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Here are five compelling reasons for putting physical activity in low- and middle-income countries high up on the public Health research agenda.

Since 2020, the world has been navigating an epidemiologic transition with both infectious diseases (COVID-19) and noncommunicable diseases (NCDs) intertwined in complex and diverse ways. In fact, the pandemics of physical inactivity, NCDs, and COVID-19 coincide in a tragically impactful ménage à trois with their detrimental long-term health consequences yet to be determined. However, we know that regularly meeting the physical activity (PA) guidelines protects us from severe COVID-19 outcomes. Hence, we argue that it is both critical and timely to firmly address the long-standing silent pandemic of physical inactivity and its health consequences as one of the most pressing global public health challenges—particularly in low- and middle-income countries (LMICs).

It is well known that physical inactivity is the fourth leading risk factor for global mortality and contributes substantially to the continuing burden of NCDs that account for more than 70% of deaths worldwide. It is perhaps less known, however, that a staggering 80% of all NCDs occur in LMICs. People in LMICs not only have the highest risk of developing chronic diseases, they also develop the diseases at a younger age, they suffer longer, and they die earlier than people in high-income countries. Alarmingly, people in LMICs not only bear the highest disease burden from physical inactivity, they are also suffering the highest morbidity and mortality burden of the COVID-19 pandemic. The unequal access to COVID-19 vaccination has added yet another challenge to the health struggles in LMICs.

Against this background, we must finally acknowledge that PA behavior and its inherent choices are more complex and nuanced than previously thought; in fact, they are often context-specific, and differ not only by socioeconomic status, but also by region, country, and sociocultural contexts. Hence, they deserve a more targeted and tailored response that addresses the specific needs of the population. In fact, in a recent publication, Lambert et al. suggested framing the discussion around the access to PA as a basic human rights question that is central to sustainable development. These suggestions are in line with Stamatakis and Bull’s view that the lack of research around PA in LMICs is more than “just another research gap.” Building on these sentiments, we argue that if our commitment to a more just and equitable global public health agenda is to result in more than just fluffy words and lofty promises, it is time to finally—belatedly—commit to inclusive and context-specific public health practices in LMICs that are paired with locally relevant and meaningful promotion and facilitation of PA practice, research, and policymaking.

Why focus on LMICs? 5 compelling reasons

  1. Preconditions and varying awareness: Unique disease profiles, often limited and untimely access to treatment for chronic conditions, and varying awareness regarding the benefits of PA present lifestyle behavior challenges for many people and communities in LMICs.
  2. Limited opportunities: Opportunities to engage in regular PA are often restricted for a potpourri of complex and interrelated reasons, including aspects, such as traffic, safety, infrastructure, limited resources, competing health and development priorities, political willpower, cultural barriers, and so on.
  3. Lifestyle changes: The technological revolution that has occurred over the past 3 decades has led to an increase in sedentary occupations, as well as an increase in sedentary leisure options and less activity in daily chores. A move away from traditional lifestyles has resulted in a shift in disease patterns and risk factors, including reduced overall PA levels in LMICs.
  4. Increased urbanization: From an infrastructure and planning perspective, rapid urbanization in LMICs has led to shifts in daily movement and travel patterns—away from walking and cycling toward an increased reliance on private motorized vehicles. This shift and the associated construction of roads has resulted in fewer “safe spaces” for walking and cycling, which can be directly linked with reductions in overall PA.
  5. Restricted support: Governments and communities across LMICs are often restricted in providing adequate support and resources for active lifestyle behavior. This specifically relates to financial contributions but also supportive infrastructure, qualified personnel, as well as cultural and political support.

Taken together, addressing these 5 points will be critical for achieving more physically active populations across LMICs and a more just and equitable global public health agenda overall. For researchers and practitioners, this means that against the background of an increasingly tense NCD situation and associated negative health and socioeconomic consequences, it is time to finally and firmly shift our focus toward research activities and practical PA initiatives where they are most needed—in LMICs. We posit that only through concerted efforts and multisectoral actions — combined with targeted and sustained interventions, as well as local voices—may we succeed in putting LMICs firmly on the global PA agenda and thus create the inclusive change that is long overdue. As a first tangible step, we have compiled the edited volume Physical Activity in Low- and Middle-Income Countries (Routledge, 2022), which brings together the latest multidisciplinary research on PA in LMICs from around the world. In this volume, we argue that through transdisciplinary research and practice—that is, bringing together a diverse group of researchers, practitioners, and policy makers from the key fields of action—we are well-equipped to move the needle and achieve comprehensive, yet targeted, context-specific, and multisectoral responses that create PA-enabling environments across LMIC settings. With this in mind, we invite and encourage readers to engage with the latest research provided in our book, and reflect on, translate, and implement suggested recommendations for critical PA areas that promise to make life-changing differences for people in LMICs.


The authors thank the chapter authors of PA in LMICs for their valuable input. No funding has been provided to compile this commentary.


Bennett JE, Kontis V, Mathers CD, et al. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet. 2018;392(10152):1072–1088.

Ding D, Lawson KD, Kolbe-Alexander T, Finkelstein EA, Katzmarzyk PT, Michelen W. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet. 2016;388(10051):1311–1324. 

Lambert EV, Kolbe-Alexander T, Adlakha D, et al. Making the case for ‘physical activity security’: the 2020 WHO guidelines on physical activity and sedentary behaviour from a Global South perspective. Br J Sports Med. 2020;54(24):1447–1448.

Sallis R, Young DR, Tartof SY, et al. Physical inactivity is associated with a higher risk for severe COVID-19 outcomes: a study in 48 440 adult patients. Br J Sports Med. 2021;55:1099–1105. 

Schulenkorf N, Siefken K. Managing sport-for-development and healthy lifestyles: the sport-for-health model. Sport Manag Rev. 2019;22(1):96–107.

Stamatakis E, Bull FC. The 2020 global guidelines on physical activity and sedentary behaviour: putting physical activity in the “must-do” list of the global agenda. Br J Sports Med. 2020;54(24):1445–1446.

Ramirez Varela A, Hallal P, Pratt M, et al., on behalf of the Global Observatory for Physical Activity (GoPA!) working group. Global Observatory for Physical Activity (GoPA!): 2nd Physical Activity Almanac. Bogotá, D. C., Colombia: Global Observatory for Physical Activity (GoPA!); ISSN: 2805-6787; 2021.

Ramirez Varela A, Sallis R, Rowlands AV, Sallis JF. Physical inactivity and COVID-19: When pandemics collide. J Phys Act Heal. 2021;18:1159–1160.


This commentary was published in the Journal of Physical Activity and Health, the primary global outlet for research relevant to the science and practice of physical activity as it relates to health and health outcomes. It is reprinted here with permission from the publisher, Human Kinetics. Follow the Journal on Twitter (@JPAHjournal) to stay up to date on physical activity research. 

Cite this commentary: Siefken, K., Ramirez Varela, A., Waqanivalu, T., & Schulenkorf, N. (2021). Better late than never?! Five compelling reasons for putting physical activity in low- and middle-income countries high up on the public health research agenda. Journal of Physical Activity and Health, 18(12), 1469-1470.



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