FORESIGHT Global Health Autumn 2020

FORESIGHT — 01 Global Health

The heavy burden of poor health NON-COMMUNICABLE DISEASES, OBESITY AND THE COVID-19 IMPETUS FOR BUILDING BETTER HEALTH SYSTEMS

GLOBAL HEALTH POLICY

OBESITY SPECIAL REPORT

Obesity casts a big shadow

Contagion of a social kind

The pandemic's lessons for urban health

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PAGES 18-37

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The hidden health crisis

OUTLOOK

OUTLOOK

NON-COMMUNICABLE DISEASES

The hidden health crisis we all can see

FORESIGHT Global Health AUTUMN / WINTER 2020

PUBLISHER FORESIGHT Global Health

CIRCULATION 2000

EDITOR Andrea Chipman andrea@foresightglobalhealth.com

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Covid-19 has exposed the impact of social inequalities on declining health in populations around the world. It is these deep inequalities that have contributed to rising rates of non-communicable diseases (NCDs), especially among the most deprived populations, making them more vulnerable to the pandemic.

Each year, NCDs cut short the lives of 15 million people in the prime of life. As a result, the steady rise in life expectancy is slowing, or even reversing in some countries. This is unacceptable, especially when prevention of vast numbers of NCD deaths is well within reach. Investment in good health would not only save lives but reduce a multi-billion-dollar burden on the global economy.

NCDs are misunderstood, under-prioritised and underestimated and consequently under-prevented, under-diagnosed and under-treated. The lack of attention to the NCD health crisis is not for lack of ideas of what to do about it. The World Health Organization has plenty of “best buy” strategies for prevention and better care. Implementation, however, is fraught with complexity and conflicting political priorities. A genuine revolution in health care is needed to flatten the NCD growth curve.

Although NCDs cause far more premature deaths than infectious disease and hurt economic productivity, they receive only a fraction of the global health funding in comparison. Despite the topic having moved up the global health agenda over the past decade, there has been little sustained effort to develop the comprehensive policies necessary to combat the manifold causes of NCDs. The structure of health systems today is no longer fit for purpose. The covid-19 pandemic has taught us that governments are capable of supporting radical change, given reason enough to do so.

We have launched FORESIGHT Global Health to contribute to knowledge-sharing and solution building across sectors; our ambition is to be the essential read on building better health systems to reduce the incidence of NCDs worldwide. The magazine, with its focus on the intersection between in-depth health insights and socioeconomic research, is intended as the journalistic platform for thought leadership and dialogue on NCDs. Our launch issue includes a special report on obesity. It also explores a number of solutions for reducing and managing NCDs, from technology to sociology to urban planning, enabling us to not only understand the climate in which NCDs flourish, but to imagine how those conditions can be changed to create a healthier world.

Amid the continuing scourge of the coronavirus pandemic, there is new impetus for change. We believe journalism that is ambitious and advocates systemic reform can accelerate the building of better health systems.

Andrea Chipman EDITOR

CONTENT

GLOBAL HEALTH POLICY

OBESITY SPECIAL REPORT

OUTLOOK

PANDEMIC BUILDS POTENTIAL FOR BETTER GLOBAL HEALTH

OBESITY CASTS A BIG SHADOW

IMAGINE A WORLD OF GOOD HEALTH

Rates of obesity are skyrocketing, and more comprehensive policies are needed to fully address the complex causes of the condition

Policies to curb NCDs need to consider broader environment for good health

The pandemic provides the catalyst and opportunity for improving the resilience of health systems PAGE 4

SPENDING MISALIGNMENT

Diseases with the highest mortality get the lowest level of financing PAGE 8

THE HIDDEN HEALTH CRISIS

NCDs account for a majority of global deaths but policymakers have been slow to make them a priority PAGE 10

PAGE 18

A RUINOUS EPIDEMIC

PAGE 38

CONTAGION OF A SOCIAL KIND

The obesity crisis could push life expectancy into reverse

Understanding social networks is key to improving outcomes for those living with NCDs

PAGE 20

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DISEASE IN DISGUISE

CORONAVIRUS COULD SPUR REFORMS TO IMPROVE HEALTH OF CITY DWELLERS

More experts are questioning the idea that obesity is a lifestyle choice PAGE 26

Better urban design can reduce the health risks of cities PAGE 44

DOUBLE BURDEN ON THE POOR

Many lower- and middle-income countries are facing a double burden of malnutrition in their populations PAGE 32

THE PROMISE AND CHALLENGE OF HEALTH TECH

Digital health is key to managing NCDs PAGE 50

OPINION: DIGITAL HEALTH CARE CAN BRING FAIRER ACCESS FOR ALL

Technology can help improve access to health PAGE 54

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GLOBAL HEALTH POLICY The novel coronavirus pandemic has exposed the fault lines in both global and national health infrastructures, highlighting inequalities and structural flaws. There has never been a timelier moment to focus on how to improve the resilience of health systems

T

he covid-19 pandemic has already transformed the world as we know it, upending policy priorities across multiple sectors.

Comprehensive changes in healthcare systems, healthcare funding and approaches to public health more broadly are more likely than not. The specific changes required in each area will shape policymaking and open the door for accelerating efforts to reverse the growth in non-communicable diseases (NCDs) around the world.

Those already living with NCDs have been, and continue to be, more susceptible to the virus and having contracted it may be left with longer-lasting side effects. In addition, the single mindedness of researchers trying to find treatments and vaccines for covid-19 is likely to mean fewer resources available in the short-term for other health needs. In hard hit parts of both developed and developing economies, many patients are likely to experience interruptions in the management of their NCDs. At the same time, the global impact of the pandemic and the need for collaboration to find solutions, could 4

suggest a blueprint for how to redesign public health infrastructure to better respond to both infectious diseases and NCDs. One of the key lessons to come out of the covid-19 crisis so far—and one with enormous ramifications for the approach to NCDs in future—is the need for health systems that are more flexible.

“Generally the performance of health systems has been underwhelming, if not catastrophic,” says Rifat Atun, a professor of global health systems at Harvard University’s T.H. Chan School of Public Health. “Even in systems we thought of as being high performing, such as Spain, the UK and Italy, the performance hasn’t been so optimal.”

Another lesson is the importance of access to health care. In many developing countries in Africa and Asia there is no universal health coverage. Notably, the same is true for America, the world’s wealthiest country. Without decent health care for all, populations in these countries were already less healthy going into the pandemic and have struggled to deal with the impact of covid-19. In its aftermath, medical professionals are likely to struggle to treat those FORESIGHT

TEXT Andrea Chipman — PHOTO Jeremy Stenuit

Pandemic builds potential for better global health

Tokyo, Japan Germany and Japan, which have previously been criticised for relative health inefficiencies, have been able to put excess capacity to use quickly in the pandemic

whose conditions have worsened or have been poorly managed during the crisis.

Many countries will also need to look at reworking service delivery to provide the coordinated care that is crucial to manage NCDs. Better sharing of information by public health agencies will be a likely requirement for improving health services.

WHAT WE HAVE LEARNED Covid-19 has had an especially severe effect on those with NCDs. They are more vulnerable to developing serious cases of the virus. A report released in June by the main public health agency in the US, Centers for Disease Control and Prevention (CDC), found that those with NCDs were hospitalised six times as often as healthy individuals infected with covid-19 during the first four months of the pandemic and were twelve times as likely to die.

As response to the outbreak has disproportionately monopolised the time and resources of healthcare providers, public health campaigns and day-to-day management of NCDs has been overshadowed.

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In some cases, progress towards addressing chronic illnesses may even have been reversed. In many developed economies there is concern that cancer cases have been missed or left too late for successful treatment due to the pressure on health systems.

In developing countries that were only beginning to introduce some cancer screening programmes, the setback in progress is likely to be magnified. Mental health is also a rising concern. Across the world, people in long periods of isolation are boosting the number of those with mental health issues.

The UK National Health Service, which has battled the worst covid-19 outbreak in Europe, has been particularly affected, according to Allyson Pollock, a consultant in public health medicine and director of the Newcastle University Centre for Excellence in Regulatory Science. “It’s been a covid-only service for the last few months, which means that there is a huge backlog for other care,” she says.

The economic dislocation caused by the coronavirus is likely to have wide-ranging consequences that could reduce the funding available for promot5

GLOBAL HEALTH POLICY

ing good health. A sustained recession or depression is likely to disproportionately affect public health funding, especially in developing countries. Lack of adequate financial resources will have an impact on health campaigns, especially those related to NCDs (such as anti-smoking, anti-obesity) and on screening programmes designed to flag people with chronic conditions. Unemployment and other hardships associated with an economic downturn could make patients with NCDs less willing or able to adhere to medical and lifestyle regimes.

A more specific dislocation will affect hospitals in countries such as the US with private healthcare systems and professionals that depend on income from surgery and elective procedures, many of which will have lost money during the pandemic. With fewer healthcare resources, policymakers will need to determine how to make the most of them.

In July, Takeshi Kusai, the World Health Organization’s (WHO) Regional Director for the Western Pacific region, said, “We can grow a new future where health is recognised as an investment. Where healthy people reach their full potential and inequalities are minimised. This new future is the dividend of covid-19 that the WHO hopes for.”

BALANCED GOVERNANCE The reality of the novel coronavirus on the ground has highlighted many of the aspects that make global coordination of health initiatives so difficult: competition for health resources such as personal protective equipment (PPE) and ventilators; the politicisation of policymaking; and growing xenophobia in some quarters.

Proper public health leadership requires governments to get the balance right between centralised and local control of services and surveillance. The pandemic crisis in the US has highlighted the problems of a health system without strong direction from the central government. States have competed for scarce PPE and received contradictory guidance on testing and tracing programmes. The CDC has appeared to be tentative and ineffective, leaving a vacuum where coordinated efforts to contain the pandemic should have been.

In the UK, by contrast, reforms under the previous Conservative government moved responsibility for public health away from regional strategic health authorities, which had been abolished, to local governments, effectively disconnecting it from the National Health Service (NHS). At the same time a new national body, Public Health England (PHE), was created. The result was a public health system that was fragmented and slow to respond. By contrast, some of the countries that have been most widely praised 6

for their ability to track and contain local outbreaks, including Germany and South Korea, have health systems that have been able to move quickly on the national and local level.

Elsewhere in Europe and Asia, variations in the way governments have used current scientific understanding have led to radically different policies toward social distancing, use of masks and length of lockdowns.

Generally, the performance of health systems has been underwhelming, if not catastrophic

Ultimately, as the search for a vaccine and cross-border research efforts demonstrate, the best way of fighting both covid-19 and NCDs is through international efforts and cooperation across both governments and non-governmental organisations.

LESSONS IN DATA SHARING Lessons can be learned from the rapid collection and sharing of data achieved during the pandemic. As covid-19 developed into a global pandemic, the political will existed to not only gather but also share the collected data. The same approach to data on NCDs would enable continued dissemination of “best buy” solutions and provide better understanding of what works.

“My hope is that for anyone either working on the research side or funding research, that covid-19 drives us as a medical community to be more collaborative, whether between NCD and infectious disease folks or global disease and national disease policymakers,” says Celina Gorre, chief executive of WomenHeart, the US National Coalition for Women with Heart Disease and former executive director of the Global Alliance for Chronic Diseases. “The system we have only leads to silos and duplication.”

Investment is also critical. A spring report by the WHO, under its Build Back Better campaign, called on governments to build bridges between national humanitarian emergency plans and NCD responses to allow for continuity in NCD treatment. WHO also called for the prevention, early diagnosis, screening and appropriate treatment of NCDs to be included FORESIGHT

GLOBAL HEALTH POLICY

in essential primary health services and universal healthcare benefit packages.

International donors and policymakers in developing countries may look to apply some of the lessons they have learned from covid-19 and other pandemics to broader public health infrastructure reforms. The WHO report advocates, “New international funding patterns, a reset of global initiatives and the building of new partnerships for NCDs.” The African Business Magazine earlier this spring predicted renewed commitment to upgrading the continent’s fraying public healthcare systems in the wake of the virus and observed that Sierra Leone, Guinea and Liberia all benefitted from government efforts to reinforce their “operational, epidemiological and logistical capabilities,” in the aftermath of the 2014-15 Ebola crisis.

The need for better access to healthcare is a specific funding priority that is likely to move to the top of the public health agenda.

“Clearly, countries that have universal health coverage, where individuals do not have to concern themselves with excess payments, are doing relatively well and have better protection,” Atun says.

We can grow a new future where health is recognised as an investment. Where healthy people reach their full potential and inequalities are minimised

Former UK Health Minister and current director of Imperial College London’s Institute of Global Health Innovation, Lord Ara Darzi, recently pointed out that many modern health systems operate as “sickness services” rather than “health and well-being services.” Noting that diabetes, obesity and cardiovascular disease are also pandemics, Darzi said prevention of NCDs must be addressed with the same urgency as treatment.

FLEXIBILITY IS KEY The immense variation in rates of covid-19 around the world have highlighted gaps in healthcare provision and weaknesses in healthcare systems—principally problems with workforce management and healthcare delivery that have made it difficult to control NCDs or react quickly to a pandemic.

FORESIGHT

“Covid unmasked many of the inefficiencies, supply systems broke down, and there was no continuity of care as many countries couldn’t repurpose systems,” Harvard’s Atun says. Even countries with adequate funding in hospital settings frequently did not have enough staff resources in public health surveillance or primary health care, he noted, a problem that must be resolved to successfully treat and prevent NCDs in future.

Notably, two countries that have often been criticized for relative health inefficiencies and excess hospital capacity, Japan and Germany, found these to be advantages in the pandemic. The extra capacity was put to use relatively quickly as was the implementation of systems to scale up testing for the virus. By comparison, many other countries struggled to respond to the virus surge. Better coordination and more nimble allocation of services could also be applied to NCDs: once “hotspots” of cardiovascular or respiratory disease are identified, resources can be channelled more quickly into preventative and primary care.

Health workforce pressures during the pandemic have increasingly been alleviated by a radical scaling up of telemedicine, which has served the dual purpose of continuing some non-covid health services at a safe distance. Technology is likely to play a much more substantial role in the management of chronic conditions, both through greater use of telemedicine and through remote systems for monitoring blood pressure or testing blood sugars in a home setting.

Inequalities in internet access, however, would be further highlighted.

Gaps in service delivery have been particularly obvious as countries around the world have struggled to mount a fully integrated response to covid-19, Atun observed.

“Patients were looked after in hospital, but upstream, in care homes and communities, they were not well managed, so many people presented late and outcomes were worse than they could have been,” he says, adding that Latin America has been especially hard hit. “All of this has implications for chronic disease, as you need highly personalised centres, with continuity of care. The system has to function as a system to manage the individual, not just one symptom at a time.”

Atun worries that after the emergency response to covid-19, health systems will return to their old practices. The risk is higher for developed countries with “sclerotic” systems. By contrast, developing countries with fewer legacy systems will find the transformation easier.

“We need health systems to become more responsive, agile and resilient,” he adds. “We must take the opportunity to change. • 7

GLOBAL HEALTH POLICY

Spending misalignment Diseases with the highest mortality get lowest levels of financing

GLOBAL CAUSES OF DEATH

FINANCING OF GLOBAL HEALTH

2017 Rank

2019

NON-COMMUNICABLE DISEASES

OTHER DISEASES

73.4%

OTHER DISEASES

26.6%

NON-COMMUNICABLE DISEASES

$730 million

8

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SOURCE: Institute for Health Metrics Evaluation. Used with permission. All rights reserved

$39.8 billion

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Not a flattening curve in sight Prevalence of non-communicable diseases continues to grow

1.4 billion 1.2 billion 1 billion 800 million 600 million 400 million 200 million 0

1990

1995

2000

2005

2010

2016

Total disease burden from non-communicable diseases (NCDs), measured in DALYs (Disability-Adjusted Life Years) per year. DALYs are used to measure total burden of disease, both from years of life lost and years lived with disability. One DALY equals one lost year of healthy life

Other NCDs

Respiratory diseases

Musculoskeletal disorders

Digestive diseases

Neurological diseases

Mental and substance use disorders

Liver diseases

Diabetes and endocrine diseases

Cancers

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Cardiovascular diseases

9

GLOBAL HEALTH POLICY A decade of initiatives to combat non-communicable diseases have failed to curb their growth.

Policymakers need a more comprehensive approach that recognises the complexity of these health failures and takes lessons from successful infectious disease campaigns

A

s the world grapples with an unprecedented viral pandemic, which has wreaked havoc on societies and economies around the globe, non-communicable diseases (NCDs) remain a less reported, but ominous longterm threat to human health.

Taken together, NCDs, primarily cancer, cardiovascular disease, diabetes and chronic respiratory conditions, now account for around 70% of all deaths worldwide.

In the first six months of the covid-19 pandemic, more than eight out of ten premature deaths from NCDs occurred in developing and emerging market countries, which are often facing the additional challenge of persistently high infectious disease rates at the same time. In addition, developing countries often do not have access to health services that can provide both treatments and preventative care for 10

conditions such as high blood pressure and diabetes —services that are taken for granted in much of the industrialised world.

Although NCDs have been identified as a threat for nearly a decade, policymakers have been slow to identify them as a priority compared with dealing with infectious diseases. Yet the economic losses associated with failing to treat and prevent NCDs could be as much as $47 trillion over two decades, according to some estimates.

At least some of those losses are avoidable. Many NCDs are preventable and sufficient knowledge and recommendations already exist to reduce their prevalence. Too often, however, a complex number of interlinked factors prevent government and decision-makers from bending the curve and implementing much needed policies and behavioural change campaigns to curb risk factors such as tobacco use, FORESIGHT

Eye-opening NCDs now account for around 70% of all deaths worldwide

TEXT Ben Hirschler ILLUSTRATION Trine NatskĂĽr PHOTO Pilar Gonzalez Prieto

The hidden health crisis

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GLOBAL HEALTH POLICY

lack of physical activity, unhealthy diet, harmful use of alcohol and air pollution.

The scale of these risk factors suggests that a multi-sectoral, rather than piecemeal, approach will be needed to reduce rates of the major chronic diseases.

In addition, many low and middle-income countries continue to struggle with severe fiscal constraints that force them to make difficult choices about where to invest and where not to invest the scarce health resources. Yet, if evidence-based interventions could be started earlier, the disease burden in many developing countries might be lower.

Governments continue to face a range of challenges in successfully combating NCDs. Weak health infrastructure and gaps in universal health coverage have made it difficult for countries to provide comprehensive programmes that focus on the risks for NCDs. In many places, policies have often lacked political commitment, especially where they have meant taking on powerful business interests.

To see real progress, health investment needs to be targeted appropriately, especially in developing countries where NCDs have received just a fraction of international aid money. Programmes must integrate expertise on health, environment and education. Where health systems are basic and will remain so in the medium term, policymakers should look to employ both technology and community health resources to expand awareness of risk factors and help people manage their conditions. These approaches were used innovatively to combat HIV/AIDS.

PANDEMIC UNDERLINES CHALLENGES Times are difficult for those pushing the NCD agenda.

With the world in the grip of the covid-19 pandemic in mid 2020, the focus is necessarily on those suffering from the virus or from related unemployment. The resources of time and money thrown at tackling the virus may lead to neglect of other global health problems, including rapidly expanding levels of NCDs. The pandemic has also shone a spotlight on the inadequacies in many health systems that will need to be repaired.

“The current pandemic highlights the work that needs to be done to make sure we have strong health systems that can address both acute and chronic disease challenges,” says Cristina Parsons Perez, Capacity Development Director for the NCD Alliance. “It also shows the importance of co-morbidities in the real world. People don’t present to their doctors with siloed conditions and it is precisely those people living with non-communicable diseases that are most at risk at present from coronavirus.”

The pandemic is severely disrupting care for these people, according to a World Health Organization 12

(WHO) assessment. Almost half of countries experiencing covid-19 community transmission in May 2020 reported disrupted services for cardiovascular emergencies, including heart attacks and strokes; over half had interrupted cancer treatment, while nearly two-thirds suffered disrupted hypertension and diabetes management.

“It’s vital that countries find innovative ways to ensure that essential services for NCDs continue, even as they fight covid-19,” WHO director-general Tedros Adhanom Ghebreyesus told the global health community in June 2020.

A DECADE OF GLOBAL EFFORTS

The burden gets ever heavier After a decade in which NCDs received increased prominence on the global health policy agenda, progress in reversing their growth remains painstakingly slow Back in 2011, the United Nations held its first-ever High-Level Meeting on Non-Communicable Diseases in New York. It was only the second such meeting to focus on disease, after one on HIV/AIDS in 2001.

Campaigners hoped the event would mark a coming of age in the fight against NCDs. But while the 2011 event did usher in greater recognition of the issue, nearly a decade later the world is still falling far short of meeting its targets. Indeed, WHO forecasts suggest the proportional global burden of NCDs will continue its current inexorable rise through 2040, in part due to older populations.

The numbers tell a stark story. In 1990, NCDs accounted for 57.7% of all deaths worldwide but by 2017—the latest year for which data is available—this had risen to 73.4%, according to the Institute for Health Metrics and Evaluation’s Global Burden of Disease (GBD) analysis. Worryingly, the curve has shown no real sign of flattening in the past decade, and could increase further as progress is made in reducing infectious diseases and as populations continue to age.

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GLOBAL HEALTH POLICY

A growing share of mortality Global deaths by cause, 1990 to 2017

100%

Communicable maternal, neonatal and nutritional diseases

80%

60%

SOURCE: IHME, Global Burden of Disease Study, 2017

NCDs 40%

20%

0%

Injuries 1990

1995

2000

2005

2010

2015

NCDs include cardiovascular disease, cancers, diabetes and respiratory disease.

Injuries include road accidents, homicides, conflict deaths, drowning, fire-related accidents, natural disasters and suicides

The steady increase in the proportion of NCD fatalities among all deaths comes despite a far-reaching political declaration arising from the 2011 meeting that recognized the NCD threat as one of the major challenges for development in the 21st century. The declaration eventually led to a decision, affirmed by heads of states and governments, to include a target in the UN Sustainable Development Goals (SDG) in 2015 to reduce premature mortality related to non-communicable conditions by one third by 2030.

“The 2011 meeting was a landmark event and the good news is that we now have NCDs included in the global health and development agenda. The bad news is that progress at the national level is insufficient and uneven,” says Parsons Perez. “It’s been five years since the SDG agenda was adopted. We’re ten years out from 2030 and we are not on track to meet these targets, so the situation is rather bleak.”

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INSUFFICIENT PROGRESS The policy failure comes despite a clear roadmap laid out for governments by the WHO, including interim targets to be achieved by 2025, such as reducing harmful alcohol consumption and physical inactivity by 10%; reducing high blood pressure by 25%; reducing salt intake and tobacco use by 30%; ensuring 80% coverage of essential NCD medicines.

Achieving these interim targets would go a long way to address the epidemiological shift in the burden of disease that has run in parallel with globalisation. As populations across Asia, Africa and Latin America adopt more urban and Western lifestyles, their prevalence of NCDs rises.

NCD Countdown 2030 is an independent collaboration of medical journal The Lancet, WHO, Imperial College London and the NCD Alliance. It warns that the SDG target to reduce by one-third premature 13

GLOBAL HEALTH POLICY

mortality from NCDs will be achieved by fewer than one in five countries by the intended date of 2030. As a result, the world may well be faced with a tsunami of disease-related impacts, both human and economic, that could have been avoided.

Perhaps unsurprisingly, most of the countries that are on track to meet the 2030 target are developed countries where premature deaths from NCDs are already relatively low. In developing countries at the other end of the spectrum, however, mortality rates have stagnated or increased for men in 24 countries and for women in 15 countries since 2010.

Drilling down into specific conditions reveals the scale of the challenge. Only one in three countries, mainly those in the developed world, currently provide drug treatments and counselling services to prevent heart attacks and strokes, even though doctors have known for decades that cheap drugs like statins, aspirin and blood pressure pills are highly effective.

Lack of funding and poor healthcare infrastructure means access to screening and early cancer care is similarly inadequate, exposing millions of patients to unnecessary suffering from an increasingly common condition. Rates of type 2 diabetes, which is linked to obesity and lack of exercise, are also spiking particularly rapidly in the developing world.

“The real problem about obesity is the increase in the large metropolitan areas throughout the world.

These large urban areas are very dependent on external food supplies, people are dissociated from food production and this leads to the consumption of a lot of unhealthy foodstuffs,” says Thomas Sanders, emeritus professor of nutrition and dietetics at King’s College London.

FIXING THE SYSTEM

Much remains to be done Investment in preventative care and risk reduction is key When the world eventually recovers from the dislocation wrought by covid-19, the strength of the arguments for tackling NCDs makes them a top priority for more investment. Countries have the opportunity to 14

build back stronger, with multi-sectoral health policies that deliver better prevention, diagnosis and care, while stepping up the fight against the key risk factors: smoking, lack of physical activity, unhealthy diet, excessive alcohol consumption and air pollution.

It is clear that plenty can be done to reverse the dramatic growth of NCDs globally over the past couple of decades. A broader, joined-up vision of public health policy might make it easier to combat the political inertia that often undermines individual initiatives. Increased investment in health systems to build up preventative care capacity should be a key priority, especially in developing countries.

One problem is that the political payback on health initiatives, from single issue programmes like campaigns to stop smoking to far-reaching efforts to provide universal healthcare, are typically slow, so politicians are unlikely to see benefits in time for the next election. Moreover, policies such as increasing “sin” taxes on sugary drinks, alcohol and tobacco are unlikely to win many votes.

Critics complain that businesses, from Big Tobacco to Big Food, are adding to the headwinds by successfully lobbying governments to be only half-hearted in the fight. According to a recent Lancet study on the implementation of NCD policies in 151 countries, the policies recommended by the WHO that have been least widely implemented by governments around the world are tobacco taxation, anti-smoking mass-media campaigns and alcohol advertising restrictions, alongside the provision of cardiovascular therapeutics.

Despite these hurdles, health experts believe it is possible to successfully reduce NCDs by tackling health problems at their roots and influencing populations at all stages of life. This so-called “life course” approach is underpinned by evidence from a wide range of disciplines showing how chronic diseases are influenced by early life factors, according to Bente Mikkelsen, director for NCDs at the WHO’s European office.

“Many of the health problems we encounter in adulthood stem from our experiences early in life, in some cases, even from before we are born,” she and colleagues wrote in the last year. “The major noncommunicable diseases are often associated with older age groups, but the evidence suggests that they affect people of all ages.”

Even before and during pregnancy, promoting healthy nutrition and regular physical activity can prevent hypertension and gestational diabetes in later life. Unborn children are adversely affected by harmful exposures such as air pollution, tobacco use and maternal consumption of alcohol. Similarly, their tendency to develop obesity may be reduced FORESIGHT

Metropolitan Large metropolitan areas magnify the physical and perceived distance from farm to fork, leading to unhealthy food consumption

GLOBAL HEALTH POLICY

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Shifting chronic care for HIV patients out of the formal healthcare system allowed scarce resources to reach more people. Enabling local blood pressure readings could do something similar to reduce the burden on hospitals, while at the same time offering patients added convenience

during fetal development, infancy and childhood by breast-feeding and healthy diet.

In addition, there is also growing awareness of environmental factors driving some NCDs. In recent years, new data has revealed the significant health hazards of air pollution, with research by scientists at the University Medical Centre Mainz in Germany calculating that 8.8 million early deaths a year are caused by outdoor air pollution worldwide.

“It is not a secret that air pollution is the new tobacco, so the public health implication is very clear: authorities need to act swiftly and comprehensively to protect their citizens from air pollution through science-based policy,” according to Samuel Cai, a senior epidemiologist at the George Institute for Global Health at the UK’s Oxford university.

LESSONS FROM HIV/AIDS Taking proper account of so many factors affecting billions of people is clearly a formidable challenge.

But global health pioneers, including Peter Piot, director of the London School of Hygiene and Tropical Medicine, believe there are useful lessons to be drawn from fighting earlier crises, in particular, the very different problem of HIV/AIDS. One of the most important innovations in the fight against HIV was the empowerment of patients to self-manage their condition under community-based healthcare supervision.

The introduction of antiretroviral therapy from the mid-1990s made HIV the first major chronic disease that many low and middle-income countries had widespread experience of treating. Coping with the burden was very different to managing acute infec16

tions. Patients with HIV were able to return home from hospital, but they then required long-term care.

The traditional public health systems could not cope, so countries across Africa turned instead to local village and family-based support, which proved remarkably successful at getting drugs to patients and conserving resources, which in turn allowed more cases to be treated.

A similar approach is possible with NCDs, Piot argues. One concrete example is a community-based blood pressure management project in Ghana, a country where one-third of adults have hypertension that is not under control. By offering blood pressure screening points in local communities, including in certain shops, and sending people mobile phone reminders, the project has been able to improve hypertension control dramatically. Significantly, hypertension control rates for patients who were followed up for 12 months doubled to 72% from 36%, resulting in an average reduction in systolic blood pressure of 12 millimetres of mercury.

Shifting chronic care for HIV patients out of the formal healthcare system allowed scarce resources to reach more people. Enabling local blood pressure readings could do something similar to reduce the burden on hospitals, while at the same time offering patients added convenience. Paying a visit to a nearby shop is a lot easier than travelling for hours to a government clinic or hospital.

Community-based civil society organisations were also a potent force in holding governments and businesses to account in fighting the HIV pandemic. It was a battle that yielded breakthroughs in making antiretroviral medicines affordable and accessible, even FORESIGHT

GLOBAL HEALTH POLICY

in the poorest settings. Similar progress is still awaited for many NCDs, especially cancer, where drugs are often hugely expensive and targeted at relatively small numbers of patients. The average cost of a newly approved cancer treatment is now around $10,000 a month, a price that stretches the budgets of even the richest countries in the world.

Jayasree Iyer, head of the Access to Medicine Foundation, a global charity, is concerned that efforts to improve access for new products to treat non-communicable diseases, particularly cancer, lag far behind those for communicable diseases.

“People say it is because the health systems are not ready, but if we keep using that argument then we are never going to actually solve the problem,” she says. “There has been quite a lot of effort, particularly in sub-Saharan Africa, to develop more community-based healthcare systems, but it doesn’t always mean treatments are getting to more patients.

As long as some products are not as affordable as they need to be, you still won’t get the necessary large-scale access.”

Worryingly, even well-established products like insulin for people with diabetes are not getting to millions who need them in resource-scarce countries.

A study of 15 insulin price and availability surveys— carried out in developing countries and published in the British Medical Journal in 2019—found that globally, one in two people needing insulin lacked access to it. Insulin can be especially out of reach in poorer countries with poor infrastructure because of tortuous supply chains and high mark-ups by middlemen.

“In infectious diseases we have a global approach but in NCDs we don’t,” points out Iyer, with a nod to FORESIGHT

big donor-backed organisations for infectious diseases like the Global Fund to Fight AIDS, Tuberculosis and Malaria and the international vaccine alliance Gavi.

The economic case for greater action on NCDs by all parties is not hard to make. The WHO has identified plenty of “best buy” interventions that represent good value for money in preventing the risk of patients developing chronic disease at all stages of life. These include regulations and taxation on tobacco and alcohol, promotion of healthy foods and the reformulation of products to reduce salt and sugar, and measures to cut air pollution. More broadly, better access to basic health coverage, preventative care in particular, will be necessary to reverse the NCD growth trend.

SMART INVESTMENT The WHO estimates that investing in its best buy strategies will yield a return of at least $7 for every $1 invested, mainly due to reduced loss of workplace productivity. The total return equates to $350 billion in aggregate economic growth in low and middle income countries between 2018 and 2030. The cost of inaction, meanwhile, is huge.

Yet despite such economic arguments, only 2% of overseas development assistance for health is currently going to NCDs, the world’s biggest cause of death from ill-health.

Late last year there was a glimmer of hope for global health campaigners when the government of Norway launched a first-ever strategy designed specifically to combat NCDs in low-income countries as a pillar of international health. “What we hope is that more countries will now follow suit,” says Parsons Perez of the NCD Alliance. • 17

OBESITY SPECIAL REPORT This special report was researched with the support of Novo Nordisk

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his special report explores the roots of the obesity crisis, why it evolved so rapidly and how its unchecked growth will become an ever larger drain on the global economy.

Obesity is not just a rich world disease. It also exists in countries with high rates of undernutrition.

Classifying it as a disease in its own right, not an avoidable lifestyle choice, could be a vital first step to slowing the growth of obesity. But not all experts agree reclassification would be beneficial for patients.

Obesity is arguably unique among non-communicable diseases (NCDs), with rates skyrocketing globally at the same time that it has become a leading risk factor for so many other chronic conditions, including diabetes, cardiovascular disease and cancer.

The associated cost to health budgets and to the broader economy from lost productivity is already accelerating. The number of people in OECD countries who are obese has risen to nearly one in four in 2019, from one in five in 2010. In 2019, the OECD estimated that 8.4% of the health budgets of member countries will be spent on treating the consequences of being overweight and obese over the next three decades.

Obesity is heavily stigmatised. Like smoking and alcohol-related illnesses, obesity is one of a small group of conditions for which those who suffer from it often take the blame. Indeed, the 2019 study “Weight bias and health care utilization: a scoping review� found that stigma has been identified as a major barrier, hindering obesity suffers from engaging with primary health services. The Awareness, Care and Treatment in

18

Obesity Management—an International Observation (ACTION IO) Study, published the same year, found that more than eight out of ten obese people believe that the need to lose weight is solely their responsibility.

Yet successive policies to combat obesity have often been piecemeal in approach and done little to reverse its current upward trajectory. Obesity is increasingly understood as a complex condition with a variety of physiological, behavioural, genetic and environmental causes. Combating it requires attention to the broad context in which obesity develops and the adoption of more ambitious, multi-faceted policies.

Mounting evidence that obesity has been an important risk factor for covid-19 is clearly focusing the minds of policymakers. A report on excess weight and covid-19 from Public Health England in July 2020 finds that excess weight is associated with an increased risk of a positive test, hospitalisation, advanced levels of treatment (including mechanical ventilation or admission to intensive or critical care) and death from the virus. These risks seem to increase progressively for people with body mass index measurements above the range for healthy weight, the report finds. Report data also indicate that excess weight may explain some of the observed differences in outcomes linked to covid-19 for older adults and some minority ethnic groups.

In the wake of the covid-19 pandemic, there is clearly renewed incentive to ramp up efforts to prevent and treat obesity. Policymakers will need to acknowledge the complex roots of the condition if they want to improve their chances for success.

FORESIGHT

TEXT Andrea Chipman

Obesity casts a big shadow

650 million adults worldwide suffer from obesity

SOURCE: Action IO and OPEN, 2019

By 2030 1.12 BILLION adults will be living with obesity globally

Obesity is a COMPLEX CHRONIC DISEASE which is influenced by psychological, genetic and environmental factors

!

Approximately 200 disorders are associated with obesity, including type 2 diabetes, cardiovascular disease and certain cancers

$ Loss of productivity accounts for OVER 50% of the economic burden of obesity

$850 BILLION was the estimated spend globally for treating the consequences of overwight and obesity in 2018, a sum predicted to rise to $1.2 TRILLION in 2025

FORESIGHT

2-7% of healthcare spending in developed countries is estimated to be due to obesity

19

OBESITY SPECIAL REPORT

The obesity crisis has been a long time in the making, gathering force despite more than a decade of individual initiatives to reduce the numbers of seriously overweight people.

Comprehensive policymaking that touches on the complex roots of obesity has huge potential to reverse the progress of a deadly epidemic linked to growth in economic prosperity

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besity is one of the greatest threats to global health. Treating it strains economies and living with it means lethal danger from type 2 diabetes, hypertension and cardiovascular disease.

It is classed as an epidemic by the Organisation for Economic Co-operation and Development (OECD) and the statistics are arresting: more than 1.9 billion adults are overweight with 650 million of them classified as obese, equivalent to almost twice the US population.

The burden and the cost of obesity grows by the day, with the OECD predicting that life expectancy is being sent into reverse for the first time in living memory because of the corrosive effects of obesity. A report in the British Medical Journal found that life expectancy was reduced across Europe because of the condition and called on public health initiatives to address “the multifactorial and complex obesity aetiology.”

After generations of medical and public health advances, the prospect of a reversal in life expectancy is chilling.

20

A myriad of initiatives, from awareness campaigns to government regulations, has failed to block the spread of obesity. Across societies and cultures the default position has been to blame and stigmatise the obese individual. The crisis has become so critical that experts are increasingly calling for a more coordinated approach that reflects the complexity of obesity, the variety of support needed to deal with it and the conditions that help to nurture it.

NO SINGLE POLICY SOLUTION Reasons for the strong hold of obesity are many, involving a complicated interplay between environment, genetics and socioeconomics. Counter measures have to work across elements such as food production, advertising and media, education, mental health and politics as well as personal behaviour.

These multiple targets have been resistant to largely fragmented approaches dealing with single issues rather than the adoption of multi-faceted strategies.

“No one policy will fix this so we need simultaneous action across a lot of domains,” says Caroline FORESIGHT

Going backwards The OECD has predicted life expectancy is being sent into reverse for the first time in life time because of the effects of obesity

TEXT Danny Buckland — ILLUSTRATION Clara Selina Bach

A ruinous epidemic

FORESIGHT

21

OBESITY SPECIAL REPORT

Men are getting heavier

Percentage of male adults living with overweight and obesity in selected countries

KUWAIT USA AUSTRALIA QATAR UAE MEXICO SCOTLAND GERMANY CZECH REPUBLIC SWEDEN SLOVAK REPUBLIC MOROCCO BRAZIL FRANCE ENGLAND

INDONESIA KENYA ZAMBIA

0

10 Obesity

20

30

50

60

70

80

90

Overweight and obesity

Cerny of the Obesity Health Alliance (OHA) a coalition of more than 40 leading charities, medical royal colleges and campaign groups supporting the UK government.

“Concentrating on one area will just displace the problem elsewhere so, for example, we need sugar and calorie reduction across all types of foods and drinks and controls on marketing so children see far less junk food marketing. We also need to look at digital marketing and sports sponsorship. And this is just to start with.”

More research on the role genetics and environment play in obesity would also help broaden the ev22

40

idence base for treatment; policymakers also need a better understanding of the impact of stigma on the mental health of those with obesity.

The warning signs have been around for a long time; in 2007 the UK government’s Foresight report predicted that the NHS would face an annual €11.2 billion bill with wider economic impact reaching €55.8 billion if the rapid increase in obesity continued its trajectory.

That report, which identified multiple drivers outside the health sphere that needed a “comprehensive, co-ordinated” approach, helped frame the UK’s obesity strategy. Despite some success, however, in FORESIGHT

100

SOURCE: © World Obesity Federation, 2020

MALAYSIA SOUTH AFRICA

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And women are more likely to be overweight

Percentage of female adults living with overweight and obesity around the world

KUWAIT MEXICO MOROCCO USA QATAR UAE SOUTH AFRICA SCOTLAND AUSTRALIA ENGLAND BRAZIL GERMANY CZECH REPUBLIC MALAYSIA SWEDEN

SOURCE: Š World Obesity Federation, 2020

FRANCE SLOVAK REPUBLIC KENYA ZAMBIA INDONESIA

0

10 Obesity

20

30

40

50

60

70

80

90

100

Overweight and obesity

2017 one of its key contributors, Susan Jebb, Professor of Diet and Population Health at the Oxford university and a member of the Public Health England Obesity Programme, called for a revisiting of its central themes of recognising the need for partnerships between governments, science, business and civil society.

BLAME GAME The most immediate causal factors of obesity are an abundance of cheap, calorie-dense food, major changes in work patterns promoting sedentary lifestyles and widespread access to media awash with FORESIGHT

powerful advertising and marketing. Public health campaigns bolstered by sugar taxes and shielding children from some advertising have scored success across many regions of the world, but national policies vary in both their scope and implementation.

They also tend to emphasise individual responsibility, which, given huge societal and cultural influences on calorie consumption, can drive stigma rather than compliance. “It is a complex issue but the real problem is the way it is positioned as an individual responsibility: You are overweight because you eat too much so you need to eat less, which is an approach that absolves 23

OBESITY SPECIAL REPORT

It is a complex issue but the real problem is the way it is positioned as an individual responsibility

the wider issues such as the food manufacturers who say they are just giving people what they want,” adds Cerny. “Advertising, marketing and promotions are very powerful and we are putting the onus on the individual to make the right choices in a flood of relentless messages telling us to do the opposite of adopting healthy eating patterns. The individual does not stand a chance.”

Stigma is a global health challenge that has a significant impact on how public health conceives its responses to obesity, according to research published in the Globalisation and Health journal in 2018.

Monika Arora, a director at the Public Health Foundation of India and a member of WHO’s Commission on Ending Childhood Obesity, believes the best intentions of world bodies will fail unless obesity’s complex drivers are fully recognised and dealt with. “Obesity is not effectively prevented or managed across health systems and societies. Of nine NCD targets set by WHO and agreed by all member states in 2013, only one—to halt the increase of diabetes and obesity at 2010 levels by 2025—is likely to be missed in every country in the world,” she points out in a paper on stigma and obesity, published in Lancet Public Health in October 2019.

CRUCIAL POLICY INTERVENTIONS Arora, a leading public health scientist who has run successful campaigns to reduce NCDs in youth populations, is calling for stronger initiatives and improved coordination across all organisations along with enhanced research into the impact of obesity. Scientific evidence provides governments with strong arguments for implementation of more effective policies.

“Obesity has not been adequately addressed from a policy perspective,” she says. “A valid approach from governments would be to invest in prevention to free up resources and reduce NCDs. Priority inter24

ventions can be front of pack labelling, bans on marketing unhealthy food and beverages to children, taxing unhealthy food products and improving access to healthy food and physical activity in schools, colleges and workplaces.”

Arora adds: “However, determinants influencing obesity go beyond individuals. Healthy behaviours require an enabling environment to sustain change, and policy interventions play a crucial role in that.

“We could see changes from policy makers and the general community and that could be a catalyst for better health in the future. But obesity remains a chronic and complex disease and we need broadbased policies across all elements to have the best chance of reducing its terrible impact.”

Family dynamics and other psychological and behavioural factors associated with an individual’s immediate surroundings all contribute to what experts call an “obesogenic” environment. They argue for comprehensive policies that offer a variety of support both inside and outside of the healthcare sector.

SOLUTIONS WITHIN REACH The challenge of obesity is monumental and global, but there is hope. The OECD estimates that a 20% lowering of calorie content in energy dense foods could result in the reduction of 1.1 million NCDs such as diabetes and hypertension, and boost economic output by 0.5% across 42 selected countries.

The World Obesity Federation has launched a Healthy Voices initiative to empower young people to avoid obesity and create a generation that can shape environments and become agents of change. A meeting at the World Economic Forum in January 2020 also advocated a future where all sectors of society contributed towards healthier food environments while noting that initiatives were springing up around the globe, citing diverse programmes in Amsterdam, FORESIGHT

OBESITY SPECIAL REPORT

London, Chile, Malaysia and Mexico dealing with aspects as diverse as nutrition, transport, food taxes and labelling.

The 2020 pandemic could be a watershed moment for obesity as the public realises that a co-morbidity increases their chances of falling ill and compromises their ability to fight infections. Many governments are moving hard and fast to use the new awareness as a lever for behavioural change and to introduce tougher measures across food production, advertising and health provision.

The obesity epidemic will continue to be a blight on the world until the full range of societal, political, commercial, physical and psychological drivers that influence our fundamental health are tackled with co-ordinated zeal. The coronavirus pandemic has provided a pivotal moment for fighting obesity: bold, strong action combined with growing public understanding can help shape a healthier and more sustainable future. • FORESIGHT

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OBESITY SPECIAL REPORT

As obesity reaches epidemic levels globally, experts are reflecting on the mixed results of policies implemented over the past decade and asking if obesity should be treated as a disease more than as a lifestyle choice that individuals can modify

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he world is getting heavier, with obesity spreading at an alarming rate across the globe. Worldwide incidence of obesity tripled between 1975 and 2016. According to the World Health Organization (WHO) most people on the planet live in countries where they are more likely to die because they are overweight and obese, than because they do not have enough to eat.

“Obesity is a gateway disease for other chronic conditions,” says Ximena Ramos-Salas, policy and research officer for the European Association for the Study of Obesity (EASO). “It’s increasing all over the world, not just in rich nations. To keep ignoring it will just increase the burden on health care services and society generally.”

WRONGLY LABELLED The WHO recognised obesity as a disease in its own right (as a nutritional disease) as far back as 1948, but so far only a handful of governments have officially acknowledged the categorisation. Portugal recognised 26

obesity as a disease back in 2004 and Italy in November 2019. Others to do so include Sweden and Turkey.

“The scientific evidence is pretty clear that the increase in obesity is as a result of an obesogenic environment,” says Simon Capewell, professor of epidemiology at Liverpool university in the UK and a member of the steering group of the Obesity Health Alliance, a UK umbrella group for health professional groups and charities that campaigns for prevention and better treatment of obesity.

“Three decades ago, obesity was a rarity. There were not many doctors who specialised in it. Our genes have not changed since then, but what has changed is that the world around us is now full of calories,” Capewell says. Children now swim through a torrent of messages, exhorting them to consume sweet things from the moment they wake up and turn on the TV, tablet or smartphone, he notes. Outside, as well, they are regularly confronted by shops advertising two-for-one offers on cheap sugary drinks and food, he adds.

FORESIGHT

TEXT By Jo Waters ILLUSTRATION Clara Selina Bach

Disease in disguise

FORESIGHT

27

OBESITY SPECIAL REPORT

Increasing number of obese children in advanced economies Percentage of overweight children in selected countries

% OVERWEIGHT

45 40 35 30 25 20 15 10

0 1960

1970

1980

United States

“Pointing the finger at overweight people and saying it is now the norm to be completely immune to these clever marketing messages is to blame the victim,” Capewell says. “We absolutely reject the idea that obesity is a lifestyle choice.”

John Wass, professor of endocrinology at Oxford university and another member of the same UK group points out that genes, as well as environment, can also play an important role. “Weight is influenced by genes at both ends of the spectrum, it isn’t the whole story, but forty to seventy per cent of a person’s weight is determined by genetics,” he says.

“If you talk to obese people, they believe they have something wrong with them and certainly do not feel they chose to be like they are. Obesity is definitely a 28

1990

England

2000

Japan

2010

Australia

disease and this approach is now gaining much wider acceptance.”

“The main advantage of recognising obesity as a disease is that it will go up the political agenda and we can de-stigmatise it because people should feel less guilty about their weight, it being largely genetic,” he adds.

THE ARGUMENT FOR SELF-HELP Not everyone agrees that classifying obesity as a disease is helpful, least of all some governments which fear treatment of it will be a further drain on resources.

Richard Pile, a medical general practitioner (GP) with a special interest in lifestyle medicine who practises in Hertfordshire, UK, has argued in the British FORESIGHT

2020

SOURCE: © World Obesity Federation, 2020

5

OBESITY SPECIAL REPORT

And adult obesity in advanced economies continue to rise Changes in percentage of obese adults in selected countries

% OBESITY BMI =>30 kg/m2

45 40 35 30 25 20 15 10

SOURCE: © World Obesity Federation, 2020

5 0 1975

1980

1985

1990

United States

1995

2000

England

Medical Journal that self-determination is vital when it comes to individuals taking control of their lives and making the best decisions for themselves.

“Labelling obesity as a disease risks reducing autonomy, disempowering and robbing people of the intrinsic motivation that is such an important enabler of change,” Pile says. “It encourages fatalism, promoting the fallacy that genetics are destiny. I don’t need to quote randomised controlled trials and systematic reviews here because I have seen it the mindset of patients every day for almost twenty years in general practice,” he adds.

“There is an important difference psychologically between having a risk factor that you have some responsibility for and control over and having a disease FORESIGHT

2005

Japan

2010

2015

2020

Australia

that someone else is responsible for treating,” Pile continues. Making obesity a disease may not benefit patients, he observes, but would benefit healthcare providers and the pharmaceutical industry when health insurance and clinical guidelines promote treatment with drugs and surgery.

Roy Taylor, professor of medicine and endocrinology at the UK’s Newcastle university, argues that obese people have acquired a physical state, characterised by a measurable property of the body such as height, waist circumference, weight or body mass index (BMI), rather than a disease state, which suggests a requirement for medical attention. “We should avoid medicalising obesity and prevent the physical state happening.

Labelling people as having a disease could make things 29

OBESITY SPECIAL REPORT

far worse, as it could be seen as self-inflicted and risk more stigma,” he warns.

CURBING OBESITY Ten years ago, the WHO recommended countries take action to control marketing of high fat, sugar and salt foods to children. In 2018, it reported back that steps had been taken by around half of the 53 countries in the WHO defined European region.

Mexico was the first country in the world to bring in a sugar tax in 2014, when it added a one peso per litre excise tax on any non-alcoholic beverage with added sugar, a 10% price increase for the consumer.

A 2017 study following the introduction of the tax, “In Mexico, Evidence of Sustained Consumer Response Two Years After Implementing A Sugar-Sweetened Beverage Tax,” showed a 7.6% reduction in sales of sugary drinks. The fall was even bigger in poorer households, where it dropped by 11.7% .

Portugal introduced a soft drinks levy in 2017.

Francisco Goiana Silva, at the time a member of government and a health ministry lawmaker, told the WHO the policy intervention was estimated to have had a far greater impact on the population’s diet than all the education and self-regulation mechanisms combined. A study by Imperial College London published in March 2020 found consumption of sugar sweetened beverages fell by 6.6 million litres a year in Portugal after the tax was introduced.

Many other countries and regions have introduced their own versions of a sugar tax, including Spain’s Catalonia, South Africa, some US states, Hungary, Brunei, Thailand, and the UK. “Some countries, such as Iceland, Finland, Cuba and Canada, have already been much firmer with controlling junk food advertising targeted at children, which makes total sense,” Capewell says. “If advertising and marketing doesn’t work, why is the food industry spending so much money on it?”

DOCTORS CAN HELP Good evidence is emerging that obesity treatments do work. An Obesity Society study from February 2020, showed that combining intensive behavioural therapy with an appetite suppressant drug can produce clinically meaningful weight loss.

In the UK, now officially the most overweight nation in Europe, doctors say they are “drowning” in illnesses connected to obesity, with 876,000 obesity-related hospital admissions in England in 2018/19.

During the same year, 67% of men and 60% of women were categorised as overweight or obese, according to “Statistics on Obesity, Physical Activity and Diet, 2020,” published by the National Health Service.

Newcastle University’s Taylor has shown in the DIRECT Trial how putting patients with type 2 diabetes 30

(and a BMI of no more than 34) on a very low calorie liquid diet of 700 calories a day for eight weeks, plus carbohydrate-free vegetables, can not only put their diabetes in remission, but lead to weight loss of around 15 kg on average.

“We then stop to offer psychological support to help patients maintain their weight,” Taylor explains.

“The success of the diet was in its simplicity; a lot of the current public health advice is confusing and not that useful. One particularly important point is that people are often told to exercise more and eat less.

But this takes no account of the characteristics of the people typically involved.”

Taylor notes that those who are starting an exercise programme often engage in unconscious compensatory eating and this is especially so far those who are overweight. “The simple fact is that most people with type 2 diabetes cannot do both of these at the same time—if they are older or overweight, with joint problems, for instance. Increased activity can be phased in once the weight has been reduced by restricting food intake,” he adds. “Trying to do both at the same time is counterproductive. The role of energy expenditure is relatively small in the process of losing weight; public health advice needs to be focused very much on food.”

Making obesity a disease may benefit the health industry but not help patients

Taylor’s very low-calorie diet is now being evaluated by the UK National Health Service (NHS) as part of a pilot exercise for achieving remission of type 2 diabetes that was about to launch before the coronavirus crisis. “If I was in charge of the NHS, I’d be looking at how this diet could be offered to a wider range of patients,” he says. “Britain is suffering from a gross excess of fatty liver disease, for instance, and premature coronary heart disease—all diseases associated with obesity.”

In New Zealand, researchers at the University of Otago published research in 2019 evaluating different types of weight loss diets and found that the Mediterranean Diet, intermittent fasting (IF) and Paleo diets each had health benefits, although adherence to the diet dropped off over 12 months. Intermittent fasting, where dieters limit their calorie intake to 25% of normal for two days a week—around 500 calories a FORESIGHT

OBESITY SPECIAL REPORT

Stigma Obesity is still viewed as something that is self-inflicted

day for women and 600 for men, led to slightly more weight loss than other diets (4 kg on average compared to 2.8 kg for intermittent fasting and 1.8 kg for Paleo). IF and Mediterranean diets were also found to reduce blood pressure and the latter also improved blood sugar levels.

David Unwin, a British GP in the northern town of Southport, is also using an approach developed to put type 2 diabetes in remission, to tackle obesity and other obesity-related diseases. “When I was a young doctor, I never saw anyone under the age of 55 with type 2 diabetes, but now the patients are much younger, including one who is just ten years old,” he says. “This is why I am upset and why doctors all over the world are saying wake up.”

Unwin has run a Low Carb Programme for his patients, offering dietary advice about following a low carbohydrate diet, as well as support groups and regular check-ups, plus psychological support with food addiction provided by his psychologist wife, Jen. So far, the couple have data from 297 patients on a low carb approach for 25 months, he says. The average starting weight was 98 kg and the finishing weight 87 kg; 153 of them had type 2 diabetes, 76 had prediabetes and 68 had some form of metabolic disease.

Of those 153 with diabetes, 70 managed to put their type 2 diabetes in remission, reports Unwin.

Pile, the UK local doctor in Hertfordshire, has also launched a local initiative to help his overweight patients shed some kilograms. He runs group sessions called ”cardiac prehab” where people who are at FORESIGHT

risk of conditions such as heart disease and diabetes join him for well-being talks and also hear from experts on smoking cessation, exercise on referral, and weight management. Patients draw up their own well-being plan for Pile to follow up on with them at three to six months. The programme has led to consistent improvements in weight, blood pressure, cholesterol and reports of physical and mental well-being he says. Its now operates in 56 practices covering 620,000 people in Hertfordshire.

REMOVING THE STIGMA Viewing obesity in a similar way to cancer or heart disease without attaching blame (consciously or unconsciously) seems to be the key to improving treatment of obesity. Ramos-Salas of the European study group EASO argues that obesity must be destigmatised and that means treating it as a disease.

“We don’t have a cure for obesity, but we do have evidence-based treatments including drugs, behavioural change techniques and bariatric surgery,” she says. “But few people are offered these as obesity is still viewed as something that is self-inflicted and not something the taxpayers’ money should be spent on or offered under private medical insurance.”

“There is still so much stigma about being obese and this has to change—we need action from policy makers at government level, but also from health care professionals in primary care who are ideally placed to help with preventing weight gain and also to offer treatments.” • 31

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Populations in more than one in three low-income countries are hit by a double burden of malnutrition in the form of both obesity and undernutrition. Effective nutrition programmes can help countries overcome the double malnutrition challenge

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alnutrition in its various forms affects every country in the world. According to the Global Nutrition Report 2020, 149 million children under five are stunted (short for their age) and 49.5 million are wasted (thin for their height). At the other end of the spectrum, tens of millions of adults and children are obese.

Conventional wisdom used to suggest that undernutrition mainly affected developing countries, while obesity was only a problem in developed economies.

But this picture is now out of date. Worldwide, food systems that used to change very slowly, across centuries, are now being transformed within generations.

The result is that many low and middle-income countries (LMICs) now face a “double burden of malnutrition” (DBM), seeing a rapid rise in obesity levels while still struggling to reduce the number of children and adults who are severely undernourished.

A recent series of papers published in UK-based medical journal The Lancet reported that of 126 LMICs for which data exist, 48 are seeing a severe DBM, where a significant percentage of children are undernourished and at least 20% of adults are overweight or obese. Research also suggests the problem is shifting towards countries in the lowest income 32

bracket in sub-Saharan Africa and Asia, whose health systems are least equipped to cope with it.

Malnutrition in all its forms exerts a heavy toll, not only on people’s health but on economic growth. The United Nations Food and Agriculture Organization (FAO) estimates that undernutrition costs up to $2.1 trillion a year. It estimates the costs of overweight and obesity at US$ 1.4 trillion a year, which includes the costs of diet-related non-communicable diseases (NCDs).

Children who are undernourished as infants and become overweight as adults are at higher risk of developing diet related NCDs, such as type 2 diabetes or certain cancers. The impact of increased healthcare costs and reduced productivity throughout life can perpetuate a cycle of ill-health and poverty, according to the World Health Organization (WHO).

CALL FOR DOUBLE-DUTY ACTIONS In 2016, the United Nations declared a Decade of Action on Nutrition, with the aim of “eliminating malnutrition in all its forms” by 2025. A year later, the WHO published a policy brief that urged countries and international agencies to tackle the DBM where it exists.

It calls for the use of evidence-based “double-duty FORESIGHT

TEXT Christine Michael ILLUSTRATION Clara Selina Bach PHOTO Jeison Higuita

Double burden on the poor

OBESITY SPECIAL REPORT

The double burden in numbers Malnutrition affects all regions worldwide

SHARE OF DEATHS ATTRIBUTED TO OBESITY 2017

No data

0%

5%

7,5%

10%

12,5%

15%

>20%

PEOPLE AFFECTED BY MALNUTRITION

1.9 billion

adults are overweight

42 million

children under the age of five years are overweight or obese

34

462 million

adults are underweight

156 million

children are stunted (too short for age)

FORESIGHT

50 million

children are wasted (too thin for height)

SOURCE: World Health Organization, 2019

264 million

women of reproductive age are affected by iron-amenable anaemia

OBESITY SPECIAL REPORT

actions”, described as interventions that have the potential to improve undernutrition and reduce obesity at the same time. Actions start with programmes of healthcare and nutrition for pregnant women and children under two and include policies to provide access to healthy foods throughout the life course.

Programmes to promote breastfeeding, subsidised or free school meals and social security safety nets are already established in many LMICs. But not all policies that deal with undernutrition in childhood are designed with the additional aim of minimising the risk of obesity and NCDs in later life. Examples of counter-productive programmes might be those that provide subsidised foods that are high in fat, sugar and salt, or provide cash to buy foods where unhealthy foods are cheap and available.

“Double-duty or even triple-duty programmes and policies aren’t rocket science,” says Lucy Westerman at the NCD Alliance, an international network of 2000 organisations that campaigns for NCD prevention and control. Triple-duty adds sustainable development and climate change. “We’d like to say progress on these actions, which efficiently give multiple returns, has been booming,” she says. “But the prevalence of diet-related NCDs and obesity is rising in all countries, including those where undernutrition has previously dominated nutrition concerns.”

“But food and food systems are at the core of all forms of malnutrition.”

GAIN recently launched an online Food Systems Dashboard together with the UN’s FAO and the Johns Hopkins Alliance for a Healthier World. The dashboard presents data on food systems in 230 countries, covering up to 170 indicators from 35 sources.

Its stated aim is to halve the time it takes policymakers to describe, diagnose and make decisions on food system challenges in their countries.

“We’ve designed the dashboard very much with the DBM in mind,” says Haddad. “We are filtering evidence from peer-reviewed reports that translates into plausible, feasible actions that have been shown to work.

The aim is to help policymakers make no-regrets decisions that will improve weaker spots in their food systems.”

Other resources for policymakers include the NOURISHING policy framework and database, set up by the World Cancer Research Fund (WCRF) to highlight where governments need to take action to promote healthy diets and reduce overweight and obesity.

In mid 2020 the database had more than 700 policies and was collecting additional policies from around the world. “Policy makers will have access to even more information about how governments are taking action,” says Kate Oldridge-Turner, head of policy and public affairs at the WCRF.

POLICY HURDLES

The prevalence of diet related disease is rising in all countries

HOLISTIC DISCONNECT Despite the high-level focus on the challenge of the DBM, evidence suggests that few countries have fully embraced the concept of taking a holistic approach to the problem. According to the Global Nutrition Report, 42% of countries have nutrition targets that include undernutrition and obesity, while 84% have targets for tackling overweight or obesity in adults.

But advocates and funding streams for different forms of malnutrition often operate as separate action silos, says Lawrence Haddad, executive director of the Global Alliance for Improved Nutrition (GAIN).

“People who are concerned with undernutrition tend to approach it through the health system, while those who worry about obesity and NCDs work through the food system and infrastructure—healthy food choices and exercise,” he says.

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As well as good data, education for healthcare professionals and policymakers is also key to building malnutrition prevention over a lifetime, says Roger Shrimpton, a former secretary of the UN Standing Committee on Nutrition.

“Child survival is a compelling motive for donors and leaders to support programmes for undernutrition, but there’s a lack of understanding about the causes of overnutrition,” he says. “There’s an assumption that obesity is a result of simply eating too much, whereas it’s a question not just of how much, but what you eat.”

Shrimpton is a founder member of the World Public Health Nutrition Association, which offers training and certification to help public health workers achieve health and nutrition objectives within their own food systems.

Shrimpton says he is “not very optimistic” about the ability of individual governments and NGOs to withstand global forces affecting food and health.

The world cancer fund’s Oldridge-Turner agrees there are difficulties in a world where global companies and institutions dominate many food systems.

“Our research has found that industry interference 35

OBESITY SPECIAL REPORT

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OBESITY SPECIAL REPORT

Governments cannot afford to allow coronavirus to shelve smart, cost-effective, evidence-based policies that improve nutrition

Guatemala A stronger case is made for double-duty actions as countries acknowledge their citizens are afflicted by a double burden of malnutrition

is one of the most significant, overarching challenges to designing robust nutrition policies that promote healthy diets,” she says. “This can range from attempting to derail policy development processes to issuing legal challenges to implemented policies.”

LACK OF COST DATA A stronger case for double-duty actions still needs to be made to influence countries to act, says Rachel Nugent, vice president of global non-communicable diseases at RTI International in Washington DC. “One thing that’s needed is an agreed definition of DBM that easily shows what’s harmful about it,” she adds.

The cost of the combined effects of obesity and undernutrition to healthcare systems and economies is hard to pin down—and this in turn makes it harder to measure the cost-effectiveness of interventions to tackle the DBM. Nugent says her work in this area is hampered by not having evidence of effective outcomes stemming from DBM-specific interventions.

“I’m not very confident that use of double-duty interventions will be widely adopted until we do better measurement of DBM impacts in a wide range of nutrition programming, ranging from emergency to school feeding to agricultural policy,” she says.

That said, the UN’s Shrimpton believes policymakers should not let a lack of gold-standard evidence deter them from implementing what is likely to work.

“If we know an intervention is effective, we should do it,” he says. “You don’t need absolute certainty that a double-duty intervention will give you a bigger bang for your buck. The evidence will add up over time.”

CONFRONTING COVID-19 With the covid-19 pandemic still rampant in many countries in mid-2020, predicting the future toll of the outbreak on healthcare and food security requires a crystal ball. In the short term, the impact of lockdowns and reduced economic activity is already causing severe disruption, with potentially catastrophic outcomes for LMICs. Preliminary assessments by the FAO suggest the number of undernourished people in the world, estimated at 690 million in 2019, will inFORESIGHT

crease by up to 132 million in 2020 and that recovery in 2021 will not fully reverse the trend.

In many LMICs, initiatives such as malnutrition monitoring, vaccination programmes, mother-and-baby clinics, access to fresh foods and school meals are also being devastated by the pandemic, posing short-term and long-term risks to health, especially for women and children. “Governments were already off-track to meet WHO targets for malnutrition and NCDs by 2025 and at pre-covid-19 progress rates, also faced an uphill effort to reach the nutrition-related Sustainable Development Goal targets by 2030,” says Westerman of the NCD Alliance.

“Governments cannot afford to allow coronavirus to shelve smart, cost-effective, evidence-based policies that improve nutrition,” she says.

FOCUS ON DIET-RELATED NCDS In the longer term, some researchers say covid-19 may prompt health agencies worldwide to return their attention to the prevention of diet related NCDs with greater vigour than before the pandemic.

“I think covid provides an important opportunity to actually measure and respond to the links between infectious and non-communicable diseases, which have become quite visible in relation to obesity and covid severity,” says Nugent of RTI International. “I am hopeful and will argue for greater attention to NCD prevention as a means of increasing resilience of health systems and reducing pandemic risks.”

GAIN’s Haddad is also optimistic that the pandemic will act as a ”mini-trigger” to focus more attention on NCD prevention. The evidence of the impact of co morbidities such as obesity on covid-19 speaks for itself. “As six of the top ten risks to public health are diet-related even in normal times, the food system was already bankrupting the health system in many countries,” he says. “There’s an opportunity to develop food systems that are resilient, diverse and able to provide nutritious diets to address all forms of malnutrition if the food industry, policymakers and the public sector are able to work together and be creative about solutions.” • 37

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H

istory tells us how we got here, but not how to fully embrace the NCD challenge and build a healthier future for global populations. That will take the vision to imagine a better world and the courage to implement the changes to achieve it. The result will be an improved outlook for global health.

The explosion in NCDs is responsible for more than two-thirds of global mortality, as well as a significant proportion of the rise in healthcare spending over the past two decades. Although NCDs are increasing around the world, the burden of dealing with them will especially rest on developing economies, where health systems are generally still struggling to provide basic primary care services and many citizens still lack access to healthcare.

The following articles will take a look at the sociology of NCDs to understand how social networks can create their own contagion. We also exam38

ine how we might reimagine urban spaces with a healthier population in mind. Lastly, we reflect on the extent to which health technology has been the victim of its own hype and identify the innovations that are likely to be a key part of managing NCDs in the future.

What our articles on the outlook for global health reveal is that reducing NCDs requires policies that take into account the immediate environment, lifestyle risks and the medical background of patients. This includes paying closer attention to the way smaller communities and social groups can encourage or discourage healthy habits through their influence on family, friends and neighbours. A macro approach to NCDs must include all the social determinants of health and involve policies that integrate them accordingly.

In the wake of the covid-19 pandemic, the importance of comprehensive policy has never been clearer.

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TEXT Andrea Chipman PHOTO Paulius Dragunas

Imagine a world of good health

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Non-communicable diseases and their risk factors seem to be common among certain groups of friends and families. Genetic reasons aside, the concepts of social contagion, shared spaces and a tendency for similar people to associate (known as homophily), might explain why these diseases appear to be more infectious than their name suggests

Contagion of a social kind

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by interpersonal relationships. With respect to public health efforts, social connectedness also offers significant opportunity for improving outcomes for those living with NCDs by harnessing the power of group dynamics.

Another older concept that partially explains some of this social connectedness is homophily, the tendency for stronger social connections to develop among people with similar defining characteristics, such as age, gender and interests, than among dissimilar people. Certain cultural, behavioural, genetic, or material information that flows through networks tends to settle in certain groups, effectively social clusters.

“We prefer our group or tribe because we find it easier to communicate and relate to people with shared cultural and experiential backgrounds,” says Kayla de la Haye, a public health advocate from the University of Southern California in Los Angeles and a researcher in the field of social connectedness in health.

CROWD MENTALITY Anette Lykke Hindhede, a medical sociologist from Aalborg university in Denmark, also supports the view that NCDs and NCD risk factors spread through society in a socially “infectious” way.

“We know that people can become overweight through social relations, meaning that social norms and behaviours are contagious,” says Lykke Hindhede.

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Like minds Homophily is the tendency for stronger social connections to develop among people with similar defining characteristics

TEXT Becky McCall ILLUSTRATION Trine Natskår

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irds of a feather flock together is a familiar and age-old proverb. Close human relationships built on a basis of similarities permeate our lives, not least similarities relating to health behaviours and risks, among them obesity, excessive alcohol intake, tobacco use or poor diet.

Such health risk factors are typically associated with a broad category of disease known as non-communicable diseases (NCDs) which include so-called “lifestyle” diseases: cancers, heart disease, chronic respiratory diseases and diabetes. As a category, NCDs are of long duration and result from a combination of genetic, physiological, environmental and behavioural factors.

As the world battles the covid-19 pandemic, NCDs seem to have paled into insignificance in the human consciousness. Sadly, it is those affected by NCDs who are at greatest risk of the serious complications of coronavirus infection.

But NCDs and infectious diseases have other commonalities. Genetic inheritance aside, clusters of people with similar health and lifestyle related habits represent a form of social contagion, a hypothesis that endows NCDs with infectious characteristics of the non-biological, social kind.

Health behaviours and outcomes related to NCDs can be influenced by social contagion in networks of friends, group activities, and co-workers connected

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Most often, social contagion manifests as someone copying a certain behaviour of others with whom they have had contact or are physically near.

The study of social contagion reputedly began with the classical theory of crowd mentality advanced by Gustave Le Bon in 1896, Lykke Hindhede says. Trained as a doctor, Le Bon drew a parallel with crowd mentality and infectious diseases, explaining that ideas circulate in a crowd as microbes do in the human body.

Lykke Hindhede notes that key to the theory of crowd mentality is irrationality. “A crowd is not merely a gathering of individuals but rather a mental unity of people and they constitute a collective mind that takes the same direction.”

In 2012 in the US, sociologists Nicholas Christakis of Yale University and colleague James Fowler from the University of California explored the theory of social contagion. They showed substantial clustering in relation to obesity within social networks, finding that if some individuals in a social network become obese, then others in that network are more likely to become obese owing to social influences, such as the contagion of social norms or “mirroring,” copying what others do.

GENETIC OR LEARNED? Chirag Patel and colleague Chirag Lakhani, data scientists from Harvard Medical School in the US, explored the respective roles of genetics and environment in determining health and disease, using a database of nearly 45 million people in the US, including 57,000 pairs of twins. The researchers looked at aggregate effects of genes and environment in 560 conditions, including some common lifestyle conditions such as obesity, cardiovascular and neuromuscular disorders. Postcode-related environmental risk factors, such as socioeconomic status, pollution exposure and climate, as well as medical data such as clinical diagnoses, were also included. “In our study, we asked, how do the genetic factors we inherit and the environment we share combine to make us individuals who get certain diseases?” Patel explains.

If some in a social network are obese others are more likely to follow

DISTANCE LEARNING The pair’s work also challenged the assumption that an individual needs to be near others to become “infected” with a social norm. Using data from the Framingham Heart Study, they found that a social norm can be contagious even if people are not in the same vicinity. “If your weight increases then there’s a high probability that your friends, who might live hundreds of kilometres away, will also increase their weight. There’s a statistical probability that this will occur,” explains Lykke Hindhede.

“This social contagion not only occurs via faceto-face interactions but also via conversations, social media and other non-person-to-person forms of communication and these comprise the mechanics of establishing a social norm in a particular social network,” she adds.

The reputed causes of social contagion are fluid and have been the subject of differing interpretations over the years. In a 2018 study, which sought clarity and lends support to the social contagion theory, researchers looked at whether exposure to communities with higher rates of obesity increases the body mass index (BMI) of individuals and their risk of being overweight or obese. The study found this to be the case in both parents and children. “There was no evidence to support self-selection, or shared built environments, as possible explanations, which suggests the presence of social contagion in obesity,” the data revealed.

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The researchers found that nearly 40% of the diseases in the study had a genetic component, while 25% were driven at least in part by factors stemming from sharing the same household and social influences. Eye disorders were most likely to be influenced by environmental factors with 27 of 42 eye diseases showing such effect, while respiratory diseases showed such an effect in 34 out of 48 conditions.

The strongest potential link to socioeconomic status was evident in morbid obesity, defined as a BMI of 35 kg or more. “Obesity is a great example of a disease that has both strong genetic and shared environmental factors,” says Patel. “Prior studies have shown the strong genetic component, but further to this, we found the shared environment was related to socio-economic background. Socio-economic status contributed to 3% of variation in obesity in the US.”

SOCIAL NETWORKS FOR GOOD At the same time, social networks can be valuable for health improvement initiatives, De la Haye of the University of Southern California explains, as both a framework to study social interactions and a focus for intervention to change health-related behaviours.

Both social networks and shared environments are interconnected and act as triggers to health risk behaviours, she says. “These relationships influence FORESIGHT

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Children, spouses, and mothers were found to be especially important in influencing others.

Intervening in a network of socially connected groups, or targeting the best connected people in a network is more successful than targeting individuals alone, De la Haye observed. “Change is often both created and maintained because people find themselves embedded in a social group that supports, rather than resists [the positive behaviour].”

In terms of both researching and improving NCD outcomes, she strongly advocates for the social network-based approach. Social networks and social contagion lend support to the concept of NCDs being socially ”infectious” and the evidence indicates that interventions using these networks can be effective. behaviours, especially daily habitual behaviours such as drinking alcohol, diets, and exercise. These are all activities influenced by subtle cues that spread through social networks and shape our ideas of what is normal.”

Changing health risk behaviours via a social network might influence NCD outcomes, since the lifestyle risks for heart disease, cancers and other chronic diseases are well established. De la Haye says studies investigating the use of social networks have found that key hubs of interaction in networks and the people best connected within them are central to outreach success. Pressing the right buttons in a network work better than a healthcare worker alone sending out a brochure with messages about diet, smoking or other health behaviour.

One randomised controlled trial of more than 10,000 secondary school pupils in England and Wales used a social network approach to successfully prevent smoking uptake. The researchers, from Glasgow University and the University of Bristol, trained the most well-connected students to act as peer supporters at gatherings outside the classroom to encourage their peers not to smoke. For all pupils, the odds of being a smoker one-year after the intervention was reduced by 23%.

LEAD BY EXAMPLE Family social networks were the focus of another study, “Social influence and motivation to change health behaviours among Mexican-origin adults: implications for diet and physical activity.” It explored making changes to dietary behaviours aimed at reducing the risks of complex disease caused by interactions between genes and environment. The results showed that among Mexicans living in the US, having at least one social network member who encourages others to eat more fruit and vegetables or do more physical activity improved these behaviours.

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REAL LIFE APPROACH Socially based approaches are also more in touch with real lives in the real world. “The individual approach so often taken by public health encourages someone to read information, be told what to think and then returns them to a social world and environment that counteracts this advice,” De la Haye points out. It is an approach often fails because families or individuals who live in a neighbourhood or network short of economic and other resources find themselves up against a major barrier to better health. “Often unjust social factors—less education, employment opportunity—are the reason they live in these environments in the first place,” she stresses. “Telling these people to just change their behaviour in social and built environments they are unjustly exposed to is especially unethical.”

Social contagion and social networks offer an opportunity to level the playing field for health and more generally too. Moving forward, health behaviour programmes based on social network approaches strongly suggest that the individual is not an island.

Stimulating and activating someone’s social environment can maximise benefits. Importantly, evidence also suggests positive effects tend to be maintained.

Social networks have been shown to be particularly beneficial in helping hard-to-reach groups, such as people who inject drugs or minority ethnic communities. They may also have particular value in reducing the prevalence of NCDs. The digital age also brings new opportunities for influencing crowd mentality.

Online social network platforms are growing in popularity, especially among adolescents. Their members may be receptive to the social network approach to health improvement.

Slowly, but surely, the scientific and public health community is waking up to the largely untapped potential held within the socially infectious nature of NCDs. You could say it is starting to catch on. • 43

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The number of people living in cities is projected to rise from 55% to 68% of the world’s population by 2050, according to the United Nations. Strong leadership and multi-sectoral planning can make our cities far healthier for human habitation

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he novel coronavirus and fossil fuel emissions that contribute to climate change are the two biggest challenges the world faces in mid-2020. Both are acutely apparent in cities. The covid-19 pandemic has hit densely populated urban areas harder than more sparsely populated rural regions. Pollution levels, from both vehicles and industrial emissions, are highest in big centres of population such as Mexico City, Beijing and Delhi.

“Challenges like covid-19 and climate change make the importance of planning for healthy cities more urgent; by highlighting city planning issues, they create a unique opportunity and impetus for change,” says Melanie Lowe, a public health lecturer at Melbourne’s Catholic University in Australia. “Lockdown policies and the need for physical distancing during covid-19 reinforce the need to support local living,” she adds.

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City living also increases the risk of developing non-communicable diseases (NCDs). Efforts to fight covid-19 and climate change with better urban design and planning can help reduce the risk factors.

Encouraging active transport such as cycling and walking can reduce the risk of developing obesity and type 2 diabetes, as can restricting the spread of fast food outlets. Similarly, providing more outdoor green space can improve mental health and give people more space to take exercise.

THE RISKS OF CITY LIVING NCDs are responsible for an increasing share of global deaths and those associated with urbanisation are one of the central challenges facing cities. A large proportion of these deaths relate to the urban built environment. Pollution, industrial emissions, lack of green space and safe streets for walking, plus the FORESIGHT

Copenhagen To stay clear of the coronavirus more people in cities have taken up cycling in preference to public transport, with health benefits for all The Bicycle Serpent

by Dissing+Weitling

TEXT Jo Waters PHOTO Rasmus Hjortshøj, Miguel Sousarkje & Ma Weiwei

Coronavirus could spur reforms to improve health of city dwellers

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There are also significant gaps between policy intentions and what is delivered on the ground

Singapore Green spaces in urban areas promote mental well being and support good physical health

stress of inner-city living and poor-quality housing all adversely affect the health of city dwellers. Cities are especially fertile environments for coronary heart disease, type 2 diabetes and respiratory illnesses, as well as obesity, largely driven by the greater access to fast food outlets and physical inactivity.

Increasingly though, public health bodies are joining forces with academics, city council transport and housing planners, environmental groups, sports clubs, and industry to prevent and reduce the problems.

“There’s now a move away from the emphasis purely on individual lifestyle choices, because sometimes people don’t feel they have choices and that they are constrained by their income or their environment,” says Helen Pineo, lecturer in sustainable development and healthy built environment at University College, London. “It’s about moving the conversation away from individual lifestyle choices and thinking more about how the economic and social structures of cities, including the urban environment, can support good health.”

BARRIERS TO CITY HEALTH Joint planning across the board is the key to meeting health and environmental challenges, Lowe says.

“Creating healthy and liveable cities requires the input of many sectors, including transport, urban design, housing, economic development, energy, social and health services and education,” she adds.

A key obstacle to making cities healthier places in which to live is poor policy and lack of integrated planning, says Lowe. Inadequate access to infrastructure and services can disadvantage some but not others. She cites the example of a new housing estate without public transport or shops or schools, making residents more car-dependent or with few opportunities for social interaction. “It is difficult and costly to retrofit urban developments, so a lack of planned development is a missed opportunity.”

Her research in Australia has revealed a disconnect between government policy aspirations to create healthy neighbourhoods and actual policy targets for walkability, public transport access and public open space. Too often the policies do not support the aspiFORESIGHT

rations, says Lowe. “There are also significant gaps between policy intentions and what is delivered on the ground,” she adds. Even modest targets for housing density and other liveability aims are not being met.

Lowe emphasises that there are many determinants of health in cities, including creating healthy and safe neighbourhoods with affordable housing, all linked by walking, cycling and public transport to open spaces, jobs and education. Transport planning is key, she observes. The balance of healthy versus unhealthy food stores in neighbourhoods can shape the diets of residents. Green space supports mental health by providing access to our natural element and also encourages recreational physical activity.

THE MELBOURNE EXAMPLE In recent years, Lowe says, interest has grown in creating “20 or 30 minute neighbourhoods” in Melbourne, where people can access most of the amenities they need within a short distance of home, either by walking, cycling or public transport. The advantages of such “village life” have come to the fore during the covid-19 pandemic, she says. Pilot programmes in 2018 launched the easy-access neighbourhood policy and cities in other countries, such as Portland in the US Northwest, have a similar model.

“With people restricted from moving about cities and encouraged to work from home, providing local living destinations has never been more important.

Crowded public transport can be problematic during a pandemic, but for physical activity and associated health outcomes, the solution is not for everyone to drive,” Lowe says. “Supporting people to walk and cycle where possible and providing appropriate transport infrastructure is essential, freeing up space on public transport for those who really need it.”

Another priority brought to light by the effects of pandemic lockdowns is the need to re-model streets and public spaces to create more space to enable people-powered mobility and make cycling, walking, roller-blading and other means of active transport safe to pursue.

“Right around the world we are seeing cities widen footpaths, remove car parks, pedestrianise streets 47

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and improve bike lanes to cater for increased rates of walking and cycling, while allowing safe physical distancing,” Lowe says. She points out that liveable cities are climate resilient cities as the policies improve air quality and make climate mitigation actions possible, such as creating space for surface drainage solutions.

Plan Melbourne identified the need for an integrated government approach to creating 20-minute neighbourhoods, one which encourages different government departments to work together. Potential benefits of local neighbourhoods identified in the plan include reduction in pollution and CO2 emissions, halving the transports costs of households, 48

easing pressure on transport and enhancing a sense of community and social cohesion.

STRONG LEADERSHIP IS KEY Strong leadership was also key to making Denmark’s capital, Copenhagen, recognised as one of the world’s healthiest cities. Copenhagen became a WHO Healthy City in 1987. The UN’s Happiness Index report has ranked it as one of the happiest places to live in the world. According to one analysis using data from the World Bank, Copenhagen ranks second overall out of 146 European cities for quality of life, has a high quality of green space, the second largest proportion of peoFORESIGHT

China Danish architects Dissing+Weitling created Xiamen's Bicycle Skyway to enable safer and healthier city mobility

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With people restricted from moving about cities and encouraged to work from home, providing local living destinations has never been more important

ple walking and cycling, the second lowest CO2 emissions and more than 10% of GDP spent on healthcare.

An incredible 62% of the city’s population walk or cycle and 41% cycle to work, partly because the city is designed for bicycles first, cars second. Promoting cycling has been key to improving the city’s environment and the health of its citizens. Cycling has increased by 15 to 20% since the city established separate bike lanes in the early 1980s. Car journeys have fallen over the same period.

“When we talk about the Copenhagen example, we talk about leadership, as they had strong leaders and they took a decision to make space for bicycles,” Pineo explains. In the early days, that was not popular—there are images of car drivers and cyclists having fights—it wasn’t a smooth ride. But by working to shift public opinion so people realised that cycling was more convenient, cheaper, and good for their health, attitudes changed.”

HOW LEICESTER IS FIGHTING DIABETES Some cities are identifying their population’s biggest health problems and working across boundaries to tackle them. Leicester, a small UK city of 340,000, has the highest prevalence of diabetes in the UK at 9% of the population. Its obesity rate is 55% and more than half of city dwellers take no exercise. In July 2020 Leicester made new poor health headlines when a renewed outbreak of covid-19 made it the first UK city to be put into lockdown for a second time.

In 2018 the city launched a coalition between doctors at the city’s diabetes centre (the biggest diabetes research centre in Europe), city authority planners, several elite sports clubs, the city’s Interfaith Council and Leicester university academics, as well as the local National Health Service clinical commissioning group. “We wanted to look at how we could tackle diabetes from beyond a medical point of view,” says Melanie Davies, professor of diabetes medicine at the university.

Leicester has joined the Cities Changing Diabetes (CCD) movement, a joint initiative launched by Novo Nordisk, a Danish pharmaceutical company, University College London, and the Stena Diabetes Center in FORESIGHT

Copenhagen. It aims to improve care for people with diabetes and prevent and reduce incidence of the disease in 26 cities worldwide.

Leicester city centre is now one of the largest conjoined pedestrian areas in the UK. The provision of a more segregated cycling infrastructure, with a central hub and spokes into residential areas, has helped the city promote walking and cycling to work. Within weeks of the covid-19 lockdown, the city authority was able to install emergency bike lanes for key workers.

Previous initiatives promoting activity and sport were well designed, but often not targeted at the right groups or geographical areas of the city, Davies adds.

“Programmes were not joined up and the messaging was not always consistent. To some extent we were working in silos.”

The Leicester CCD programme has featured elite sports clubs launching walking cricket sessions targeted at over 50s and healthy goals activity sessions for all-female groups. Chefs in the city’s faith centres are receiving healthy eating education and council food hygiene experts are advising retailers on making fast food healthier. Local doctor practices are now directing patients who could benefit from exercise to a network of green gyms and sports courses.

“We are trying to show what effects we can have through a behaviour programme run by professional sports clubs and researchers and how we can upscale that to a wider population,” explains Deirdre Harrington, a lecturer in physical activity and sedentary behaviour at Leicester university.

The initiative has led to the creation of 31 outdoor green gyms in every ward of the city, giving people free access to a place to exercise, says Adam Clare, deputy mayor of Leicester City Council. “The people of Leicester are already reaping benefits, with participation in sport activities rising and the demographics of who is participating shifting, too,” he adds.

Cities will need to support the health of their populations in the aftermath of the pandemic as well as at the height of the crisis. Urban planners already have a number of tools for redrawing existing cities and designing new with the aim of combating both NCDs and climate change. • 49

OUTLOOK Can information technology save the world from the rising burden of ill-health?

And can personal data be guarded with sufficient vigilance for people to put their trust in the authorities to handle it with due responsibility? There are no easy answers

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he ill-health and economic burden caused by cardiovascular diseases, diabetes, chronic respiratory conditions, cancer and mental illness has continued to grow through 2020 while world attention has been focused on covid-19’s rapid spread.

The financial drain from these and other non-communicable diseases (NCDs) is calamitous, with the global costs likely to reach an estimated €39 trillion between 2010 and 2030. The human fall-out in reduced life expectancy is as equally disastrous as the economic hit to people’s lives. Across Europe, type 2 diabetes alone is increasing its prevalence in most age groups, with 60 million people diagnosed with the condition.

The great hope has been that advances in information technology (IT) will enable the synchronisation of health management systems, energise personal responsibility, revolutionise social behaviour and provide transformative therapy. Telemedicine, remote 50

monitoring and wearable measurement devices are positioned as saviours, recalibrating patient contact and treatment delivery while algorithms interrogate data to create better and cheaper healthcare.

The realisation of those goals has been slow, but the pandemic appears to be an accelerant for health IT to reach its potential. In the UK, more than 434,000 downloaded the National Health Service (NHS) app —which gives people access to NHS services such as booking appointments and viewing medical records —during the first month of the coronavirus lockdown compared to 915,500 in the previous 12 months.

“Technology and data can play a vital role in making our healthcare systems more sustainable, both now and in the future. There are two main factors that are putting significant strain on our healthcare systems, ageing and chronic disease,” says Jan Philipp Beck, head of health at the European Institute of Innovation and Technology (EIT), which is funded under the European Union’s Horizon 2020 framework.

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TEXT Danny Buckland ILLUSTRATION Trine Natskår

The promise and challenge of health tech

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During the covid-19 outbreak, 95% of triaged patient enquiries were resolved without the need for a face-to-face doctor consultation. In the longer term, I believe that we will never go back to a practice where the patient journey starts with a face-to-face GP consultation

Beck says artificial intelligence (AI) has the potential to streamline or even eliminate administrative tasks, freeing up anywhere from 20% to 80% of a healthcare professional’s time for more productive work.

DATA PRIVACY CHALLENGE The NCD Alliance, a group of 200 organisations across 170 countries dedicated to improving world health, believes digital health provides cost-effective healthcare support, particularly in emerging countries where the lack of established systems has provided the freedom to deploy more ambitious technology. The alliance also believes that health IT allows countries to tailor services to local needs, strengthening the prevention message and allowing multiple interventions along disease pathways.

But advances into healthcare by the IT giants are clouded by public concern that personal information might be turned for a commercial profit rather than societal good. Fears about who has access to personal data and losing control over how it is shared are rife among the general public, says Beck.

“A common assumption is that patient data will be sold to large corporations for profit. Their concern is understandable but their Amazon account or their social media profiles collect much more data than any healthcare provider would ever even have the capacity to know,” adds Beck.

“The public does need more and better information about how data sharing in healthcare works.

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They need to know how it’s being used and to have the control to opt out when they want to. There is also the debate around whether patients should be compensated for use of their data if, for example, that data helps launch a new treatment that is marketed for profit.”

James Barlow, professor of healthcare technology and innovation management at the UK’s Imperial College Business School in London believes attitudes are softening around data sharing but adds: “The big unknown is around the global tech giants, Google, Apple, IBM and Alibaba, who are increasingly getting involved in healthcare. Their business model is data, personal data, that’s how they work and make their money.”

“So the questions are to what extent are we prepared to let Apple be a doctor in the future and either make profit out of our personal health data or share it with others? We haven’t even begun to address that problem. I think that’s a challenge particularly as those companies will be part of healthcare in the future.”

CARE NOT HOSPITALISATION Conversely, an area for huge technological progress is in recalibrating healthcare systems rather than marching towards Big Brother style access to medical records. The Future Health Index 2020, published by Philips, revealed that 81% of health care professionals under the age of 40 believe digital health technologies could reduce their non-clinical workload while voicing mounting frustration over its slow adoption.

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So the questions are to what extent are we prepared to let Apple be a doctor in the future and either make profit out of our personal health data or share it with others?

We haven't even begun to address that problem

“The really big gains are going to be had from organisational changes such as new ways of funding services, increased integration between primary, secondary and social care and rethinking how we provide and deliver services and support people with long term conditions,” Barlow adds.

“Technological innovation certainly plays its part in underpinning those organisational changes, but it’s the boring stuff that actually will really bring maximum benefits across the next five to ten years,” he says. “It is clear that new technology can make a difference in the health and social care sector by shifting demand away from expensive hospital care with improved community and primary care. That is something we ought to be concentrating on, but to date have not done as much as we should have.”

While technology is relatively simple, Barlow notes that the challenge is deploying it across complex eco-systems. This is likely to involve a new chain of responsibilities and relationship needs. The clear benefit, however, is that telemedicine can be used to monitor and evaluate interventions for people who have been identified as being at risk with diabetes or another NCD. “It helps you pick up and intervene with problems earlier to slow the rate at which people need to go into hospital,” he says. “By placing a sort of electronic security blanket around them, we can also mitigate some of the risk of discharging them out of hospital so there are benefits at both ends of the care pathway.”

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THE CORONAVIRUS TIPPING POINT Healthcare systems, often hard-set in established practice, may have been slow to take up the promise of digital technology, but the pandemic has kick-started its uptake.

“Covid-19 has shown that digital health tools are highly effective, add value and actually enhance the continuity of care, both for immediate reactions to highly contagious viruses and also ensuring the treatment of long-term conditions continue normally,” says Murray Ellender, founder of e-consult, a triage platform used by the National Health Service in England. The platform has seen a 500% take up in doctors’ surgeries over two months in mid 2020.

“During the covid-19 outbreak, 95% of triaged patient enquiries were resolved without the need for a face-to-face doctor consultation,” Ellender adds. “In the longer term, I believe that we will never go back to a practice where the patient journey starts with a face-to-face GP consultation.”

His view is echoed by Chris Barker, CEO of Spirit Healthcare, which offers an online monitoring platform for people with long term conditions across healthcare settings. “We have jumped ten years in terms of tech take up. Our system is evidence-based, but over the last five years’ adoption had been slow paced, but now we are getting calls from right across the spectrum about deploying our system,” he says.

“Covid-19 is a tipping point for digital care. The world has moved.” • 53

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Opinion: Digital health care can bring fairer access for all

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ell-designed digital health solutions— those that provide quality care that is truly accessible and available for all, including the poorest and most vulnerable communities—require investment and the right regulatory framework. Where both requirements are present, digital solutions show great promise for health care and health equity, across and within countries. The development of health tech combined with ready and equal access to health services is particularly important in times of a rising epidemic of non-communicable diseases (NCDs) alongside the covid-19 pandemic. It is also especially important given that the greatest NCD burden falls on LMICs. While the priority during the coronavirus pandemic has been preventing infection, minimising the spread, and providing adequate care and treatment to those with covid-19, NCDs, which include diabetes, cancer, cardiovascular diseases and conditions such as obesity and hypertension, continue to pose the greatest health burden worldwide. The diversion of limited health resources to the pandemic response has had an especially profound negative impact on continuity of care for people with NCDs. A recent rapid risk assessment survey on health service disruptions during the pandemic from the World Health Organization (WHO) showed that out of

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a total of 155 countries responding to the survey, 53% reported partially or completely disrupted services for hypertension treatment; 49% for treatment for diabetes and diabetes-related complications; 42% for cancer treatment; and 31% for cardiovascular emergencies.

These disruptions are happening even though NCDs continue to be the world’s biggest killer, responsible for the premature deaths of 15 million people aged 3069 each year; and the numbers are rising, most of all in LMICs. The covid-19 pandemic has highlighted that reliable NCD management and care must be a part of every health system, everywhere—also during times of emergency. Digital health solutions and innovations can play a key role in abating NCDs. Many countries have already begun to integrate them into health services. Use of digital tools, however, implies a drastic shift in the way care is delivered, as has become evident through the covid-19 response. Mitigation strategies including lockdowns preventing travel to health services, plus people giving health centres a wide berth for fear of covid-19 contagion, have catapulted us into the digital health age.

According to WHO, 58% of countries are reporting using telemedicine during the pandemic to replace in-person consultations whenever possible. In some cases, the use of telemedicine has skyrocketed. Virtual urgent care visits at one US health centre grew FORESIGHT

ILLUSTRATION Clara Selina Bach

Digital health solutions have the potential to enhance the reach and capacity of the health workforce and the efficiency of health services, write Katie Dain and Lobna Salem of the NCD Alliance. They have been a key factor in battling the covid-19 pandemic, helping health systems to function under tremendous pressure, particularly in lower and middle-income countries (LMICs), where care resources tend to be scarce even in non-pandemic times

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KATIE DAIN CEO of the NCD Alliance

by nearly seven-fold and non-urgent virtual care visits grew by an unprecedented 40 times. China implemented a wide range of digital solutions throughout different stages of the outbreak. South Africa is developing a complete digital health framework, laying out international standards to ensure interoperability and replicability. Such new digital services do not need to disappear once the pandemic is brought under control. To the contrary, they need to be further refined and developed for permanent integration and more specifically for NCD prevention, treatment and care.

Within the context of NCD care, digital solutions can improve efficiency, affordability and reach by ensuring that human resources are focused primarily on tasks in which human contact cannot be replaced.

The options for digital tools span much further than just virtual and telephone consultations. Software and digital platforms can offer diverse solutions to make NCD management and care more autonomous.

Empowering people living with NCDs who require day-to-day care to manage their conditions, on their own and from their homes, gives them greater freedom from their conditions. Digital tools can work similarly for health workers. Even simple text messages can help health workers in their decision making, allow them to track their patients’ records, follow up with them more easily and communicate more effectively with their teams.

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Beyond treatment and care, digital training tools like the new NCD Academy represent innovative health learning solutions that can be used and adapted in diverse settings, including LMICs. The academy is an online learning platform developed to equip frontline health workers like clinicians, nurses and community health workers with professional knowledge and skills on NCD care. Digital training can cover a diverse range of competencies in medical knowledge, specialisations, and clinical practice; and it provides a cost-effective, flexible and much-needed solution to health workforce capacity building.

Despite the potential benefits of digital solutions, their uptake has remained slow and there are challenges to be overcome before health systems can make use of their full potential. Public awareness and trust in the storing and use of data needs to be raised; information communications technology infrastructure needs to be improved in many countries; data protection and privacy need to be ensured for patients; and innovative digital health policies must be implemented.

Digital solutions are also challenging for some demographics, particularly older populations. Moreover, they remain out of reach for many people living in low-resource settings where access to the internet and mobiles phones can be absent or limited.

For people living with dementia who rely on regular in-person care and support, the shift to telephone and web-based support during the pandemic has been challenging, increasing stress, anxiety and loneliness. For all these reasons it remains critical that digital strategies and solutions are designed and planned to be accessible and available for all, including the most vulnerable and poorest communities.

Provided the barriers to digital health are recognised and dismantled, the promise of digital tools for all countries is great. They can increase the reach and capacity of the health workforce, improve NCD care, achieve greater health equity and contribute to the attainment of universal health coverage. The time is overdue for governments to support the development of digital health tools and services, including establishing a regulatory framework. Good governance helps protect and improve health for people living with NCDs and for people everywhere, both during a pandemic and beyond. The message is clear: We have no time to lose in seeking solutions to our global health crisis—in all its dimensions. •

Katie Dain is CEO of the NCD Alliance, a global public health lobby. Lobna Salem, MD, MSc, MBA, is the group's chief medical officer for developed markets 55

FORESIGHT — Global Health

FORESIGHT Global Health is the essential read on prevention and control of noncommunicable diseases through transformation of health systems worldwide.

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