1. Preventing global NCDs: do targets work? Neil Pearce Centre for Global NCDs London School of Hygiene and Tropical Medicine

2. Globalization and NCDs The current paradigm for preventing global NCDs Why the current paradigm falls short An alternative/complementary paradigm

3. Preventing Global NCDs NCDs Deaths CVD Diabetes Cancer COPD 87% of NCD deaths Causes Tobacco Diet/exercise Salt Alcohol 80% of cases Tobacco use, foods high in saturated and trans fats, salt, and sugar, physical inactivity, and... alcohol cause more than 2/3rds of new cases of NCDs. [Lancet 2011; 377: 1438-1447]

4. Globalization and NCDs The current paradigm for preventing global NCDs Why the current paradigm falls short An alternative/complementary paradigm

5. Why the current paradigm falls short It doesn’t work very well in High Income Countries

6. Health promotion: experience in developed countries North Karelia study –Local community support –Comprehensive approach –Mass media –Workplace –Primary care, hospitals, schools –Training programmes –Food shops and food industry

7. North Karelia: death rates during the course of the study in Finland

8. Disappointing results replicated many times Cardiovascular community control programs Stanford Heart Disease Prevention Program Stanford Five-City project Minnesota Heart Health Program Pawtucket Heart Health Program Heart Beat Wales COMMIT study

9. Systematic review of multiple risk factor interventions: effect on CHD mortality Ebrahim and Davey Smith BMJ 1997 and Cochrane Library

10. Why the current paradigm falls short It doesn’t work very well in High Income Countries Morbidity vs mortality The missing NCDs The missing causes

11. The ‘main four’ NCDs account for 87% of NCD deaths [Lancet 2012; 380: 2095-2128 (GBD)] 87%

12. The ‘main four’ NCDs account for 50% of NCD DALYS [Lancet 2012; 380: 2197-2223 (GBD)] 50%

13. Preventing Global NCDs NCDs DALYs CVD Diabetes Cancer COPD ---------------- Mental illness Neurological Musculoskeletal Others Causes Tobacco Diet/exercise Salt Alcohol

14. Preventing Global NCDs NCDs DALYs CVD Diabetes Cancer COPD ---------------- Mental illness Neurological Asthma Others Causes Tobacco Diet/exercise Salt Alcohol ----------------- Infections Occupational Environmental Others

15. Why the current paradigm falls short It doesn’t work very well in High Income Countries Morbidity vs mortality The missing NCDs The missing causes The causes of the causes

16. The causes of the causes Example 1: urban design

19. Changes in physical activity over time “Leisure Time Physical Activity (LTPA) accounts for only a small part of total physical energy expenditure… although…LTPA has not decreased, and may even have increased moderately, this increase has not compensated for the substantial decline in occupational, household and transportation activities. Thus, overall physical activity in the population has decreased considerably” [Hu FB. Obesity epidemiology. Oxford: 2008]

20. Who cut down the last tree? “What did the Easter Islander who cut down the last palm tree say as he was doing it?... [In fact] the changes in forest cover from year to year would have been almost undetectable... Only the oldest islanders thinking back to their childhoods... could have recognised a difference. Gradually Easter Island’s trees became fewer, smaller, and less important... No one would have noticed the falling of the last little palm sapling” [Jarrod Diamond. Collapse: how societies choose to fail or survive]

21. Preventing Global NCDs NCDs DALYs CVD Diabetes Cancer COPD ---------------- Mental illness Neurological Musculoskeletal Others Causes Tobacco Diet/exercise Salt Alcohol ----------------- Occupational Environmental Infections Unknown causes Causes of causes Urban design Development Poverty SES Agriculture

22. Globalization and NCDs The growing global burden of NCDs The current paradigm for preventing global NCDs Why the current paradigm falls short An alternative/complementary paradigm

23. Three strands of global health and NCDs Sustainable development Combating climate change Preventing NCDs

25. Change in disease burdenChange in premature deaths Ischaemic heart disease10-19%1443-2207 Cerebrovascular disease 10-18%866-1271 Dementia 7-8%195-250 Breast cancer 12-13%203-211 Road traffic crashes 19-39%47-86 Health effects of increased active travel by disease (London) diabetes, depression and bowel cancer not shown ( Woodcock et al 2009)

27. The Vienna Declaration on nutrition and non- communicable disease [Lawlor DA, Pearce NE. Br Med J, in press] ‘People may support health environmental changes for non- health reasons... Most Londoners probably would not have supported the congestion charge because it would improve their health... but because it makes London a nicer place to live... Most people won’t vote to be lectured about healthy lifestyles... But they will vote for safe liveable neighbourhoods... In which it is easy to walk or cycle to work or school and in which locally produced foods are widely available and affordable... Some lateral thinking is needed.’

28. Relevant publications Lawlor DA, Pearce N. The Vienna Declaration on nutrition and noncommunicable diseases – time to look upstream. Br Med J 2013; 347: f4417. Pearce N, Ebrahim S, McKee M, Lamptey P, Barreto ML, Matheson D, Walls H, Foliaki S, Miranda J, Chimeddamba O, Garcia Marcos L, Haines A, Vineis P. The road to 25x25: how can the five-target strategy reach its destination? Lancet Global Health 2014; 2: e126.

29. Preventing global NCDs: do targets work? Neil Pearce Centre for Global NCDs London School of Hygiene and Tropical Medicine