People worldwide are not getting enough physical activity — despite long-running promotion efforts. About 80% of young adults move less than recommended by the World Health Organization (WHO), an international research team found in a qualitative case study published in Nature Health, one of three studies in a series. Physical inactivity is associated with an increased risk for premature death and is responsible for about 5 million deaths per year worldwide. That is comparable to the number of deaths caused by smoking or excess weight.

Yet many measures, promotion initiatives, and strategies to increase physical activity were recommended by international health organizations between 2004 and 2023. Globally, however, less than half of those recommendations were implemented. Andrea Ramírez Varela, MD, Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, and her colleagues discuss several factors that can hinder implementation: a lack of interdisciplinary approaches, disagreement about the importance of promoting physical activity, and a lack of resources in the form of responsible ministries or institutional structures.

In Germany, statutory health insurers (the country’s public health insurance funds) offer incentive programs and preventive courses, daycare centers and schools run physical activity programs, and workplace health promotion is supported through tax incentives. Municipal and national strategies round out these efforts. Still, Germany ranks only in the lower middle for implementing physical activity prevention measures on the Public Health Index — “Health Protection in European Comparison 2025.”

Surveillance and Data

“The international initiatives have certainly helped raise the profile of physical activity promotion,” said Sven Messing, research associate at the WHO Collaborating Centre for Physical Activity and Public Health at Friedrich-Alexander University Erlangen-Nuremberg in Erlangen, Germany, in remarks to the Science Media Center. Many initiatives to promote physical activity are being carried out enthusiastically, Messing said. But the data show a fundamental problem in Germany: “There are scientific pilot projects that demonstrably promote physical activity, but these usually have a limited reach. On the other hand, there are large-scale initiatives with a wide reach, for which, due to a lack of evaluation, it is unclear to what extent they promote physical activity.”

“The German landscape of physical activity has always suffered from federal fragmentation and short-term project-driven approaches,” said Sven Schneider, head of the Research Department for Child Health at the Mannheim Institute for Public Health, Social and Preventive Medicine, University of Heidelberg, Heidelberg, Germany.

“We urgently need a nationwide, standardized, and regular collection of reliable physical activity indicators — starting with the youngest children, through our teenagers, and up to senior citizens,” Schneider stressed. Only then can prevention successes be measured, problem areas detected, and regional deficits remedied. An investment backlog has led in some municipalities to a catastrophic state of sports infrastructure, he said: “Closed swimming pools, decayed gymnasiums, and cuts to school sports send a clear message to our children and adolescents: We don’t care whether you move.”

Peter Gelius, Institute of Sports Sciences, University of Lausanne, Lausanne, Switzerland, also described the results as rather sobering. But he said it would be premature to call the efforts a failure. Changes take time, Gelius said. “Our living conditions are becoming increasingly less active — in terms of transportation, at work, and in our leisure time. If there had been no political measures in the past 20 years, the level of physical activity in the population might even have declined,” he noted.

Heike Köckler, PhD, Community Health, Bochum University of Applied Sciences, Bochum, Germany, believes the potential of active mobility in Germany is still underused. The debate over gasoline prices at the pump shows that a shift from motorized private transport to active mobility can achieve many goals: less local air and noise pollution, a more active population, reduced resource use, and lower global emissions.

“Extensive concepts exist in Germany as well, but implementation is proceeding very slowly,” Köckler said. She also emphasized that existing concepts do not adequately address social inequality in health.

Urban Design Solutions

The cooperation platform “Children and Youth Sports” has formulated concrete recommendations at the end of 2025. As an example, Messing cites the recommendation to establish daily movement, play, and sports offerings in all-day school programs in cooperation with sports clubs. Other countries have shown this can work, Messing said: “In Denmark, 45 minutes of physical activity during the school day has been mandatory since 2014. Scientific studies show that Danish schools have subsequently significantly expanded their physical education hours, and children and young people are becoming more physically active.”

Germany can learn from other countries, Gelius said: “I would look primarily to the Netherlands and Scandinavia: In these countries, there has been a consistent focus on active transport, active leisure activities, and the promotion of physical activity in schools over the past decades, which German policy can take as a model.”

Schneider cites Japan and Netherlands, and cities such as Copenhagen and Paris, as positive examples. In Japan, class time is regularly interrupted for movement breaks; in Netherlands, traffic signals are timed so cyclists don’t have to wait as long at red lights when it’s raining. Copenhagen has grade-separated fast bicycle routes and long inner-city bridges exclusively for cyclists. In Paris, within 1 year, new play spaces, expanded bike lanes, and reduced tourist car traffic increased cycling by roughly 40%. “In all cases, urban planning and structural measures have made it easier to integrate exercise into everyday life as a simpler and more pleasant alternative,” Schneider explained.

Invest in Infrastructure

Germany now has the highest healthcare spending per capita in Europe, the Public Health Index showed. Schneider said this is largely because prevention and health promotion have been “criminally neglected” in Germany for decades.

Current research indicates measures are particularly promising for children and adolescents, while activity in older age is also crucial because it helps preserve independence and quality of life, Gelius said. “From a societal perspective, promoting cycling and walking is considered an important lever that links goals such as health, quality of life, and the reduction of CO₂ emissions.”

To implement physical activity promotion in Germany, it is necessary to integrate it into administrative routines and for various stakeholders to collaborate, Köckler said. She suggested tying the Special Fund for Infrastructure and Climate Neutrality to activity promotion “by investing in bicycle and pedestrian paths as well as play, movement, and meeting spaces — and their maintenance.”

Three prevention fields in Germany could yield particularly large gains:

1. Significant quantitative and qualitative expansion of school sports
2. Financial support and bureaucratic relief for clubs and associations
3. Massive investment in sports infrastructure — not only in sports and swimming halls but also in exercise opportunities in public spaces such as playgrounds, skate parks, football pitches, and calisthenics facilities

This story was translated from Medscape’s German edition.