The paper by Salvo et al¹ is a bold and visionary contribution to reframing the physical activity (PA) agenda by demonstrating links to the United Nations Sustainable Development Goals (SDGs). The SDGs are a framework for solving “wicked” global problems, including poverty reduction, improving societal and individual health and well-being, reducing gender and other inequalities, and most importantly, action on climate change. The SDGs imply integration across diverse societal programs and strategies, to produce synergistic “policy coherence.” This commentary focuses on the implications and context of this paper for PA research and practice.

Despite decades of effort, PA remains the Cinderella of chronic disease risk factors, defined as “poverty of position relative to its importance.”² In the 2020 iteration of the Global Burden of Disease report, the relative position of PA has fallen relative to the contribution attributed to other risk factors.³ Furthermore, there has been a recent interest in syndemics (coexistent and interrelated epidemics); those related to noncommunicable disease focus on obesity and nutrition, and their interrelationship with climate change.⁴ Across syndemic papers, PA does not yet rate a mention.

Noting this recent history, it is important to re-emphasise the contribution of PA to solving large-scale problems. The evidence base has extended beyond the usual noncommunicable diseases prevention to myriad other health benefits. This SDG analysis extends the evidence base beyond the health sector to broader cobenefits across society. In thinking about addressing PA, we need to locate population PA strategies in an integrated “systems-thinking” framework.^5,6

The Salvo paper aggregates several interrelated research projects into one comprehensive contribution. The authors define the PA relevance of SDG objectives, and conduct 3 research projects to demonstrate the plausible evidence for PA achieving SDG goals. This includes a qualitative expert consensus consultation, a review of the role of the WHO Global Action Plan (GAPPA⁶), and a scoping review of the literature in meeting SDG goals. This process identifies the overlapping common SDG targets across all 3 audit methods and identifies those SDG areas identified by only one or 2 of the 3 audits, requiring further investigation. They then conduct an agent-based modeling exercise, combining strategies to assess their potential influence on PA and on related SDGs. In particular, the optimal PA strategies to improve active travel and public transportation will have maximal cobenefits for SDGs of reducing traffic-related deaths, improving air quality, and decreasing carbon emissions. In particular, these benefits will be realized in cities from low- and middle-income countries, where PA-related actions have been least well implemented.

The relationship between implementing PA plans and many SDG indicators are mutually supportive and bidirectional, as are the benefits.¹ If the planetary health agenda is taken seriously, then PA promotion is an immediate part of the solution. Upstream PA efforts are needed, targeting complex socioenvironmental causes of inactive populations, an approach reinforced by WHO.⁶ The central precept is that most influences and effectors of PA are located outside of the health sector, an idea that is difficult to translate in practice.

This concept has been described in health promotion since the 1980s, but the more recent versions, labeled “Health in all policies” remain easy to plan but challenging to implement.⁷ New approaches to systems mapping, and planning cross-sectoral policy is strengthened politically by links to the whole-of-Government SDG mandate. Nonetheless, this requires Government, non-Government and academic partnerships, sufficient planning and resources, and commitment and realistic timescales to meet the agendas of all engaged agencies.

There is a transdisciplinary research agenda suggested by this approach,¹ but a more urgent imperative is to fundamentally change PA policy and practice. Such culture change in the discipline of PA would contribute more to population scale change than the plethora of published small-scale correlates or efficacy studies. We have accumulated “academic evidence” for several decades, without substantial impact on the prevalence of inactivity. Nearly a decade after the first Lancet series on PA, the cobenefits of working with SDG targets can provide new momentum and a revitalized government imprimatur for change. This will re-energize efforts to tackle the notion that “more of the same is not enough,” for without systems-level interventions, we will not succeed in redressing the crisis in physical inactivity.⁸