2013 47: 1003-1011 Br J Sports Med
Gordon O Matheson, Martin Klügl, Lars Engebretsen, et al.
consensus statement, Lausanne 2013
non-communicable disease: the IOC
Prevention and management of
Updated information and services can be found at:
This article cites 63 articles, 20 of which can be accessed free at:
the box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in
(167 articles)Editor's choice
Articles on similar topics can be found in the following collections
To request permissions go to:
To order reprints go to:
To subscribe to BMJ go to:
group.bmj.com on October 11, 2013 - Published by bjsm.bmj.comDownloaded from
Prevention and management of non-communicable
disease: the IOC consensus statement, Lausanne 2013
Gordon O Matheson,1,2Martin Klügl,3Lars Engebretsen,4,5,6Fredrik Bendiksen,4
Steven N Blair,7Mats Börjesson,8,9Richard Budgett,5Wayne Derman,10
Uğur Erdener,5John P A Ioannidis,11Karim M Khan,12Rodrigo Martinez,13
Willem Van Mechelen,10,14,15Margo Mountjoy,16Robert E Sallis,17
Martin Schwellnus,10Rebecca Shultz,1,2Torbjørn Soligard,5Kathrin Steffen,4
Carl Johan Sundberg,18Richard Weiler,19,20Arne Ljungqvist5
For numbered affiliations see
end of article.
Dr Gordon O Matheson, Sports
Medicine Center 341 Galvez
Street, Stanford, CA 94305,
Received 27 August 2013
Accepted 27 August 2013
To cite: Matheson GO,
Klügl M, Engebretsen L,
et al. Br J Sports Med
Morbidity and mortality from preventable, non-
communicable chronic disease (NCD) threatens the
health of our populations and our economies. The
accumulation of vast amounts of scientific knowledge
has done little to change this. New and innovative
thinking is essential to foster new creative approaches
that leverage and integrate evidence through the support
of big data, technology and design thinking. The
purpose of this paper is to summarise the results of a
consensus meeting on NCD prevention sponsored by the
IOC in April 2013. Within the context of advocacy for
multifaceted systems change, the IOC’s focus is to create
solutions that gain traction within healthcare systems.
The group of participants attending the meeting
achieved consensus on a strategy for the prevention and
management of chronic disease that includes the
following: (1) Focus on behavioural change as the core
component of all clinical programmes for the prevention
and management of chronic disease. (2) Establish actual
centres to design, implement, study and improve
preventive programmes for chronic disease. (3) Use
human-centred design in the creation of prevention
programmes with an inclination to action, rapid
prototyping and multiple iterations. (4) Extend the
knowledge and skills of Sports and Exercise Medicine
(SEM) professionals to build new programmes for the
prevention and treatment of chronic disease focused on
physical activity, diet and lifestyle. (5) Mobilise resources
and leverage networks to scale and distribute
programmes of prevention. True innovation lies in the
ability to align thinking around these core strategies to
ensure successful implementation of NCD prevention and
management programmes within healthcare. The IOC
and SEM community are in an ideal position to lead this
disruptive change. The outcome of the consensus
meeting was the creation of the IOC Non-Communicable
Diseases ad hoc Working Group charged with the
responsibility of moving this agenda forward.
Non-communicable diseases (NCD, box 1) account
for 60% of all deaths and 44% of premature
deaths.1 2NCD are now the greatest cause of mor-
bidity and mortality even in developing countries
where they account for twice as many deaths as
HIV/AIDS, tuberculosis, malaria and all other
infectious diseases combined.1–3They are a barrier
to achieving the UN’s Millennium Development
Goals4and are a global threat to our economies in
addition to our health. A report by the World
Economic Forum and Harvard University estimates
that chronic diseases, currently costing 2% of the
global gross domestic product (GDP), will cost the
global economy US$30 trillion over the next two
decades, cumulatively 48% of the global GDP in
2010.3But, chronic diseases are largely prevent-
able. Their main causes are related to lifestyle, that
is, physical inactivity (recently labelled by The
Lancet as being pandemic5), an unhealthy diet and
tobacco and alcohol abuse.
In 2010, the WHO and the IOC signed a memo-
randum of understanding to jointly promote activ-
ities and policy choices designed to reduce the risk
of NCD.6This was followed by a landmark speech
given by the IOC President to the plenary session
of the 66th General Assembly of the United
Nations, September 19, 2011; a “watershed event”
to “replace ignorance and inertia with awareness
and right actions”.7IOC President Dr Jacques
Rogge told the Assembly: “The problem is acute,
the solution is at hand. It is a grim picture, except
for one thing: We can do something about it.”
Low cost, highly effective solutions for the pre-
vention and management of NCD are available.5
The IOC President emphasised the WHO recom-
mendations on physical activity as central to NCD
prevention.6He called for safe and accessible
public spaces for physical activity and sport, part-
nerships with transportation and urban planning,
increased physical education and better sport infra-
structure and organisation, thus building on the
comprehensive, broad-based, long-term approaches
recommended by International Society for Physical
Activity and Health (ISPAH), the Grand Challenges
Global Partnership, the WHO, the European
Commission (EC), the World Economic Forum
(WEF), Active Canada, Exercise is Medicine, the
Development (OECD)1–3 8–13and many others.
To date, efforts to promote a ‘home’ for preven-
tion within healthcare have largely failed. Waiting
for comprehensive, emergent reform of dysfunc-
tional healthcare systems is unrealistic. Likewise,
results from reductionist research studies have not
been successfully implemented and scaled in such a
way as to create population-wide impact.
Scan to access more
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-0930341 of 11
group.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.comgroup.bmj.com on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by on October 11, 2013 - Published by bjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.combjsm.bmj.comDownloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from Downloaded from
The current approaches to chronic disease prevention and
management involving public health and global health strategy14
may need to be merged with human-centred design (HCD). The
latter approach, used as a catalyst for change in other industries,
focuses on the importance of the human element in behavioural
approaches will require committed, visionary leadership willing
to reframe the problem from a practical, human-design perspec-
tive while sticking to a clear strategy to mobilise the resources
and capacities needed for change.
The objective of this IOC consensus meeting was to achieve
alignment on a strategy to design a sustainable plan of action for
the prevention and management of NCD, coupling existing scien-
tific evidence with HCD, focusing particularly on physical activity/
exercise and behavioural change. In order to accomplish this
objective, the sport and exercise medicine (SEM) community must
overcome considerable inertia created by the complexity and mag-
nitude of the NCD problem and its context. The SEM community
must bundle its efforts and embrace a new, creative approach
aligned with a strategy that is clear, concrete and human-centred.
For most of human history, people needed to be physically
active to survive. Today, for instance, only 20% of Norwegian,15
8.2% of the USA16and 5% of the UK17adults meet physical
activity guidelines. Over a four-decade period, physical activity
in the US has declined 32% and is projected to decline even
further to 46% by 2030,18while from 1991 to 2009, China’s
physical activity rates dropped by 45%.18In the Arab World,
eight countries have physical inactivity levels ranging from 33%
to 70% of the population.19Over the past 50 years there has
been a marked decline in energy expenditure for household
management20and civilian occupation,21sufficient to explain
the rising prevalence of obesity.22Worldwide, physical inactivity
and smoking are responsible for more deaths than any other
modifiable risk factors.5Clinical scientists are continuing to
identify more characteristics that magnify the problem. For
example, sitting time has been shown to be associated with
increased cardiometabolic risk independent of levels of physical
activity.23–25Low aerobic fitness is a risk factor for all-cause
mortality, cancer and cardiovascular disease, independent of
body fatness.26 27
While the problem of physical inactivity, poor diet and
unhealthy lifestyle behaviours is evident and clear, the real
problem is that we have not been able to mitigate the steady rise
in NCD. In fact, the morbidity and mortality from NCD has
worsened during the time we have been accumulating research
data and publishing position statements and recommenda-
tions.28The mere existence of national physical activity policies
or action plans does not ensure their functionality or implemen-
tation. Physical activity guidelines are not implementation and
implementation does not guarantee change.29We can no longer
opine that governments, schools, employers, facility managers,
urban planners, ministries of education, global organisations,
healthcare professionals, universities, recreation and health
departments, community organisations, sport federations, the
healthcare system and transportation departments, ‘should’ do
something.8The SEM community can do something, because its
expertise lies closest to the intersection of physical activity, diet
Despite global advocacy for a sound ‘whole of government’
systems approach,30the direct and indirect costs of NCD
remain staggering and unsustainable due to the financial, polit-
ical and structural complexity involved. The healthcare industry
pushes government agencies to formulate policies leading to
change and the government pushes the healthcare industry to
develop programmes of prevention. The failed attempt to limit
the serving size of sugar-sweetened beverages by Mayor
Bloomberg in New York City is an example of the limits of
authority even with well-intended policy interventions.31In
contrast, the Director of the Swedish Bureau of National Health
and Welfare declared there is enough evidence32 33for the
healthcare system to act ‘now’; an example of the government’s
expectation that real change requires the medical system to act.
Prevention remains caught in the middle with policy makers
asking healthcare to implement change and vice versa. With
broad and ill-defined objectives that lack alignment and strategic
focus, prevention remains in the realm of passive and suggestive
theory and the vast amount of scientific evidence while true, has
been useless for effecting change.34Not surprisingly, there is no
clear plan to respond. We readily acknowledge the conflict
between the complexity of chronic disease and the reductionist
approach being used to solve it as well as the potential blind
spots that result from determinist thinking.35 36The complex
non-linearity of health behaviour does not allow for simplifica-
tion by solely focusing on a single intervention. We must resist,
on the one hand, lofty position statements and recommenda-
tions that lack concreteness and clarity and that displace respon-
sibility to amorphous entities and on the other hand, a
top-down approach conceived by medical and scientific experts
that reproduce knowledge and guidelines that do not translate
We must figure out how to get around the obstacles that
prevent us from making progress in prevention. These include:
(1) the reductionist, determinist approach to thinking within
medical science which has become the default approach to
healthcare delivery, (2) the financial model of disease-based and
event-based medicine, (3) the single intervention model, (4) the
lack of disease-burden matched and prevention-oriented curric-
ula for training healthcare professionals, (5) the absence of a tai-
lored distribution channel to deliver knowledge and (6) the
uncertainty of changing human behaviour.37
In order to create a consensus action plan for the prevention and
management of chronic disease, the IOC convened a group of
Box 1List of non-communicable diseases
▸ Cardiovascular disease
▸ Chronic respiratory disease
▸ Metabolic syndrome
▸ Degenerative disc disease
▸ Sarcopenia and frailty
▸ Cognitive impairment
▸ Cerebrovascular disease
▸ Neurodegenerative disease
▸ Rheumatoid arthritis
2 of 11Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034
experts 10–12 April 2013 in Lausanne representing sport and
exercise medicine, public health, clinical epidemiology, design
thinking, industry leadership, advocacy, exercise science, reliability
and reproducibility of biomedical evidence, social marketing, edu-
cation, technology and lifestyle behaviour interventions. Prior to
this, five participants met for 1 day in New York in December,
2012 to plan a design thinking approach to the meeting.
The 2.5 day meeting opened with an introduction and state-
ment of the problem followed by 15 min lectures and discussion
by each participant, addressing the following three questions:
(1) Why did you accept the invitation to this meeting (why are
you here)? (2) What do you believe is the single most important
thing that needs to happen (actually take place) to reduce
the morbidity and mortality associated with chronic disease?
(3) What steps would you take to implement that ‘thing’ in the
next 1 year? Experts were urged to use existing systematic collec-
tions of evidence as well as point to new areas of opportunity.
These presentations and discussions led the group to formulate
the following issues for consideration: (1) the problem, (2) oppor-
tunities for behavioural change, (3) the importance of HCD, (4)
the value of the SEM model of function and performance, (5) the
requirement for actual centres within which to develop prevention
programmes and (6) the importance of the IOC’s leadership. Half
the meeting time was spent using a design thinking approach to
integrate scientific evidence with human reality to achieve a con-
sensus for an action plan. The last half-day was spent formulating
a rough draft of the manuscript and an 18-month action agenda.
Given the impact of unhealthy lifestyles on the chronic disease
pandemic,5 16 29governments began, decades ago, to emphasise
lifestyle and behaviour changes to broaden the scope of national
health policies beyond traditional medical and surgical interven-
tions.38–40For this reason, a primary focus on behavioural
change as the core component of all clinical programmes for the
prevention and management of chronic disease is essential.
Understanding and guiding human behaviour is very complex
given the wide range and overlapping correlation of individual
(beliefs and attitudes), interpersonal (cultural and social norms),
environmental (social, built and natural environment) and
policy (regional, national and global) factors.16In a Swedish
study, 76% of patients recognised responsibility for changing
their own behaviour but still expected the healthcare system to
help them change.41This complexity reflects the underlying dis-
cussion as to personal or social ‘responsibility’ for physical
inactivity and other lifestyle ‘choices’.
The emphasis of interventions can be on proximal (individ-
ual) or more distal (social–cultural and/or environmental–polit-
ical) correlates of physical inactivity and other lifestyle-related
behaviours. There is good reason to believe the proper emphasis
is changing the environment by engineering physical activity
into our daily lives without individual awareness. Insights such
as the so called ‘nudges’ encourage and support people through
change toward a choice architecture that alters their behaviour
in a predictable way, while fully preserving their autonomy and
respecting cultural norms. In simple terms, nudging can be used
to change the default option towards a healthier choice,42 43for
example, by placing healthier products at a more prominent and
convenient place in the cafeteria. However, altering choice
architecture through advocating for concurrent, system-wide
strategies to build a supportive environment requires huge
efforts to orchestrate multiple stakeholders including policy
makers, non-governmental organisation (NGO), schools and
corporations to bring about desired changes.
Various social cognitive theories that solely emphasise the
intention of self-regulation and self-control as key determinants
of behaviour for example, Theory of Reasoned Action44and
Theory of Planned Behaviour45fall short when taking into
account the importance of the habit formation process46and
the contextual nature of behaviour.47Traditional interventions
assume that people make rational lifestyle decisions whereas, in
reality, many such decisions are actually irrational, using unrea-
soned shortcuts or heuristics (habits) instead of logic.48Thus,
most interventions, which are designed solely from a content
perspective without acknowledging the user as the expert of
their own experience, are more likely to fail. Interventions and
solutions need to “go with the grain of how people behave.”49
The power of habit formation in behaviour counselling
remains relatively untapped for NCD prevention. Habits are
automatic responses to contextual cues, acquired through repeti-
tion of behaviour in the presence of these cues.50In order to
change these habits one needs to take into account that a spe-
cific cue will trigger action if motivation and ability to perform
the task are adequate to result in a physical or psychological
reward.51For example, even if an unfit person becomes highly
motivated to run a marathon tomorrow, he or she will most
likely not succeed since the physical ability (eg, cardiovascular
capacity and muscular endurance) needs to be developed over
time. Thus, the difficulty of the task needs to be lowered and
thereby the ability to perform increased. Habit formation starts
with simple, very specific tasks of daily physical activity that can
be gradually increased as one builds confidence and control (eg,
taking the stairs instead of the elevator at work). With incremen-
tal success and the adoption of more ambitious behaviours, a
more tractable and specific behaviour change is targeted rather
than a complex task such as ‘running a marathon’. Upon suc-
cessful formation of one specific healthy habit in isolation, there
may be a spillover effect to many other aspects of the indivi-
dual’s life.52 53Additionally, targeting one person with a behav-
iour change programme may impact his or her social network
by triggering substantial behaviour change in that person’s
friends, thereby shaping a social norm.52Thus, the cumulative
impact of a preventive intervention is the sum of the direct
health outcome of the individual, plus the collateral health out-
comes in those socially connected (collateral health effects).
This emphasises the connection between the individual and sur-
rounding social determinants of health.54Of course, collateral
effects can be both positive and negative, and therefore both
possibilities should be considered.
A large opportunity is appearing related to the conversion of
data into information that helps guide sound decisions by both
clinicians and patients. Tools like patient activation measures
help to stratify and individualise patient care by tailoring coach-
ing, education, prevention and care protocols to different
patients at different levels of readiness.55Technological advances
are readily available, such as pedometers or tracking devices,
that may include sensors in smartphones, to provide important
Persuasive technology uses interactive smartphone applications
as a decision support tool to trigger certain user behaviours
through instant feedback and support.51By incorporating the
feedback from real-time patient data analysis, it is possible to
provide insights in the choice architecture towards much more
targeted behaviour counselling.51
The explosion of big data produced by the digital society has
caused a management revolution in other industries in decision-
making and customer engagement.57 58Companies worldwide
invest heavily in sophisticated analytical capabilities aiming to
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-0930343 of 11
draw meaningful customer insights.56For example, traditional
retailers analyse buying habits of their customers and run algo-
rithms to better predict their needs and customise their product
suggestions based on unique preferences of the individual.59In
public health, Google is able to predict the spread of an influenza
pandemic more accurately and several weeks earlier than the trad-
itional surveillance systems of the US Centers for Disease Control
(CDC).60Comprehensive data analytics have long been used in
sports such as baseball and soccer to determine success factors and
adjust the tactics accordingly.61In healthcare, electronic medical
records (EMR) generate massive data sets, offering the challenge
of how to convert largely unstructured by-products of healthcare
delivery into useful assets for patients’ insight.62These techno-
logical advances will leverage insights, foster behavioural change
and ultimately lead to habit formation by influencing the individ-
ual, interpersonal or environmental factors, a necessity for a suc-
cessful prevention plan.
In preventive healthcare we too often jump from our knowledge
of a situation to ‘learned solutions’, bypassing critically import-
ant steps including observing, discovering, interpreting, ideating,
prototyping, iterating and monitoring (figure 2A). This works
for many of our daily tasks (eg, prescribing β-blockers for high-
blood pressure) but reaches its limits with lifestyle change. For
example, we do not always know how to translate precise, well-
established guidelines and recommendations into an individual’s
daily routine.63Nor do we educate healthcare providers with
the knowledge and skills to deliver well-established and
evidence-based interventions to our patients.64From a scientific,
analytical perspective we know the dose–response relationship
of regular exercise with regard to frequency, duration and inten-
sity.65In fact, every healthcare professional and layperson
knows more or less about the importance of physical activity to
well-being and quality of life. Still, the compliance rate with
evidence-based guidelines is poor and inconsistent, from the
provider and the patient perspective63 66
Interventions designed from a content perspective that only
see the user as the beneficiary of the final product or service
often fail because, by directing people using a top-down
approach, impediments for implementation and adherence at
the individual and organisational level are not taken into
account.67Patients are often given solutions that only focus on
the treatment of their diseases instead of solutions that also
incorporate aspects of desirability (figure 1). For example, pre-
scribing a medication is one treatment option for many diseases,
however, without a behavioural plan for habit formation, com-
pliance may impede the success of this treatment option. When
designing prevention programmes, framing the context for
behavioural change requires asking the right question, which is
often “what matters most to you” rather than “what’s the
matter”. The lack of active human engagement in understanding
patients’ underlying problems and developing feasible solutions
may explain why, after decades of tool development, we have
not achieved results with prevention.
Yet “providing care that is respectful of and responsive to
individual patient preferences, needs and values and ensuring
that patient values guide all clinical decisions”68has long been
identified as a key quality improvement parameter towards
patient-centred care.69–71Indeed, there is an entire industry
known as HCD that relies on understanding people’s needs and
motivations in order to design desirable, feasible, quality solu-
tions that meet those needs.72–74
Prevention differs from treatment from a behavioural perspec-
tive because future health problems are ‘invisible’ (subclinical,
asymptomatic),75resulting from deeply ingrained habits. With pre-
vention, ‘success’ is defined as the absence of an outcome (eg,
avoidance of a heart attack). Thus, empathic solutions become crit-
ically important in prevention. The challenge for healthcare, one
that has not yet been embraced, is to accept responsibility for
understanding the factors that direct behavioural change within
this context. HCD embraces constraints to innovate solutions
from the human perspective (figure 1) and combines empathy, cre-
ativity and rationality in analysing and fitting solutions to context
and personal preferences. HCD uses techniques and methodolo-
gies to understand the complex context of internal motivators and
external barriers to behavioural change and habit formation.
Direct observation and interaction with people are used to under-
stand the context of what they want and need in their lives and
what they like or dislike about the way particular products or ser-
vices are made and delivered (figure 1).72By investigating—and
designing for—the human element it is possible to gain unex-
pected insights on how to frame the problem from the individual’s
perspective in a way that can help to develop sustainable solutions.
A design attitude toward problem solving allows us to ask basic,
but fundamental questions like “What is the real problem being
faced and how might we overcome it?”.76The initial solutions are
created with human desirability in mind and focus later on the tech-
nical feasibility and viability of possible solutions.77For example, an
increased attention to age appropriateness, fun, incentives and
innovation that requires engaging people in order to understand their
preferences. With innovation, there are three overlapping constraints.
Feasibility is what is functionally or technically possible within the
foreseeable future. Viability is the likelihood the innovation will become
part of a sustainable business model. Desirability refers to what makes
sense to people and for people (important human factors). These
constraints inspire innovation and an HCD approach will bring them
into harmonious balance. Willing and even enthusiastic acceptance of
competing constraints is the foundation of HCD. The design thinking
process involves: (1) Understanding—challenging the status quo (too
often we jump from ideas to solutions without understanding
underlying motivators and drivers), (2) observation—gaining insights
through on-site observations, (3) synthesis—framing and grouping
insights to identify problems and opportunities using visual techniques
—it is critical to find the right question to ask because the way a
problem is framed often identifies the approach to innovation, (4)
ideate—various approaches are used for innovation and (5) prototype
—rapid prototyping allows quick feedback for iterations (modified from
Human-centred design72(HCD) is a methodology for
4 of 11Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034
motivation, social support, feedback and style of teaching/coaching/
mentoring in interventions targeting children can be substantial to
the experience and feeling of the intervention.78HCD is an
approach that can incorporate other methodologies such as
Intervention Mapping79 80and that compensates for the deficien-
cies that require “implementation research”.81 82With these cat-
egories in hand, designing a simple and easily understandable
programme (more user-centric) avoids the confusion which often
takes place at the end of programme development when it is discov-
ered that compliance with the intervention is low.
There is an immense opportunity arising as healthcare profes-
sionals show increased interest in focusing on user-centricity
and acknowledge that designers can have a profound influence
on social innovation.83The critical balance of creative and intui-
tive thinking (design thinking) with technical and content
expertise (analytical thinking) has been very successful in diverse
settings and organisations.72 74HCD with its inclination to
action, rapid prototyping and multiple iterations can be piloted,
scaled and formally tested for its ability to create effective pre-
ventive programmes for chronic disease.
Unique attributes of SEM for disease prevention
The modern medical discipline of SEM has its roots deeply
embedded in the scientific study of human function and the benefi-
cial adaptations to physical activity and exercise that accrue in
multiple organ systems. The human body has profound capacity
to increase performance in response to training. Increases in
muscle mass, stroke volume and ejection fraction, RBC mass, capil-
lary density, mitochondrial volume density as well as changes in
fuel storage and utilisation result in improvements in muscle
strength, endurance, aerobic and anaerobic capacity as well as
agility, balance and flexibility. These adaptations are profound.
The term performance tends to be used to describe these adapta-
tions in the competitive athlete while functional capacity is most
often used for non-athletes. For an aged person or one with
chronic disease and multiple comorbidities, functional capacity
remains trainable in the same way performance is trainable in ath-
letes.84The training that results in these physiological adaptations
is the same training associated with substantial health benefits.
Despite this rather noble foundation for SEM, a clinical dis-
cipline less than four decades old, its potential to benefit health
and function outside of competitive athletes has not been rea-
lised. For this reason, it is necessary to extend the knowledge
and skills of SEM to the general population to build new pro-
grammes for the prevention and management of chronic disease
focused on physical activity, diet and other lifestyle components.
Virtually everyone develops chronic disease and most people
develop multiple chronic diseases. For this reason, creating a
culture of health versus disease is not realistic. The much more
realistic approach is acknowledging the reality of chronic disease
and working to prevent and manage it over the lifespan.
Symptoms of chronic disease are simply events along a continuum
that spans many years during which preventive practices may influ-
ence the onset and severity of the symptoms. Traditional medicine
sees the absence of symptoms as health and the onset of disease
symptoms as an acute event requiring treatment (eg, medication or
surgery). Prevention attempts to identify risk factors early, address
these factors and thereby delay the onset of symptoms of chronic
disease. Furthermore, prevention can ameliorate the effects of
existing chronic disease on functional capacity and the develop-
ment of related chronic diseases (comorbidities).
There is an urgent challenge as to how to successfully include
the prevention and management of chronic disease in the daily
clinical practice of SEM and primary care medicine.37The
challenge is one of addition—developing new capacity, clinical
programmes and expertise in chronic disease prevention and man-
agement to provide new preventive services to the general public
in an effective and cost-effective way.85The focus of most SEM
practitioners and clinics is still on the care of competitive athletes.
One of the unique features of the scope of SEM is that, unlike
other medical specialties, it is not organ system or disease spe-
cific.86To date, knowledge and clinical skills in the area of chronic
disease prevention and management have not been the focus of
continuing professional development in SEM even though this
would be a relatively simple and potentially influential step to
take. Formal clinical training in chronic disease prevention and
management must be developed and provided for SEM and
primary care practitioners that includes role identification, com-
munication and integration between healthcare providers and the
fitness and wellness industry.
Creating actual programmes and centres for disease prevention
Right now, there is no ‘home’ for prevention within healthcare.
There are no community-based prevention centres that can be dir-
ectly accessed by anyone seeking to maintain or improve their
health. Despite some existing rehabilitation facilities and lifestyle
units in primary care, there are no programmes of population-wide
scale that focus on behavioural change with regard to physical activ-
ity, exercise or other lifestyle options. This vacuum is being filled by
weight loss centres, fitness and wellness studios; a multibillion
dollar industry founded on principles that differ from those that
underpin the healthcare industry. This results in a low level of inter-
action and coordination since the healthcare system tends to view
these industries as lacking the ‘credibility’ and ‘authenticity’ to
partner on prevention. To establish actual centres to design, imple-
ment, study and improve preventive programmes for chronic
disease, the value provided by evidence-based medicine needs to be
combined with the value provided by the fitness, wellness and
weight-loss industries with their action-oriented approach and wide
The creation of a sustainable foundation for prevention requires
actual, physical centres (figure 2). Initially, these could be pilot
centres that meet robust criteria for the integration of evidence with
HCD, the use of technology and the inclination to action and rapid
prototyping. Several of these centres, with meaningful collabora-
tions with healthcare, academia, industry and technology can serve
as development sites. While there are a number of excellent, well-
conducted studies of behavioural change using sound conceptual
models, the current clinical approach tends to be an intuitive,
trial-and-error process mostly relying on the experience and skills
of individual practitioners and health coaches. The first centres
would provide the structure for an ideal prevention programme by
fostering the seedbeds of behavioural design through understand-
ing, observing, synthesising, ideating, prototyping and iterating.
The factor that determines success will be, first and foremost, the
ability to meet the human needs that are currently ‘hidden behind’
what is often viewed as more important (quantitative measurements
of disease status, figure 1). By starting with empathy and human
desirability, the experience factors of the programmes are built
around the ‘job-to-be-done’ for the individual behind the disease.
Thus, an initial screening needsto include cognitive and behavioural
assessments along with the traditional functional assessment.
The traditional grouping into primary, secondary and tertiary
prevention holds value for healthcare providers, medical scientists
and programme development strategists concerned with population
However, categorisations such as these have little relevance to indi-
viduals entering a prevention programme since they are remnants
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-0930345 of 11
are combined to develop and implement prevention programmes. While much of the interdisciplinary interaction remains to be precisely defined, the
road map shown integrates the HCD approach with the traditional method of programme development. Initially, the medical status (MS) of each
client is assessed as well cognitive function (CF), physical capacity (PC), and behavioural quotient (BQ). This input assists the healthcare professional
in observing and understanding the context of the individual’s current situation and generates insights regarding possibilities for behavioural
change. Interpreting and synthesising these insights and contexts enables the development of archetypal personas that can be used to classify client
services based on key characteristics that relate to the likelihood of success for certain interventions. Based on the experience and history with
certain persona profiles, the healthcare professional can engage the client in an ideation process to target healthier behaviour. Single, achievable
tasks that result in behavioural change are used as prototypes for iterations that build confidence and control. The evolving loop of habit formation
(A) Community Prevention Centers (CPCs) are actual facilities where scientific evidence-based medicine and human-centred design (HCD)
6 of 11Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034
of reductionist thinking related to the presence or absence of
disease or risk factors. Organising programmes around such cat-
egories falls short of acknowledging, among other things, the
human elements that transcend the medical-biological origin of
those prevention categories: namely personal interests, personality
traits, temperament, skills and abilities. By thinking in disease cat-
egories, any prevention programme subordinates its process and
function to the stage and progression of a certain disease.
Likewise, it can be confusing if not overwhelming to deter-
mine what constitutes prevention versus management of chronic
disease. It is clear that prevention applies to those without
disease or risk factors and management applies to those with
chronic disease. But, this distinction is arbitrary and prevention,
as an umbrella term, applies to behavioural change with or
without the presence or absence of disease or risk factors. What
matters most to people is that the programme is desirable. That
is the starting point.
In addressing the real needs of people, it is essential to iden-
tify certain persona profiles and characteristics of particular
population groups. This helps to move from purely labelling
people based on manifestations of disease toward valuing their
needs and goals, which is the heart of prevention. Ninety per
cent of healthcare spending is for sicker patients with 80% of
healthcare spending traced to patients with largely predictable
healthcare needs and expenses: the chronically ill.87This
bloated number is a mirror of our structures in medicine which
are heavily tilted toward ‘fixing’ disease. While tertiary preven-
tion (management) might provide immediate gains from a cost-
benefit perspective, we must avoid the rigidity of categorisation
of prevention into primary, secondary and tertiary since this
focuses the scope of service, yet again, on the reductionist
model of type and stage of disease. Clinical, comprehensive life-
style intervention programmes bear substantial similarity with
respect to the fundmental principles of behavioural design
regardless of how a person is ‘labeled’ or what category they are
assigned. Any clinical programme failing to recognise this by
focusing on one prevention category only would fall short of
creating true population-wide impact. For this reason we need
to move from abstract concepts of prevention to concrete, rele-
vant programmes for groups of people, reflected in different
personas, clustered according to their functional, behavioural
and cognitive status. This approach, using factors that character-
ise human desirability for clustering and stratification is a key
differentiation factor for the success of prevention programmes.
Alignment on this is absolutely essential.
The fundamental components of a prevention programme
include assessment (medical, cognitive, physical capacity, behav-
iour), programme design and implementation and monitoring and
reassessment (figure 2A). Individual components of the pro-
gramme must be based on evidence and current guidelines and
delivered by trained healthcare professionals with experience and
expertise. Much of this remains to be developed. Functional
capacity includes all the factors that correlate with the physical
ability to perform a given task. Behavioural quotient is a set of
attributes that indicate motivation such as the readiness for
change.88Cognitive function refers to information processing and
learning. These four sets of factors shape the structure of a preven-
tion programme. In aggregation these variables and attributes con-
tribute to a set of differing persona profiles. Upon taking into
account the different preferences from various perspectives of per-
sonal development, programmes can be much better designed to
fit personal needs. Thus, using factors that characterise human
desirability for clustering and stratification is a key differentiation
factor for the success of prevention programmes (figure 2A).
Based upon these assessment results and persona profiles, a pro-
gramme can be designed and customised to meet the individual’s
goals. Multiple options for health-related data exist (eg, EMR, phys-
ical activity tracking devices, purchase histories, social media pro-
files), that can help in stratifying at the population level and later at
the individual level to support rational decision making.48The ever-
growing patient throughput in pilot programmes of prevention will
generate a large database and hands-on experience that can help to
identify and spot patterns at the population level allowing predic-
tion in probabilistic terms of what works for whom under which
circumstances. This would formalise the currently intuitive, infor-
mal process of providing behavioural change advice by healthcare
professionals and move prevention toward a precise and persona-
lised approach of mass customisation. As a result, standardised yet
individualised programmes of high quality and low cost could be
scaled at the population level.
Growing and scaling prevention programmes and centres
At the core of the development of prevention programmes and
centres is the creation of value for patients and care-givers
through HCD (desirability, figure 1). Likewise, a sound business
model is necessary in order to scale programmes and generate
population-wide impact (viability, figure 1). A strong partner-
ship between the global SEM and primary care communities,
sport federations and National Olympic Committees (NOCs)
can mobilise resources and leverage networks to scale and dis-
tribute prevention programmes (feasibility, figure 1). Working
within these three constraints; desirability, viability and feasibil-
ity provides the greatest chance for innovation in prevention.
Progress in chronic disease prevention and management will
require exceptionally strong leadership, a willingness to be dis-
ruptive89and a focus on rapid innovation. Success will require a
deliberate, systematic approach with strategy clearly and con-
tinuously mapped to mission and vision, and resources devel-
oped to create capacity.
Sport and exercise have an important role to play in the preven-
tion and management of NCD85 90and the IOC is the natural
leader in this area.91Both the International Federations and the
National Olympic Committees can play an integral role in promot-
ing physical activity through sport by partnering with the IOC,
is dynamic and non-linear. Monitoring by e-Health tools includes measurement of outcomes in addition to reassessment. (B) CPCs integrate,
communicate and coordinate client experience within an ecosystem that includes health care providers, fitness and wellness providers, worksite
health promotion partners, and information technology partners. This communication, coordination and integration is critically important to bridge
CPCs with existing structures in order to provide the client with an integrated service. Close medical follow-up and communication is especially
important for chronically ill patients. The ideal setting for initial development and testing of these programs is in dedicated research centers that
meet robust criteria for collaboration and feasability. The specifics of such programs will shape over time with the help of data analytics such that
the initially intuitive process will become a more standardized, precise way of behavioural change design. By achieving that, the program will
become more affordable and it will be possible to achieve scale through, for example, licensing agreements to other health care providers or fitness
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-0930347 of 11
WHO, International Physical Activity Networks, SEM associations
and non-governmental organisations (NGOs).92Many countries
now focus on leaving a legacy of improving the health of the popu-
lation by increasing physical activity as part of hosting major sport-
ing events such as the Olympic and Paralympic Games.93 94
The IOC has already demonstrated its leadership capability in the
establishment of programmes such as Sport for All,95Olympic Day
Celebrations,96 97IOC Medical Commission initiatives such as
health and fitness for young people through physical activity and
sports98and education programmes,99–101the Youth Olympic
Games102and through its collaboration with the WHO6and the
UN.7The Olympic Games and the Olympic brand itself are based
on positive universal values, which give it a powerful, emotive and
unique identity that transcends sport and resonates strongly with
people of all ages and cultures from around the world.103Olympic
athletes inspire people to be the best they can in their everyday lives.
Corporate partnerships build on this inspiration in cause-related
marketing campaigns, which helps companies build socially respon-
sible images and brand affinity within their customer base, translat-
ing into higher brand memorability, preference and purchasing.
These partners are in a mutually beneficial, synergetic rela-
tionship with the IOC, which operates as an NGO. There is a
great opportunity to promote an IOC accredited prevention
programme through an alliance with well-known and respected
corporate partners, medical societies and academic groups in
order to penetrate and persuade a massive customer base.104
The facilities and distribution channels already exist through the
SEM and primary care networks. Upon developing successful
and cost-effective prevention programmes with adapted but
stable financial models, these programmes can be scaled inter-
nationally to lead to widespread change toward prevention.
The IOC, as a governing body, will continue its shared com-
mitment and partnership with the SEM community by initiating
and sustaining its efforts toward the prevention of chronic
disease, using a framework for change of the type described by
Kotter (box 2).105Some of the IOC’s activities will include new
and innovative methods like design thinking, which will require
autonomy and appropriate opportunity for creative work, while
others will foster collaboration, diversity and integration, main-
taining the respect for traditions.
While it remains essential for the IOC, given its political
influence, to advocate a multifaceted approach1–3 8 11and to
collaborate with policy makers, NGOs, schools and corpora-
tions,106 107it is critical for the IOC to focus on one goal in the
present to prevent the overwhelming paralysis that occurs when
trying to simultaneously balance all public health issues at once.
What is true for the individual, applies to organisations as well:
“you can eat an elephant, but only one bite at a time”. The IOC
will work with the SEM community on the primary goal of
designing clinical lifestyle intervention tools for healthcare
professionals to adequately direct and assist patients in behav-
iour change. Given the talent, knowledge and resources within
the IOC and the vested interest of the SEM community, the
influence of this partnership, focused on the individual, has the
potential to be immense.
The creation of prevention centres permits the leadership to
pursue one clear strategy, a simple, immediate and amenable
method of influence from within healthcare that will have popu-
lation wide impact. These centres will incorporate evidence
while systematically applying design thinking alongside current
health promotion principles. In order to gain support and bring
to life ideas, which are currently abstract (such as behavioural
change) grass roots pilot projects with an inclination to rapid
prototyping are required. This will raise aspirations and inspire
action in skeptics. Thus, it is critical to identify a core group of
early supporters and strategic key stakeholders with personal
passion, enthusiasm and commitment, ready to defer conven-
tional judgment and express their willingness to stimulate break-
Initial prototyping and experimentation is likely to take place
in the clinical setting. However, upon development of a
working programme, its success depends on its distribution and
scale. Thus, it is important to successfully transfer such pro-
grammes to primary care, the workplace, wellness initiatives,3 108
and the fitness industry. This can take place through licensing
agreements transferring content, skills and expertise to inter-
ested healthcare professionals in order to create a network of
branded prevention centres (figure 2B).
Training and education are critically important components
for the development of future professionals working in the field
of disease prevention and management. Currently, there is no
single group of healthcare professionals that possesses the full
spectrum of knowledge and skills required for clinical work in
disease prevention.64 109Various components are fragmented
between physicians, fitness experts, physical therapy, nursing,
exercise physiologists (kinesiologists) and other professions.2
Coordination of the development of curricula, training and cer-
tification between and within these professions is essential. The
IOC-SEM partnership has the ability to certify practitioners in
prevention and management. Given the new approach to open-
learning99–101 110 111resources could be made available globally,
providing immediate and wide distribution and scaling. For
example, the IOC has developed a 2-year diploma programme
in nutrition and sports medicine,99–101but could move a step
further towards integrating the prevention scholar into a
network of prevention centres operating under accreditation
standards. The idea is to move beyond education, training and
skill development to provide essential frameworks of sound
business models that allow the practice of prevention within the
This will further generate momentum for a renewed commit-
ment to prevention even within traditional healthcare stake-
holders. The under-representation of comprehensive lifestyle
intervention, including physical activity in the curricula of medi-
cine112and other health professions64will be addressed more
efficiently, when sound and reasonable alternatives like an IOC
accredited prevention programme are ready at hand.
The IOC Working Group on NCD aims to establish a road map
for change that respects both evidence and innovation through
HCD. While supporting large, long-term visions that require coor-
dinated, massive and complex political and systemic shifts, the
IOC will pursue an active role with a vision focused on providing
Box 2Kotter’s 8-step change model for leadership105
1. Establish a sense of urgency
2. Create a guiding coalition
3. Develop a vision for change
4. Communicate the vision for buy-in
5. Empower broad-based action
6. Generate short-term wins
7. Never let up—build on the change
8. Incorporate changes into the culture
8 of 11Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034
services to individual patients. Our current healthcare systems,
with their reductionist underpinnings, can only respond awk-
wardly to the notion that a disruptive approach is urgently needed
if we are to be successful in stemming the tide of preventable
chronic disease. The issues are not those of more research and sci-
entific evidence, sufficient funding or healthcare restructuring.
The issue is one of in-action, on the one hand and untenable plans
on the other, in the midst of an overwhelming problem and resist-
ance to change. Creative solutions are available, beginning with
evidence-based, human-centred programmes to provide preventive
services immediately. Leadership is the key.
1Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford
University School of Medicine, Stanford, California, USA
2Human Performance Laboratory, Department of Orthopaedic Surgery, Stanford
University School of Medicine, Stanford, California, USA
3Department of Healthy Policy and Management, Harvard University, Boston, USA
4Department of Sports Medicine, Oslo Sports Trauma Research Center, Norwegian
School of Sports Science, Oslo, Norway
5Medical & Scientific Department, International Olympic Committee, Lausanne,
6Orthopaedic Center, Ullevål University Hospital, University of Oslo, Oslo, Norway
7Departments of Exercise Science and Epidemiology & Biostatistics, Arnold School of
Public Health, University of South Carolina, Columbia, USA
8Åstrands Laboratory, The Swedish School of Sports and Health Sciences, Stockholm,
9Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
10Clinical Sports & Exercise Medicine Research Group, UCT/MRC Research Unit for
Exercise Science and Sports Medicine, Department of Human Biology, University of
Cape Town, Cape Town, South Africa
11Department of Medicine and Department of Health Research & Policy, Department
of Statistics, Stanford Prevention Research Center, Stanford University School of
Medicine, Stanford University School of Humanities and Sciences, Stanford,
12Department of Family Practice and School of Kinesiology, The University of British
Columbia, Vancouver, Canada and Aspetar: The Qatar Orthopaedic and Sports
13IDEO, Design and Biology, Boston, USA
14Department of Public & Occupational Health and EMGO Institute for Health &
Care Research, VU University Medical Center, Amsterdam, The Netherlands
15School of Human Movement Studies, University of Queensland, Brisbane, Australia
16Department of Family Medicine, Michael G DeGroote School of Medicine,
McMaster University, Hamilton, Canada
17Department of Family Medicine, Fontana Medical Center, Kaiser Permanente
Southern California, Fontana, USA
18Department of Physiology & Pharmacology, Karolinska Institutet, Stockholm,
19Population Health Domain Physical Activity Research Group, Department of
Epidemiology & Public Health, University College London, London, UK
20University College London Hospitals NHS Foundation Trust, London, UK
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
1 Daar AS, Singer PA, Persad DL, et al. Grand challenges in chronic
non-communicable diseases. Nature 2007;450:494–6.
2Global Status Report on Noncommunicable Diseases 2010. World Health
Organization, ed. 2011.
3 Bloom DE, Cafiero ET, Jane-Llopis E, et al. The global economic burden of
non-communicable diseases. Geneva: World Economic Forum, 2011.
4Fuster V. Cardiovascular disease and the UN millennium development goals: a
serious concern. Nat Clin Pract Cardiovasc Med 2006;3:401.
5Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major
non-communicable diseases worldwide: an analysis of burden of disease and life
expectancy. Lancet 2012;380:219–29.
6 Rogge J. High-level meeting of the UN General Assembly on the Prevention and
Control of Non-communicable Diseases: Statement by Dr. Jacques Rogge,
President of the IOC. . New York: United Nations, 2011.
7 Non-communicable Diseases Deemed Development Challenge of “Epidemic
proportions” in Political Declaration Adopted During Landmark General Assembly
Summit. New York, USA: Department of Public Information United Nations, United
8Active Canada 20/20: A Physical Activity Strategy & Change Agenda for Canada
Creating a Culture of an Active Nation. 2012.
NICE public health guidance. Promoting physical activity in the work place. UK:
National Institute for Health and Clinical Excellence, 2008.
Sassi F, Hurst J. The prevention of lifestyle-related chronic diseases: an economic
framework. In: Development OfEC-oa, ed. Paris, France: OECD Health Working
Non communicable disease prevention: investments that work for physical activity.
Br J Sports Med 2011;46:709–12.
Exercise is Medicine. The Global Initiative 2008. http://exerciseismedicine.org/
EU Working Group Sport & Health. EU physical activity guidelines: recommended
policy actions in support of health-enhancing physical activity. Brussels, Germany,
Rose G. The strategy of preventive medicine. Oxford, UK: Oxford University Press,
Nordic Nutrition Recommendations 2004, 2005. http://www.norden.org/en/
Bauman AE, Reis RS, Sallis JF, et al. Correlates of physical activity: why are some
people physically active and others not?. Lancet 2012;380:258–71.
Chapter 6: Accelerometry in children. In: Craig R, Mindell JVH. eds Health Survey
for England 2008: physical activity and fitness. Leeds: Health and Social Care
Information Centre, 2009:160–73.
Ng SW, Popkin BM. Time use and physical activity: a shift away from movement
across the globe. Obes Rev 2012;13:659–80.
Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of
disease and injury attributable to 67 risk factors and risk factor clusters in 21
regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study
2010. Lancet 2013;3:2224–60.
Archer E, Shook RP, Thomas DM, et al. 45-year trends in women’s use of time
and household management energy expenditure. PLoS ONE 2013;8:
Church TS, Thomas DM, Tudor-Locke C, et al. Trends over 5 decades in US
occupation-related physical activity and their associations with obesity. PLoS ONE
Hill JO, Peters JC. Environmental contributions to the obesity epidemic. Science
Healy GN, Eakin EG, Lamontagne AD, et al. Reducing sitting time in office
workers: short-term efficacy of a multicomponent intervention. Prev Med
Dunstan DW, Thorp AA, Healy GN. Prolonged sitting: is it a distinct coronary heart
disease risk factor? Curr Opin Cardiol 2011;26:412–19.
Owen N, Healy GN, Matthews CE, et al. Too much sitting: the population health
science of sedentary behavior. Exerc Sport Sci Rev 2010;38:105–13.
Lee DC, Sui X, Church TS, et al. Changes in fitness and fatness on the
development of cardiovascular disease risk factors hypertension, metabolic
syndrome, and hypercholesterolemia. J Am Coll Cardiol 2012;59:
Bacon L, Aphramor L. Weight science: evaluating the evidence for a paradigm
shift. Nutr J1 2011;10:9.
Remington PL, Brownson RC, Centers for Disease Control Prevention. Fifty years of
progress in chronic disease epidemiology and control. MMWR Surveill Summ
Kohl HW, Craig CL, Lambert EV, et al. The pandemic of physical inactivity: global
action for public health. Lancet 2012;380:294–305.
Sacks G, Swinburn BA, Lawrence MA. A systematic policy approach to changing
the food system and physical activity environments to prevent obesity. Aust N ZL
Health Policy 2008;5:13.
Mariner WK, Annas GJ. Limiting sugary drinks to reduce obesity—who decides? N
Engl J Med 2013;368:1763–5.
National guidelines for methods of preventing disease. Swedish National Board of
Health and welfare. 2011. http://www.socialstyrelsen.se
Physical activity in the prevention and treatment of disease Stockholm. Sweden:
Swedish National Institute of Public Health: Professional Associations for physical
activity, 2010. http://www.fyss.se
Heath C, Heath D. Switch: how to change things when change is hard. New York:
Broadway Books, 2010:305.
Heng HHQ. The conflict between complex systems and reductionism. JAMA
Federoff HJ, Gostin LO. Evolving from reductionism to holism: is there a future for
systems medicine? JAMA 2009;302:994–6.
Matheson GO, Klugl M, Dvorak J, et al. Responsibility of sport and exercise
medicine in preventing and managing chronic disease: applying our knowledge
and skill is overdue. Br J Sports Med 2011;45:1272–82.
Healthy People: The Surgeon General’s Report on Health Promotion and Disease
Prevention. In: United States. Public Health Service. Office of the Surgeon General
and Office of the Assistant Secretary for Health, ed. 1979:262.
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-0930349 of 11
39Lalonde M. A new perspective on the health of Canadians: a working document.
Ottawa, On, Canada: Minister of Supply and Services Canada, Government of
Great Britain. Dept. of Health and Social Security, Northern Ireland. Dept. of Health
and Social Security. Prevention and health: everybody’s business: a reassessment of
public and personal health. London: Majesty’s Stationery Office, 1976.
Leijon M, Stark-Ekman D, Nilsen P, et al. Is there a demand for physical activity
interventions provided by the health care sector? Findings from a population
survey. BMC Public Health 2010;10:34.
Sunstein CR. Empirically informed regulation. University of Chicago Law Rev
Thaler DS. Improving introspection to inform free will regarding the choice by
healthy individuals to use or not use cognitive enhancing drugs. Harm Reduction J
Sheppard BH, Hartwick J, Warshaw PR. The theory of reasoned action: a
meta-analysis of past research with recommendations for modifications and future
research. J Consum Res 1988;15.
Ajzen I. The theory of planned behavior. Organ Behav Hum Decis Processes
Aarts H, Paulussen T, Schaalma H. Physical exercise habit: on the
conceptualization and formation of habitual health behaviours. Health Educ Res
Kremers SP, De Bruijn GJ, Visscher TL, et al. Environmental influences on energy
balance-related behaviors: a dual-process view. Int J Behav Nutr Phys Act
Kahneman D. Thinking, fast and slow. 1st edn. New York: Farrar, Straus and
Behavioural Insights Team. Behavioural Insights Team Annual Report 2010–2011.
In: Cabinet Office, ed. London, UK: Crown, 2011.
Nilsen P, Roback K, Broström A, et al. Creatures of habit: accounting for the role
of habit in implementation research on clinical behaviour change. Implement Sci
Fogg BJ. Creating persuasive technologies: an eight-step design process. 4th
International conference on persuasive technology. New York: ACM, 2009.
Christakis NA, Fowler JH. Social contagion theory: examining dynamic social
networks and human behavior. Stats Med 2013;32:556–77.
Blair SN, Jacobs DR Jr., Powell KE. Relationships between exercise or physical
activity and other health behaviors. Public Health Rep 1985;100:172–80.
Centola D. The spread of behavior in an online social network experiment. Science
Hibbard JH, Greene J. What the evidence shows about patient activation: better health
outcomes and care experiences; fewer data on costs. Health Aff 2013;32:207–14.
Committee on Depicting Innovation in Information Technology, Computer Science
and Telecommunications Board, Division on Engineering and Physical Sciences
NRC. Continuing innovation in information technology. Washington, DC: The
National Academies Press, 2012.
McAfee A, Brynjolfsson E. Big data: the management revolution. Harv Bus Rev
2012;90:60–6, 8, 128.
Brynjolfsson E, Hitt LM, Kim HH. Strength in numbers: how does data-driven
decisionmaking affect firm performance? Social Science Research Network, 2011.
http://ssrn.com/abstract=1819486 or http://dx.doi.org/10.2139/ssrn.1819486.
Duhigg C. How companies learn your secrets. New York Times. 16 February 2012.
Ginsberg J, Mohebbi MH, Patel RS, et al. Detecting influenza epidemics using
search engine query data. 2009;457:1014.
Wolfe R, Wright PM, Smart DL. Radical HRM innovation and competitive
advantage: the moneyball story. Hum Resource Manag 2006;45:111–45.
Murdoch TB, Detsky AS. The inevitable application of big data to health care.
Weiler R, Feldschreiber P, Stamatakis E. Medicolegal neglect? The case for
physical activity promotion and exercise medicine. Br J Sports Med
Weiler R, Chew S, Coombs N, et al. Physical activity education in the
undergraduate curricula of all UK medical schools: are tomorrow’s doctors
equipped to follow clinical guidelines? Br J Sports Med 2012;46:1024–6.
Swedish National Institute of Public Health. Physical activity in the prevention and
treatment of disease Stockholm. Sweden 2010. http://www.fyss.se
Douglas F, Torrance N, Van Teijlingen E, et al. Primary care staff’s views and
experiences related to routinely advising patients about physical activity.
A questionnaire survey. BMC Public Health 2006;6:138.
Bodenheimer T, Lorig K, Holman H, et al. Patient self-management of chronic
disease in primary care. JAMA 2002;288:2469–75.
Kierkegaard S, Lowrie W. The point of view, etc: including the point of view for
my work as an author, two notes about the individua’ and on my work as an
author. London, New York: Oxford University Press, 1939: xvi, 174 p 1.
Berwick DM. What patient-centered should mean: confessions of an extremist.
Health Aff 2009;28:555–65.
Berwick DM. A primer on leading the improvement of systems. BMJ
71Crossing the Quality Chasm. A new health system for the 21st century. In:
Institute of Medicine, ed, National Academy Press, 2001.
Brown T. Change by design: how design thinking can transform organizations and
inspire innovation. 1st edn. New York, NY: HarperCollins Publishers, 2009:27.
Luma Institute L. Innovating for people: handbook for human-centered design
methods. PA, USA: Luma Institute, LLC, 2012.
Martin RL. The design of business: why design thinking is the next competitive
advantage. Boston, Mass: Harvard Business Press, 2009:xiii191.
Gordon J. Beyond knowledge: guidelines for effective health promotion messages.
J Extension 2002;40. Available from: http://www.Joe.org/rev1.html
Boland R, Collopy F. Managing as designing. Stanford, CA: Stanford Business
Hall A. Experimental design: design experimentation. Design Issues
Design to Move: A Physical Activity Action Agenda. Nike Inc, 2012.
Kok G, Mesters I. Getting inside the black box of health promotion programmes
using intervention mapping. Chronic Illn 2011;7:176–80.
Kok G, Schaalma H, Ruiter RA, et al. Intervention mapping: protocol for applying
health psychology theory to prevention programmes. J Health Psychol
Finch CF, Donaldson A. A sports setting matrix for understanding the
implementation context for community sport. Br J Sports Med 2010;44:973–8.
Donaldson A, Finch CF. Sport as a setting for promoting health. Br J Sports Med
Tromp N, Hekkert P, Verbeek P-P. Design for socially responsible behavior: a
classification of influence based on intended user experience. Design Issues
Investigators LS, Pahor M, Blair SN, et al. Effects of a physical activity intervention
on measures of physical performance: results of the lifestyle interventions and
independence for Elders Pilot (LIFE-P) Study. J Gerontol A Biol Sci Med Sci
Jones NSC, Weiler R. SEM: A Fresh Approach NHS Information Document, 2011.
McCrory P. What is sports and exercise medicine? Br J Sports Med
Thorpe KE. The rise in health care spending and what to do about it. Health Aff
Prochaska JO, Velicer WF, Rossi JS, et al. Stages of change and decisional balance
for 12 problem behaviors. Health Psychol 1994;13:39–46.
Darzi A, Beales S, Hallsworth M, et al. The five bad habits of healthcare: how
new thinking about behaviour could reduce health spending. In: World Economic
Forum, ed. London, 2011.
Mountjoy M. Health and fitness of young people: what is the role of sport? Br J
Sports Med 2011;45:837–8.
Olympic Congress 2009 Copenhagen Recommendation #51, Recommendations
of Theme: ‘Olympism and Youth’. XIII Olympic Congress. Copenhagen, Denmark,
Micheli L, Mountjoy M, Engebretsen L, et al. Fitness and health of children
through sport: the context for action. Br J Sports Med 2011;45:931–6.
Tew GA, Copeland RJ, Till SH. Sport and exercise medicine and the Olympic health
legacy. BMC Med 2012;10:74.
Black ME. An Olympic legacy for couch potatoes? BMJ 2012;345:5578.
International Olympic Committee. Sport for All Lausanne. Switzerland, 2000.
Khan KM, Thompson AM, Blair SN, et al. Sport and exercise as contributors to the
health of nations. Lancet 2012;380:59–64.
International Olympic Committee. What is Olympic Day? Lausanne, Switzerland,
Mountjoy M, Andersen LB, Armstrong N, et al. International Olympic Committee
consensus statement on the health and fitness of young people through physical
activity and sport. Br J Sports Med 2011;45:839–48.
International Olympic Committee. IOC diploma in sports nutrition Lausanne.
International Olympic Committee. IOC diploma in sports medicine. 2013.
International Olympic Committee. Education Through Sport Lausanne. Switzerland,
International Olympic Committee. YOG news: what is YOG? Lausanne.
Switzerland, 2013. http://www.olympic.org/news/what-is-yog/195805
International Olympic Committee. IOC marketing: media guide, London Lausanne.
Switzerland, 2012. http://www.olympic.org/Documents/IOC_Marketing/London_
Berglinda M, Nakata C. Cause-related marketing: more buck than bang? Bus
Kotter J. Leading change: why transformation efforts fail. Harv Bus Rev
Wierenga D, Engbers LH, Van Empelen P, et al. The design of a real-time
formative evaluation of the implementation process of lifestyle interventions at two
10 of 11Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034
worksites using a 7-step strategy (BRAVO@Work). BMC Public Health
De Meij JS, Chinapaw MJ, Van Stralen MM, et al. Effectiveness of JUMP-in, a
Dutch primary school-based community intervention aimed at the promotion of
physical activity. Br J Sports Med 2011;45:1052–7.
Carnethon M, Whitsel LP, Franklin BA, et al. Worksite wellness programs for
cardiovascular disease prevention: a policy statement from the American Heart
Association. Circulation 2009;120:1725–41.
109Weiler R, Murray A, Joy E. Do all health care professionals have a responsibility to
prescribe and promote regular physical activity: or let us carry on doing nothing.
Curr Sports Med Rep 2013;12:272–5.
Stanford University. Stanford Online 2013. http://online.stanford.edu/courses
Carnegie Mellon University. Open Learning Initiative 2013. http://oli.cmu.edu/
Jaques R, Loosemore M. Sports and exercise medicine in undergraduate training.
Matheson GO, et al. Br J Sports Med 2013;47:1003–1011. doi:10.1136/bjsports-2013-093034 11 of 11