BACKGROUNDThere are little data on the relationship between physical activity and suicidal behavior in medical students. Therefore, this cross-sectional study aimed to investigate the association between physical activity and suicidal behavior and identify mediating factors involved in the association among medical students from the United States.METHODSData from the Healthy Minds Study (2007-2023) were used. Physical activity and suicidal behavior (i.e., suicidal ideation, suicide plans, and suicide attempts) were self-reported. Control variables included age, gender, ethnicity/race, relationship status, citizenship, current financial stress, and academic year. Mediating factors were flourishing, generalized anxiety disorder symptoms, depressive symptoms, eating disorder symptoms, binge drinking, smoking, and drug use.RESULTSThere were 6452 medical students included in the study (median [IQR] age 25.0 [3.0] years; 4032 [62.5 %] women). After adjusting for control variables, compared with <1 hour of physical activity per week, the odds of any suicidal behavior were significantly lower for 3-4 hours (OR = 0.57, 95 % CI = 0.41-0.79) and ≥5 hours of physical activity per week (OR = 0.52, 95 % CI = 0.39-0.70). The physical activity-any suicidal behavior relationship was partially explained by decreased depressive symptoms (39.4 %), increased flourishing (27.6 %), and decreased generalized anxiety disorder symptoms (18.7 %).LIMITATIONSData are of a cross-sectional nature.CONCLUSIONSThere was an inverse association between physical activity and suicidal behavior in medical students from the United States, while several variables were identified as mediating factors (i.e., depressive symptoms, flourishing, and general anxiety disorder symptoms). Further research is needed to corroborate these findings in other settings, while longitudinal data are urgently warranted.