Table 1 Reconceptualization of physical activity for public health in the 21st century

(1) Physical activity for health and wellbeing

We propose using the term ‘physical activity for health and wellbeing’ to refer to physical activity that promotes optimal, holistic health, in alignment with the WHO’s definition of health. This term inherently excludes physical activity that occurs in unsafe, economically coercive and/or undignified conditions, that has potential health risks and is associated with social inequalities. This proposal stems from the theoretically informed global analysis of domain-specific and intersectional physical activity inequalities presented in this paper and draws on elements of theories and concepts, including physical activity security, the necessity-based versus choice-based physical activity framework and intersectionality theory.

It is recommended to apply this reconceptualization to physical activity measurement, surveillance, research and promotion.

• ‘Overall physical activity’ and ‘physical activity for health and wellbeing’ should be differentiated when measuring, tracking population levels (that is, surveillance) and conducting physical activity studies. Researchers should work to develop self-reported measures or statistical approaches that allow for this differentiation.

• Promotion efforts should focus on physical activity for health and wellbeing.

(2) Physical activity goals and benchmarking

The findings presented in this paper of the global analysis of domain-specific and intersectional physical activity inequalities support the need to increase the overall prevalence of people meeting physical activity guidelines of international agencies (for example, the WHO), and countries should set targets and use their surveillance systems to track progress for:

• Increasing opportunities for physical activity for health and wellbeing, as described in this reconceptualized model of physical activity for 21st century public health.

• Reducing physical activity inequalities across multiple dimensions (socioeconomic, gender, race, ethnicity, sexual orientation, disabilities, immigration status, etc.).

• Increasing the proportion of the population with access to free, accessible, safe and enjoyable spaces for active leisure.

• Improving the safety and overall conditions for transport-related physical activity (walking, bicycling and public transit), especially in areas where these modes are primarily driven by economic necessity and among populations experiencing transport disadvantage.

It is recommended that physical activity inequalities tracking should:

• Use domain-specific physical activity data. To support this, researchers should work toward developing more accurate measures of domain-specific physical activity.

• Assess the extent to which active transport occurs in safe and dignified conditions. This will require developing measures to determine the environmental and sociocultural conditions where active transport takes place and including them as part of physical activity surveillance systems.

• Develop measures to assess and track choice-based versus necessity-based physical activity in populations and set benchmarking goals aiming to maximize choice-based physical activity.

• Employ an intersectionality approach to assess the combined impact of multiple dimensions of social disadvantage on physical activity inequalities.

(3) Research on the health and societal effects of physical activity

The summaries presented in this paper on the less well-recognized health benefits of physical activity as well as the global analysis of domain-specific and intersectional physical activity inequalities, plus the insights provided by Series Papers 2 and 3 (refs. ^48,49), support the need for expanding and improving research on the effects of physical activity for infectious disease prevention and control, mental health disorder prevention and treatment, cancer prevention and control, the reduction of health inequities and climate action.

Recommended research priorities:

• Studies testing the effects of structural-level changes, targeting social injustices, in reducing physical activity inequalities and in increasing physical activity security.

• Studies exploring the role of physical activity domains, of choice-based versus necessity-based physical activity and of physical activity settings (for example, open green space) on infectious disease and mental health outcomes.

• Studies assessing physical activity as an adjuvant in the evaluation of new vaccines. Both vaccine effectiveness and duration of effect should be evaluated.

• Studies directly testing the comparative effectiveness of physical activity as an alternative treatment for mental health relative to established treatments, using newer, more robust designs for causal inference (for example, Mendelian randomization, advanced technologies and data science).

• Studies on the biological mechanisms by which physical activity enhances site-specific cancer prevention and survivorship; on the possible effects of physical activity on late-stage cancer; on the role of physical activity intensity on cancer outcomes; and on less researched cancers with regard to the role of physical activity.

• Studies on how to safely promote ‘physical activity for health and wellbeing’ and support physical activity security during times of crises (for example, infectious disease pandemics, natural disasters and extreme temperatures/weather).

• Studies assessing the impact of large-scale physical activity promotion strategies on both human and planetary health outcomes, including climate resilience and climate change mitigation and adaptation.

(4) Physical activity promotion policies, programs and messaging

The evidence summarized across all sections of this paper as well as that of Series Papers 2 and 3 (refs. ^48,49) support that attaining physical activity security through the promotion of ‘physical activity for health and wellbeing’ should be prioritized in physical activity policies, programs and messaging across sectors and levels of government as well as by international agencies.

• All physical activity promotion efforts, including those by healthcare providers and public health agencies, should emphasize the full range of health benefits of physical activity.

• Physical activity policies should aim to reduce physical activity insecurity, increase access to choice-based physical activity and create safe and dignified conditions for the environments where necessity-based physical activity is common.

• Physical activity promotion should not be limited to obesity, cardiometabolic health or even broad NCD prevention and management plans, policies and programs. Within the health sector, entities in charge of mental health and societal wellbeing, as well as infectious disease and cancer prevention and control, should also be engaged. As emphasized by Series Papers 2 and 3 (refs. ^48,49), actors beyond the health sector should partake in physical activity policy development, implementation and evaluation and especially those with connections to climate action and planetary health (for example, environment, urban planning and transport).

• Physical activity promotion strategies and messaging should use decolonized approaches that are ethical, respectful and responsive to the local culture, values and context.

• Messages indicating that ‘every move counts’ for health should be avoided in contexts where a large portion of physical activity is necessity driven and occurs in unsafe, economically coercive and undignified conditions misaligned with physical activity for health and wellbeing.

• Strategies for resolving social injustices, including changing unfair social structures, contexts, policies and norms, and the oppressive systems that drive inequalities in choice-based versus necessity-based physical activity should be included in physical activity promotion plans.