophageal reflux disease and the level of physical activity. Swiss Med Wkly 2007;137:465–470.
46. Nilsson M, Johnsen R, Ye W, et al. Lifestyle related risk factors in the aetiology of gastro-oesophageal reflux. Gut 2004;53:1730–1735.
47. Nocon M, Labenz J, Willich SN. Lifestyle factors and symptoms of gastro-oesophageal reflux—a population based study. Aliment Pharmacol Ther 2006;23:169–174.
48. Zheng Z, Nordenstedt H, Pedersen NL, et al. Lifestyle factors and risk for symptomatic gastroesophageal reflux in monozygotic twins. Gastroenterology 2007;132:87–95.
49. Sonnenberg A. Factors which influence the incidence and course of peptic ulcer. Scand J Gastroenterol Suppl 1988;155:119–140.
50. Katschinski BD, Logan RF, Edmond M, et al. Physical activity at work and duodenal ulcer risk. Gut 1991;32:983–986.
51. Suadicani P, Hein HO, Gyntelberg F. Genetic and life-style determinants of peptic ulcer. A study of 3387 men aged 54 to 74 years: the Copenhagen Male Study. Scand J Gastroenterol 1999;34:12–17.
52. Rosenstock S, Jørgensen T, Bonnevie O, et al. Risk factors for peptic ulcer disease: a population based prospective cohort study comprising 2416 Danish adults. Gut 2003;52:186–193.
53. Thoma C, Day CP, Trenell MI. Lifestyle interventions for the treatment of non-alcoholic fatty liver disease in adults: a systematic review [published online ahead of print June 30, 2011]. J Hepatol 2011.
54. Goodpaster BH, Delany JP, Otto AD, et al. Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial [published online ahead of print October 9, 2010]. JAMA 2010;304:1795–1802.
55. Rissanen A, Fogelholm M. Physical activity in the prevention and treatment of other morbid conditions and impairments associated with obesity: current evidence and research issues. Med Sci Sports Exerc 1999;31:S635–S645.
56. Banim PJ, Luben RN, Wareham NJ, et al. Physical activity reduces the risk of symptomatic gallstones: a prospective cohort study. Eur J Gastroenterol Hepatol 2010;22:983–988.
57. Tran ZV, Weltman A, Glass GV, et al. The effects of exercise on blood lipids and lipoproteins: a meta-analysis of studies. Med Sci Sports Exerc 1983;15:393–402.
58. Kirwan JP, Kohrt WM, Wojta DM, et al. Endurance exercise training reduces glucose-stimulated insulin levels in 60 to70-year-old men and women. J Gerontol 1993;48:M84–M90.
59. Mingrone G, Greco AV, Finotti E, et al. Free fatty acids: a stimulus for mucin hypersecretion in cholesterol gallstone biles. Biochim Biophys Acta 1988;958:52–59.
60. Petitti DB, Friedman GD, Klatsky AL. Association of a history of gallbladder disease with a reduced concentration of high-density-lipoprotein cholesterol. N Engl J Med 1981;304:1396–1398.
61. Baker TT, Allen D, Lei KY, et al. Alterations in lipid and protein profiles of plasma lipoproteins in middle-aged men consequent to an aerobic exercise program. Metabolism 1986;35:1037–1043.
62. Leon AS, Sanchez OA. Response of blood lipids to exercise training alone or combined with dietary intervention. Med Sci Sports Exerc 2001;33:S502–S515, discussion S28–S29.
63. Halloran LG, Schwartz CC, Vlahcevic ZR, et al. Evidence for high-density lipoprotein free cholesterol as the primary precursor for bile acid synthesis in man. Surgery 1978;84:1–7.
64. Koffler KH, Menkes A, Redmond RA, et al. Strength training accelerates gastrointestinal transit in middle-aged and older men. Med Sci Sports Exerc 1992;24:415–419.
65. Philipp E, Wilckens T, Friess E, et al. Cholecystokinin, gastrin and stress hormone responses in marathon runners. Peptides 1992;13:125–128.
66. Pahor M, Guralnik JM, Salive ME, et al. Physical activity and risk of severe gastrointestinal hemorrhage in older persons. JAMA 1994;272:595–599.
67. Sonnenberg A. Occupational distribution of inflammatory bowel disease among German employees. Gut 1990;31:1037–1040.
68. Persson PG, Leijonmarck CE, Bernell O, et al. Risk indicators for inflammatory bowel disease. Int J Epidemiol 1993;22:268–272.
69. Klein I, Reif S, Farbstein H, et al. Preillness non dietary factors and habits in inflammatory bowel disease. Ital J Gastroenterol Hepatol 1998;30:247–251.
70. Sørensen VZ, Olsen BG, Binder V. Life prospects and quality of life in patients with Crohn’s disease. Gut 1987;28:382–385.
71. Loudon CP, Corroll V, Butcher J, et al. The effects of physical exercise on patients with Crohn’s disease. Am J Gastroenterol 1999;94:697–703.
72. Elsenbruch S, Langhorst J, Popkirowa K, et al. Effects of mind-body therapy on quality of life and neuroendocrine and cellular immune functions in patients with ulcerative colitis. Psychother Psychosom 2005;74:277–287.
73. Gupta N, Khera S, Vempati RP, et al. Effect of yoga based lifestyle intervention on state and trait anxiety. Indian J Physiol Pharmacol 2006;50:41–47.
74. Ng V, Millard W, Lebrun C, et al. Low-intensity exercise improves quality of life in patients with Crohn’s disease. Clin J Sport Med 2007;17:384–388.
75. D’Inca R, Varnier M, Mestriner C, et al. Effect of moderate exercise on Crohn’s disease patients in remission. Ital J Gastroenterol Hepatol 1999;31:205–210.
76. Robinson RJ, Krzywicki T, Almond L, et al. Effect of a low-impact exercise program on bone mineral density in Crohn’s disease: a randomized controlled trial. Gastroenterology 1998;115:36–41.
77. Manousos ON, Vrachliotis G, Papaevangelou G, et al. Relation of diverticulosis of the colon to environmental factors in Greece. Am J Dig Dis 1973;18:174–176.
78. Strate LL, Liu YL, Aldoori WH, et al. Physical activity decreases diverticular complications [published online ahead of print April 14, 2009]. Am J Gastroenterol 2009;104:1221–1230.
79. Daley AJ, Grimmett C, Roberts L, et al. The effects of exercise upon symptoms and quality of life in patients diagnosed with irritable bowel syndrome: a randomized controlled trial [published online ahead of print May 6, 2008]. Int J Sports Med 2008;29:778–782.
80. Lustyk MK, Jarrett ME, Bennett JC, et al. Does a physically active lifestyle improve symptoms in women with irritable bowel syndrome? Gastroenterol Nurs 2001;24:129–137.
81. Donald IP, Smith RG, Cruikshank JG, et al. A study of constipation in the elderly living at home. Gerontology 1985;31:112–118.
82. Kinnunen O. Study of constipation in a geriatric hospital, day hospital, old people’s home and at home. Aging 1991;3:161–170.
83. Meshkinpour H, Selod S, Movahedi H, et al. Effects of regular exercise in management of chronic idiopathic constipation. Dig Dis Sci 1998;43:2379–2383.
84. Karam SE, Nies DM. Student/staff collaboration: a pilot bowel management program. J Gerontol Nurs 1994;20:32–40.
85. Oettlé GJ. Effect of moderate exercise on bowel habit. Gut 1991;32:941–944.