Res Exerc Epidemiol 2011; 13(1): 1-10.
c 2011 by the Japanese Association of Exercise Epidemiology
Copyright ○【Special Article】

Global Advocacy for Physical Activity - Development and Progress of theToronto Charter for Physical Activity: A Global Call for Action
Fiona C. Bull1-3)1）Global Advocacy for Physical Activity (GAPA) the Advocacy Council of the International
Society for Physical Activity and Health (ISPAH)
2）University of Western Australia, School of Population Health, Perth, Australia
3）Loughborough University, School of Sport, Exercise and Health Science, Loughborough, UK

ABSTRACT There is well established scientific evidence on the role of regular physical activity in promoting
health and preventing non communicable disease (NCD) and this provides a solid platform for stronger
commitment and national programs aimed at increasing levels of participation in most countries. Globally, NCD‟saccount for 60% of all deaths worldwide and 80% of these occur in low and middle income countries (LMIC).
The need to scale up NCD prevention efforts, particularly in LMIC is well recognised, however evidence a lone
has yet to translate into increased action and investment in prevention strategies.
Using an „active living‟ approach, national strategies should promote and support physical activity in different
settings, including at home, in „active transport‟ (e.g. walking and cycling to get from place to place), and inleisure time (e.g. sports, recreation, exercise and play). However, what is missing in most countries is sufficient
political commitment and the necessary long term investment. For this reason, there is a need for greater advocacy
work to promote the importance of physical activity, its central role in NCD prevention along side tobacco control
and healthy diets, and the co benefits for other related agenda‟s such as environmental sustainability. The
development of the Toronto Charter for Physical Activity: A global call for action was undertaken to addressthese gaps and provide the field with a powerful advocacy tool.
Guided by an expert writing group the development used a stepped approach including an open, global
web-based consultation phase allowing a wide range of stakeholder, institutions, governments and individuals tocomment on the content and structure. The Charter took about 2 years to develop and received over 2000
individual comments from over 450 individuals or organisations from across 55 countries and all regions of theworld.
Overall, there was strong endorsement on the need for a Charter to articulate „the case‟ for physical activity andprovide an international consensus on a set of common actions that should be implemented to promote physicalactivity. The Toronto Charter provides a short, clear internationally agreed consensus highlighting all benefits ofphysical activity, beyond just health. It outlines specific examples of actions and these address all relevant sectors
including: education, transport, sports and recreation and urban planning. The Charter was launched during theclosing plenary session of the 3rd International Congress on Physical Activity and Public Health in Toronto, May
2010. Since then, the Charter has been translated into 11 languages and has received over 500 individual and 135
organisational indications of support with representation from around the world. Given the forthcoming United
Nation‟s High Level Meeting of the General Assembly on chronic non-communicable disease (Sept 2011) it istimely to have the Toronto Charter, and the recently released supporting document „NCD Prevention: Investmentsthat work for physical activity‟, to present at preceding consultation meetings and to support the inclusion ofphysical activity in relevant discussions.
Key words: advocacy, health promotion, chronic disease, partnership, policy
Address for correspondence: Fiona C. Bull; School of Population Health, M341 Clifton Street Campus, University ofWestern Australia, Perth, WA 6009, Australia; fiona.bull@uwa.edu.au1Res Exerc Epidemiol 2011; 13(1): 1-10.

Regular physical activity promotes health and wellbeing and prevents disease. The scientific evidence
underpinning this statement started over 50 years ago
by Jerry Morris in the UK1) and is now wellestablished. This solid base of epidemiological andexperimental evidence has been an essential building
block for the promotion of physical activity as animportant public health priority. 2) Globally, the need toscale up efforts to prevent non communicable disease(NCD) has received much attention, particularly in thelast 5 years by the World Health Organization 3-8) andothers.9-11) However, despite the strong evidence andthe increasing magnitude of the NCD burden, many
are noting that evidence alone has yet to translate into
increased action and investment in prevention
strategies.12)
Recent global estimates indicate that approximately
two thirds (60%) of the worlds adult population are
physically inactive.8,13) Given that NCD account for
60% of all deaths worldwide, 6) with 80% of deaths
occurring in low and middle income countries (LMIC),
it is clear that promoting adequate levels of physicalactivity can contribute to disease prevention in LMIC
as well as high income countries (HIC). This isparticularly important for regions such as South East
Asia, Latin America and Africa where rapid economic
and social transitions are underway and increasing
amounts of time may be spent in sedentary activity atwork, for transport and in leisure and recreation.
One particular concern is the position of physicalinactivity within the NCD prevention agenda.
Although WHO has made clear efforts to present
physical activity within a comprehensive approach to
NCD prevention7,14) it is not often visible in national
NCD planning and, where present, often does notreceive the same attention or resources compared withother behavioural risk factors such as tobacco control
and nutrition.15) This is despite recent global assessments placing physical inactivity as the fourth leadingrisk factor of chronic disease mortality such as heartdisease, stroke, diabetes, cancers; and inactivity
contributing to over three million preventable deaths
annually worldwide.16)
The benefits of regular physical activity extend
beyond primary prevention and there is a solid
evidence base on the effectiveness of physical activity

interventions for treating and managing patients withlong term conditions.2) The role of physical activity inprimary and secondary prevention provides a strong
case for a systematic approach to integrating NCD
prevention and assessment and counselling on
physical activity within national health care systems
as part of both prevention and clinical treatment
pathways. However, to date few countries have such
systems developed and the potential of this entry point
for addressing behavioural risk factors remains largely
un fulfilled.10,17)
In addition to the public health benefits, an active
lifestyle can improve psychological health, social
connectedness and quality of life for individuals andcommunity.18,19) The promotion of physical activity
can also provide economic benefits20,21) and contributeto environmental sustainability.22) For example, effective promotion of increased walking and cycling
can reduce traffic congestion and contribute to cleaner
air.23) These co benefits are of increasing importancegiven trends such as the rapid advancements in newtechnologies, urbanization, population growth, thewidespread „car culture‟, loss of public and green
open space through urban development, and theincrease in electronic entertainment options. These
contemporary societal changes are highly likely tolead to a decrease in levels of physical activity andtotal energy expenditure. Such changes are welladvanced, particularly in high and middle income
countries and if left unchecked will lead to fewer
opportunities to be physically activity and an increasein preventable disease and widening gaps in thequality of life and health outcomes between the richand poor. Also, in many low income countries thesechanges are happening rapidly, and are likely to makeit more difficult to maintain an active lifestyle.
Alarming increases in overweight and obesity are
already being reported24-27) and there is evidence thaturbanisation, and especially the transition fromhuman-powered transport to automobiles is independently associated with weight gain over time, forexample in China28) and Columbia.29)
Solutions to increase physical activity are known.
An „active living‟ approach to different domains andsettings, including at home, in „active transport‟ (e.g.
walking and cycling to get from place to place), and in2

Res Exerc Epidemiol 2011; 13(1): 1-10.

leisure time (e.g. sports, recreation, exercise and play).
Effective interventions are available to promote
physical activity across the life course and there is avery large body of literature on the actions andstrategies required at national, regional and local levelto support „active living‟.23,30-32) Although much of theevidence is from high income countries, an increasing
amount is coming from middle income countries, 33)
particularly from Latin America. 34,35) Yet, despite thisevidence some six years after the launch of the World
Health Organ- ization‟s (WHO) Global Strategy on
Diet, Physical Activity and Health, 14) only a dozen or
so countries have national plans for physical activity
and even in these mostly high income countries,
implementation on the ground is often underresourced.15,36)
What is clearly missing in many countries is thepolitical will to make the necessary long term
investments in NCD prevention, and specifically instrategies aimed at physical activity. For this reason,
there is a need for greater advocacy to promote theimportance of physical activity, develop physicalactivity relevant policy, and implement programs andpolicies to support physical activity at the populationlevel.37,38) Advocacy itself has been defined as the“combination of individual and social actions
designed to gain political commitment, policy support,social acceptance and systems support for a particular
health goal or programme.”38,39)
Public health success in reducing tobacco use
provides those working on physical activity advocacy
with several key lessons40) three of which areparticularly relevant for the current advocacy agenda
for physical activity. Firstly, we must acknowledge
and communicate clearly and widely that there issufficient evidence to act. Secondly, we need a concise„message‟ about the benefits of physical activity and
one which creates links with other relevant agendas tomaximise the reach and salience. Thirdly, we need aclear set of actions that are proven, widely applicableand easily transferable to different countries andsettings. The development of the Toronto Charter for
Physical Activity: A global call for action wasundertaken to address these gaps and provide the fieldwith a powerful advocacy tool.

The Toronto Charter Development Process
In 2009, the Global Advocacy Council for Physical
Activity (GAPA) of the International Society for
Physical Activity and Health (ISPAH) in conjunction
with the 3rd International Congress on Physical
Activity and Public Health commenced the development of a global call to action in the form of aphysical activity charter. Guided by an expert writing
group comprising academics and public healthprofessionals,*1 the development process used a
stepped (see Figure 1) approach involving initial firstdraft consultation with a small group of expert
colleagues and stakeholders within and outside
physical activity and health, and in a wide variety ofcountries. After valuable feedback on the general
structure and direction, the second draft of the Charter
was developed and translated into French and Spanishand posted for an open, global web-based consultation
with a wide range of agencies, governments andindividuals. The consultation sought commentary andindications of support for the content, structure, title
and the Charter‟s potential usefulness. This phase of
consultation commenced January 2010 and wascompleted in April 2010. Over 2000 individual comments were provided from over 450 individuals ororganisations from across 55 countries and all regionsof the world.
All feedback was collated, French and Spanish
comments were translated to English and reviewed.
Overall, the comments strongly endorsed the need fora document that articulates „the case‟ for physicalactivity and which provides an international consensus
on the common actions to promote physical activity.

*1

Professor Fiona C. Bull, School of Population Health, The University of Western Australia, Perth, Australia and School ofSport, Exercise and Health Science, Loughborough University, UK; Professor Lise Gauvin, Université of Montréal,
Department of Preventive and Social Medicine, Canada; Professor Adrian Bauman, School of Public Health, Universit y of
Sydney, Sydney, Australia; Trevor Shilton, National Heart Foundation, Perth, Australia; Professor Harold W. Kohl III,
University of Texas Health Science Center –Houston, School of Public Health, University of Texas at Austin, Department ofKinesiology and Health Education, Austin, USA; Art Salmon, Ontario Ministry of Health Promotion, Toronto, Canada.

3

Res Exerc Epidemiol 2011; 13(1): 1-10.

Figure 1

Development steps of the Toronto Charter for
Physical Activity: A global call for action

Extensive editing was undertaken to incorporate all
relevant feedback and provide a shorter, concise
document that highlighted all the varied benefits ofphysical activity, particularly those beyond the healthsector. Clear and specific examples of actions werecalled for across the different sections of the Charteras well as a stronger more focused final „call to act‟.
One very important revision was to avoid the text
„coming from‟ and „speaking to‟ only the health sector.
We were asked to emphasize the already inclusive
nature of the draft Charter and highlight the relevanceof physical activity to sectors other than health whose
actions and engagement are so important (for example
transport, urban design, landscape and architecture,
education, sport and recreation). Avoiding „healthcentric‟ writing included ensuring that an equal
number of examples were provided for each sector
and not listing the health related issues first! Other
amendments ensure that the Toronto Charter addressed issues of inequalities, safety, gender, accessand inclusiveness.
The final text of the Charter was launched during
the closing plenary session of the 3rd International
Congress on Physical Activity and Public Health inToronto, May 2010. During the congress over 1,200
delegates had the opportunity to make additionalcomments and they received a final copy in theclosing session. It was evident from the overwhelming
response from the audience that the Toronto Charter
for Physical Activity was fully accepted and seen as alandmark document. Further details on the edits anddevelopment process can be seen in the video of the
final closing session [see www.globalpa.org.uk] orfrom the author.

The Toronto Charter for Physical Activity:
A global call for action
The Toronto Charter for Physical Activity: A global
call for action41) is first and foremost an advocacy toolfor use with political leaders, decisions makers, andcolleagues at the local, city, regional and national
level by all professionals involved in physical activity.
The goal is for the Charter to be a representative of aninternationally agreed, summary of the need to act on
physical activity and the strategies required. The
purpose is to gain increased political priority andinvestment in policy and programs aimed at increasing
and supporting active living across the life course in
all countries.
The Charter is divided into five sections. The firstand second sections provide a short „case‟ for theCharter and for physical activity outlining the arguments on why physical activity is important across4Res Exerc Epidemiol 2011; 13(1): 1-10.

Figure 2

The Toronto Charter platform for Action: Four Areas

several government portfolios, and the multiple cobenefits available from increasing population levels ofphysical activity. The third section sets out nine
principles for action which are consistent with contemporary health promotion and global public healthpractice. The fourth section provides a framework offour priority areas for strategic action which are
relevant and applicable to all countries and consistent
with scientific evidence. These are: 1) develop andimplement national strategy; 2) introduce polices andregulations; 3) provide and reorientate programs,
services and supportive environments; and, 4) develop
partnerships for action. These are shown in Figure 2
and in the charter itself each area has a brief
description and a set of examples.
The final section of the Charter is the global call toaction and this sets out specific ways in which theToronto Charter can be supported and used for
advocacy locally, nationally, and globally. These
actions range from individual and institutional
endorsement via the GAPA website and a „virtual signup‟ through to actions supporting dissemination bysending the charter itself and the web link to colleagues and networks within countries and worldwide.
Both of these are useful in raising the visibility of theCharter with interested stakeholders but they are notsufficient on their own to achieve the main goal ofincreased commitment and investment by national
governments. The global call invites everyone, individuals, academics, practitioners, government officials
and leaders from different sectors, and interested
organisations, to use the Charter in at least three ways:
1) to guide their current work; 2) to support thescaling up of efforts within countries and regions; and3) as a platform to meet with key decision makers to
influence their level of knowledge and commitment
towards the agenda on physical activity. The power of
meeting with decision makers and provision of
relevant examples of what can be done should not be
underestimated and is a well recognised necessary partof the policy process.42,43) At the Launch of theToronto Charter in May 2010, these ideas andambitions were summarised as the „Call to Action‟ anddelegates were invited to respond to the challenge.

Reflections on the Charter: 9 months on
During the nine months since the May 2010 Charterlaunch, GAPA has tracked the dissemination and useof the Toronto Charter via: the GAPA website; throughsearches for use via the internet; through the physicalactivity networks*2 and partners; and personal emailcommunications. The most immediate signal that theCharter was well accepted, had global relevance and*2

Health Enhancing Physical Activity European Network (HEPA) [www.euro.who.int/hepa]; Physical activity networks of
the Americas (PANA/RAFA) [www.rafapana.org]; Asia Pacific Physical Activity Network (APPAN) [www.ap-pan.org];
African Physical Activity Network (AFPAN) [www.essm.uct.ac.za/afpan/index.htm]

5Res Exerc Epidemiol 2011; 13(1): 1-10.

fulfilled a need was from the early and ongoing
response to voluntarily translate the Charter in todifferent languages. The Charter is now available in
12 languages, including Japanese and another 8
language translations are underway. Another indication of the support for and the relevance of theToronto Charter is evident from the GAPA website
which as now received over 500 individual and 135
organisational signatures of support with representation from around the world. This is in addition to thehundreds of signatures received in person at the
primary launch of the Charter in Toronto and thesubsequent launch of the Spanish and Portuguese
versions in Sao Paulo in October 2010. It is noted that
support to date has been strongest from North
America and Europe but is increasing from different
countries in other regions as the translated versions
become available. For example, in a very shorttimeframe the Norwegian and Czech translations havereached high levels of downloads. This is importantbecause it shows that it is the combination ofinternationally agreed content and local translation
with local adaptation to ensure cultural relevancealong with visual illustrations (photographic images
are tailored for each language to increase country
relevance) are important attributes of this advocacy
tool. Although the translation process has been
undertaken with only modest resources covering
centralized typesetting and design, *3 and has relied onvoluntary time to cover translation tasks, *4 this is an
important phase of work to increase dissemination anduptake.
In addition to translation, formal adoption, endorsement and/or letters of support for the Toronto Charter
have been received from a variety of sources since
May 2010. Examples include: national physicalactivity initiatives such as ParticipACTION in
Canada; State level support (e.g. the whole-of government Physical Activity Task Force in Western
Australia); City Government level support (e.g. Major
of Bogota); national and international non government
support (e.g. Heart Foundation of Australia and theWorld Heart Federation); and scientific and professional associations (e.g. The International Union of
Health Promotion and Education). This work is
ongoing as part of the dissemination agenda andrequires the commitment of individuals - in every
country - to introduce and secure completion throughthe relevant formal processes. Further work to secure
support and endorsements from local, state, national
and international agencies and other stakeholders
interested in physical activity, is very much welcomed
to further enhance the position of the Toronto Charteras an internationally agreed direction and platformfrom which to start, and scale up, our efforts toaddress physical activity. This is a particularly valued
feature of the Toronto Charter for those in low andmiddle income countries where action on physicalactivity is in a very early stage or as yet to beestablished. In these contexts there is often very little
capacity on physical activity and the direction provided by the Charter, supported by the international„voice‟ is vital to gaining and securing attention on thephysical activity agenda. Readers of this paper are
invited to consider what action they can take to secureawareness, support and use of the Toronto Charter.
Over and above dissemination of the Charter via thewebsites and scientific and professional list serves,colleagues and collaborators have sought publicationin relevant scientific journals and other media outlets.
Examples of countries that have led publication of theCharter itself and/or an article on the Charter include
Australia, Canada, Germany, Sweden, Japan (in thisissue) and the UK. More media coverage is welcomedand support for such activity is available from GAPA.
Influencing the priority given to physical activity
and gaining tangible commitment to resource relevant
policies and programs is the key goal of the Toronto
Charter. Outcome indicators of success would include:
new national policies; increased resourcing to physicalactivity; new partnerships between relevant sectors
within a country; commencement and commitment
towards surveillance of population levels of activity.
Our ongoing tracking has revealed that the Toronto*3

The ongoing support from Art Salmon at Ontario Ministry of Health Promotion, Toronto, Canada and the 3 rd International
Congress Committee is greatly appreciated*4
See www.globalpa.org.uk/charter/translation.php for full details of those involved in the voluntary translations for eachlanguage6

Res Exerc Epidemiol 2011; 13(1): 1-10.

Charter is being used as a background template for thedevelopment of national strategies. One example isthe new work underway in Canada, which despite its
well known leadership in physical activity, does not
currently have a national strategy on physical activity.
Canada is using the Charter as a foundation document
for the development of a National physical activity
plan for Canada. Other examples include recent
developments in Thailand, where work on physicalactivity is in an early stage and being led by the nongovernment sector and specifically Thai HealthFoundation.44) The Charter was viewed as providing
the internationally agreed direction and a guiding toolfor commencing both national policy and program andused as the central platform for a cross sector national
meeting in November 2010. GAPA encourages further
use of the Toronto Charter in ways that will stimulate
and support the agenda of physical activity. Further
examples and support is available from GAPA
Executive Committee (www.globalpa.org.uk).

national and international consultations involving thegovernment, non government and private sector, it isvital that the issues related to physical activity are
well represented. It is timely to have a document suchas the Toronto Charter to present at such meetings andsupport relevant discussions. As previously stated, it is
now essential that the physical activity community
communicate clearly and widely that there issufficient evidence to act. It will be useful to refer to acommon concise „message‟ about the benefits ofphysical activity, create links with other relevant
agendas and maximise the reach and relevance ofaction on physical activity.
It is also necessary to provide the international
audience with a set of specific program and policy
measures that are widely applicable to different
countries and settings. The Toronto Charter provides
strategic direction however to supplement this and add
specificity, GAPA has developed a short document on
the „best buys‟ for physical activity. NCD Prevention:
Investments that work for physical activity identifies
seven specific interventions which are supported bygood evidence of effectiveness and that haveworldwide applicability.41) Although it is known there
is no one single solution to increasing physical activity,
the seven actions are proposed as well as therecommendation that an effective comprehensive
approach will require multiple concurrent strategies tobe implemented. To download a copy visit www.
globalpa.org.uk.
Advocacy for physical activity requires the
economic evidence of cost effectiveness as this is an
essential component to policy decisions. It is however
an area of weakness in the physical activity literatureand more work is urgently required. Nonetheless, allavailable evidence is being utilized to secure a place
for physical activity within the discussions both
leading up to the UN meeting and in the national andinternational debate that follows. Although major
initiatives are underway to develop better methods andinformation on „what works‟ both within WHO and by
the scientific community,47) it is worth highlighting
two other relevant key lessons from our colleagues intobacco control.40) Action should not be delayed due
to insufficient evidence but rather undertaken basedon sound judgement and in ways that allow for critical

The Toronto Charter: Next steps for 2011 andbeyondThe Toronto Charter on Physical Activity: A global
call to action41) provides the worldwide physicalactivity community, including those directly andindirectly working on related issues, with aninternationally agreed platform for policy and action
to encourage and support active living across the life
course. In addition to continuing to support translationand dissemination of the Charter, 2011 represents animportant year for GAPA and the global community
interested in physical activity and the wider agenda ofNCD prevention. The United Nation‟s High Level
Meeting of the General Assembly on chronic noncommunicable disease45) scheduled for Sept 2011 isrecognised as an historic opportunity for gaining
greater recognition and response at the global andnational levels.46) The focus of the meeting will be on
the rising incidence and the social and economic
impact of non-communicable diseases, particularly in
low and middle income countries as well as on the key
NCD risk factors and strengthening national capacities
and policies for NCD prevention and control. A large
coordinated process is underway for a series of7Res Exerc Epidemiol 2011; 13(1): 1-10.

evaluation; this seems particularly true for addressing
gaps in the economic evidence for interventions on
physical activity. Secondly, experience from developed countries, under different political leaderships,
has repeatedly shown government action being
delayed by hiding behind the debate of „individual
versus societal‟ responsibility. 40) In all societies there
is a role for both, but as Yach et al., (2005) point out,
individual action and choice can only be fully realised
in societies where governments and private sector
interests work to support the provision of individual
choice.40) The provision of choice and opportunities tolead active lifestyles through enjoyable, safe physicalactivity in different domains of life is the central focusof the Toronto Charter. 2011 is the year for all
interested parties to voice their support for individual
and societal action on physical activity, to provide
their expertise and guide discussions on physicalactivity to achieve our shared vision - active andhealthy living for all.

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Acknowledgments
The author gratefully acknowledges the work of theCharter Writing Group and the GAPA Executive
Committee for their contributions and leadership inthe development and dissemination of the Toronto
Charter and the Investments that Work documents. In
addition, the author wishes to thank Professor Adrian
Bauman for his review and comments.

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