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Disease prevention: what's really important?
  1. Gordon O Matheson1,2,
  2. Holly O Witteman3,4,5,
  3. Terry G Mochar6
  1. 1Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California, USA
  2. 2Human Biology Program, School of Humanities and Sciences, Stanford University, Stanford, California, USA
  3. 3Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec City, Québec, Canada
  4. 4Faculty of Medicine, Office of Education and Continuing Professional Development, Université Laval, Québec City, Québec, Canada
  5. 5Research Centre of the Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
  6. 6Formal Global Director, Reckitt Benckiser plc
  1. Correspondence to Dr Gordon O Matheson, Division of Sports Medicine, Department of Orthopaedic Surgery, Stanford University School of Medicine, 341 Galvez Street, Stanford, CA 94305, USA; gord{at}

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Preventable chronic disease has proven to be a stubborn problem, responsible for 60% of deaths worldwide, and its associated morbidity and mortality has not changed in 40 years. The real issue in disease prevention is the lack of progress and the seeming absence of innovation.1

Beedie et al's2 recent editorial reminds us of the importance of phase IV trials to study effectiveness, not just efficacy, of exercise, arguing that what matters to those who make funding decisions are health outcomes, not proxy measures. We argue that these are also the outcomes that matter to the people whom these interventions are supposed to help: patients and members of the public. It is well past time to include them in solving this long-standing problem.

Disease prevention is not a problem for which the core issue is a lack of scientific evidence for and against exercise, regardless of the phase of research. Restricting our perspective to what can be accomplished by continuing to accumulate scientific evidence in the fight against chronic disease relegates us to the fringes of a complex problem when we ought to be at the heart of it. The same holds true for other top-down approaches—they are not very effective at addressing complex problems.3 Top-down approaches to implementing preventive programmes leave out the essential component: incorporating what really matters to the end user. That cannot be assumed; it must be determined. At present, aligning evidence-based recommendations with user needs, goals and preferences is not even close to being mainstream in disease prevention.

We can no longer spend limited resources creating top-down approaches aimed at telling people what to do. Instead, we must engage with end users and actively co-create solutions.

It turns out that we in sport and exercise medicine have been a little overconfident about our potential to provide leadership in disease prevention.2 While exercise training is a powerful method for increasing functional capacity and preventing disease, it is the ‘what’ of disease prevention. Prevention requires the ‘how’. How might we best create and then implement programmes of physical activity? In the past, we hoped that passive approaches such as ‘Sport for All’ and ‘Everyone's an Athlete’ would be effective for transferring what we know about physical training from competitive athletes to the general population. We now know these approaches do not work, even when the message is delivered by ‘ambassadors’ and ‘role models’ from competitive sport.4–6

The most important activity we can be engaged in for disease prevention is innovation related to the ‘how’. Innovation can be defined as new solutions designed from insights gained through empathic partnership with users. This type of innovation requires approaches such as human-centred design (sometimes referred to as user-centred design), an approach that uses validated methods to create programmes for the way people are, not for the way we think they are or wish they were.7 While this approach may seem self-evident, it is anything but established in prevention.

Human-centred design (HCD) systematically observes people's natural tendencies and elicits their goals, and then iteratively develops, tests and revises programmes to meet those goals. It collects data about how people use, do not use or are unable to use the preliminary designs and revises them accordingly. In this way, HCD is a systematic approach that meets people where they are and then helps them move to where they want to be.7 This creative process may feel foreign inside the typical healthcare environment, but it produces data that are critical to the development of prevention plans adapted to each individual.

Sport and exercise medicine can play a major role in shifting the mindset from ‘cure’ to ‘prevent’ and from ‘disease’ to ‘function’ in the target audiences that represent the many sectorsi of influence in disease prevention. Experts in sport and exercise medicine could collaborate more with colleagues in the sciences of design and behaviour change, and with the people whose lives are at stake. Widespread dissemination of online training to combine evidence-based recommendations with HCD is a realistic goal. Implementing this approach would offer something new to a longstanding problem8 and is not nearly as difficult, expensive, or uncertain as many of the current suggestions such as changing the urban environment, revamping transportation policy, regulating the food industry, overhauling medical and nursing school curricula, rebuilding healthcare, establishing public school educational standards and trying to convince every person that they really are an athlete. Moreover, it is within our ability to do this in a shorter period of time than any of the aforementioned system-wide changes.

In a recent editorial, Verhagen, Bolling and Finch state the ‘exercise is medicine’ community is neglecting the adverse effects of physical activity.9 They need not worry. While their concerns are valid, they are simply non-sequitur. Until such time as the long-standing static numbers of exercise participants in the general population begins to show an upward swing, studying the adverse effects of physical activity is little more than a distraction. Preventable chronic disease has turned out to be stubborn. It is time for innovation.



  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

  • i Target audiences are not limited to healthcare professionals; they include patients/members of the public, researchers, administrators, workplace wellness, the fitness industry; medical insurance companies, public school administrators; and medical product companies—indeed, all service and industry sectors that cross the path of disease prevention.