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CitiesChangingDiabetes.com#UrbanDiabetes@CitiesDiabetes

JOIN THE GLOBAL FIGHT AGAINST URBAN DIABETES

By 2035, over half a billion people will have diabetes. Urban development is one of the key drivers behind the global diabetes challenge.

Already, nearly two-thirds of all people with diabetes live in urban areas. It’s an emergency in slow motion.

But urban diabetes is not inevitable. We can stop diabetes ruining people’s lives.

If we work together – businesses, city leaders and planners, healthcare professionals, academics and community leaders – we can create cities which help us live more healthy lives.

NOVO NORDISKCHIEF EXECUTIVE OFFICERLARS REBIEN SØRENSEN

MEXICO CITYMAYORMIGUEL ÁNGEL MANCERA ESPINOSA

COPENHAGENMAYOR OF HEALTH AND CARENINNA THOMSEN

HOUSTONMAYORANNISE PARKER

TIANJINDIRECTOR FOR TIANJIN HEALTH & FAMILY PLANNING COMMISSION WANG HESHENG

SHANGHAISHANGHAI INSTITUTE OF DIABETES DIRECTORPROFESSOR JIA WEIPING

When we initiated Cities Changing Diabetes early in 2014, I stood alongside the leaders of Mexico City and some of the world’s foremost researchers. We asked people to join us in a global fight against urban diabetes.

The response that we have seen has been incredible. Mexico City has been joined by more pioneering study cities: Houston, Copenhagen, Tianjin and Shanghai – a group which is home to nearly 60 million people.Diabetes is not an issue the world can take lightly. But it’s not too late for the world to wake up to what’s happening – and we need to start in cities.

The rise of urban diabetes is unrelenting, but it is not inevitable. We are beginning to understand the driving factors behind the challenge, and those of us who can make a difference are now connecting better. The world needs cities that help us live more healthily. Join us.

Houston is one of the most diverse, productive and vibrant cities in the US. Sometimes described as the energy capital of the world, we are growing fast and are number one for job creation in the US. But the rise of cities, and ours in particular, can come with a price. One of these is urban diabetes.

In Houston, 11% of the adult population have diabetes, significantly higher than the proportion of those living in Texas as a whole. One of the challenges with this disease is that many don’t know they have it.

I want to thank Novo Nordisk for initiating the Cities Changing Diabetes public-private partnership, and partners including the University of Texas, the Clinton Global Initiative and the American Diabetes Association for joining with us. For me this is about substance over talk, and ultimately the chance to create long-term impact by sharing what we know, learning from others and working towards a common goal.

There is no question about it: diabetes is the number one health challenge in Mexico City. In July I set out a new strategy for obesity and diabetes. We have a lot to do, from encouraging healthy lifestyles, to supporting treatment which can avoid some of the tragic complications. diabetes is today the primary cause of death across the country.

I see Cities Changing Diabetes as an important contribution to tackling diabetes in Mexico City. For the first time, people leading some of the city’s most impactful initiatives are coming together to share and develop learning. That Dr Ahued Ortega, our city Minister of Health, travelled to help launch the programme in Copenhagen shows our desire to connect with others around the world on this issue. I’m proud that Mexico City helped launch this programme beside Novo Nordisk, and I look forward to working together to take on this significant challenge.

Shanghai is an important city, and in the top five largest cities globally, it acts as a model for many cities across the world. For over a decade now Shanghai has had a plan in place for chronic disease prevention and control. A huge amount is being done backed by significant healthcare resources, yet the number of patients and complications are increasing. That shows the force of the urban diabetes challenge for us.

The dynamics driving urban diabetes in Shanghai are complex: growing wealth, changing lifestyles and an ageing population, alongside a rising number of younger people getting the disease. Also fast-paced working lives can stand in the way of the management and treatment of diabetes. We all have more to learn, and more we can do. Through in-depth learning and connecting our knowledge, Cities Changing Diabetes can help us to improve even further the effectiveness of taking on diabetes in our city.

In 2014, Copenhagen was named the world’s most liveable city by Monocle magazine. This is a tribute to our great political ambitions for creating an active, healthy and green city.

Yet, the challenge of urban diabetes in Copenhagen is real and still on the rise. In particular, it is a consequence of social inequality. Copenhageners with no formal secondary school qualifications, as well as those without a job and receiving social benefits, are three times more likely to get diabetes than people of the same age with a higher education.

I’m determined that we can improve the health of all Copenhageners, and the treatment of diabetes in the city. Cities Changing Diabetes will challenge us to do more – providing new data and new routes to collaboration across our own city, as well as a window on important work in other cities across the world.

Tianjin is the fifth-largest urban area in China – with a population of 11 million today that’s set to grow to nearly 15 million in the next 15 years. As China’s National Development Plan sees tens of millions pour into cities in the next decade, it’s critical we learn from cities like ours to solve future problems.

With our economic development has come improved quality of life. But as we grow we also face challenges – and one of those is urban diabetes. The Tianjin Health & Family Planning Commission takes diabetes prevention and control very seriously, investing a lot in scientific research, clinical treatment, and community health centers. This work is paying off, yet the population with diabetes is still growing.

It’s a long journey requiring the collaboration of multiple partners, including city leaders and planners, the social sector, and academic partners: that’s why we’re pleased to be a part of Cities Changing Diabetes.

THE RISE IN DIABETES IS AN

EMERGENCY IN SLOW MOTION

While some disasters happen in a split second, others can take years to develop and no one realises what is happening until it’s too late.

The global diabetes challenge falls into the second category: it’s an emergency in slow motion and unless we act now, the world will have sleepwalked into a catastrophe. This is a devastating disease and we need urgent action to face up to it.

Among the multiple reasons why the rise of diabetes is an alarming global challenge, two stand out.

The first is the impact on individuals. Although diabetes care has greatly improved in recent decades, the truth remains that the potential complications from diabetes can be devastating.

There are still millions of people dying from the disease annually. The disease caused 4.9 million deaths in 2014: every seven seconds someone dies from diabetes.2 Others are losing their eyesight or requiring amputations because of poorly controlled diabetes. People with diabetes are nearly four times as likely to suffer from a stroke,6 as well as being significantly more likely to suffer from heart attacks than the general population.4

The second reason is the economic and financial burden of diabetes. As health budgets continue to be placed under massive strain, the cost represented by the rise of global diabetes will present a major challenge. We cannot assume that health systems will be able to cope if we continue along the current trajectory.

For both these reasons, diabetes is not an issue the world can take lightly.

Many of today’s most pressing global health problems can be understood and solved only by getting to grips with the cultural determinants, social risk factors, and environmental settings that shape health and that also drive disease. Fortunately, healthcare communities around the globe are doing so increasingly. The World Health Organisation, for example, has made addressing the social, economic and environmental determinants of health a priority area for its work in 2014 to 2019, and will now also take steps to concentrate on the cultural determinants of health and wellbeing. We are rightly grateful for advances in the medical sciences. Biological approaches to health and illness have contributed to vast reductions in mortality and morbidity worldwide. But in general these approaches have yet to account for the strong effects of culture, society and environment on individual health. We cannot afford to ignore the impact of these factors when attempting to tackle an issue as overwhelming as the current diabetes pandemic. Yet, diabetes

research and healthcare budgets are seemingly dominated by biological under-standings of health. Many other factors – cultural, social and economic – play an important role in the lives of people with diabetes, but are not devoted the same level of attention in research and healthcare.

I believe that funding for addressing these complex factors should reflect the fact that the vast majority of diabetes-related morbidity and mortality is socially mediated. In theory, we know how to treat the body of a diabetic person; yet diagnostic procedures and treatment outcomes remain, more often than not, unsatisfactory. Due to a dispro-portionate focus on medical inter ventions in the clinic, primary prevention has not received enough attention.

Yet the clinic is a place often inaccessible to those who are most vulnerable to developing diabetes, and to those suffering from its consequences. Nowadays, too many people remain undiagnosed, or (because of complex socio-economic and cultural

barriers) are prevented from accessing the treatment they need.

While today’s cities have made it possible for millions to access services and care, urban areas have also become hotspots for inequality, increasing human suffering and the burden of diabetes. This confluence of ever-growing cities and the rise in diabetes must be taken seriously as a force determining the health outcomes of increasing numbers of people across the globe. The problem is undeniably complex and will require both local and global cooperation.

“This confluence of ever-growing cities and the rise in diabetes must be taken seriously”

STROKE

HEART ATTACK

BLINDNESS

TOTAL KIDNEY FAILURE

AMPUTATION

BLINDNESS5,6

Risk: Diabetes is a leading cause of blindness.Effective treatment: Reduces deterioration in eyesight.

TOTAL KIDNEY FAILURE7

Risk: Three times as likely.Effective treatment: Reduces the causes of kidney failure.

STROKE6

Risk: Up to four times as likely.Effective treatment: Reduces stroke.

HEART ATTACK9

Risk: Three times as likely, and heart disease is up to four times as likely.Effective treatment: Reduces the risk of heart failure.

AMPUTATION9

Risk: A leading cause of non-traumatic lower-limb amputations.Effective treatment: Reduces the number of amputations.

POTENTIAL COMPLICATIONS OF UNCONTROLLED DIABETES

PLACING THE SPOTLIGHT ON THE SOCIAL AND CULTURAL DETERMINANTS OF THE DIABETES PANDEMIC BY PROFESSOR DAVID NAPIER, UNIVERSITY COLLEGE LONDON

GLOBAL CITIES

GLOBAL DIABETES

ACROSS THE WORLD, OVER THE COMING DECADES MORE AND MORE PEOPLE ARE SET TO LIVE IN URBAN AREAS, INCLUDING IN A GROWING NUMBER OF VAST MEGACITIES.

When the history of the twenty-first century is written, it will be the story of cities.

Since 2014, more than half of the world’s population lives in a city.1 By 2050, urban populations are set to grow to two-thirds of the population globally.1 And the number of megacities of over 10 million inhabitants will rise from 28 today to 41 in 2030.1

This trend is creating a wide range of new opportunities and challenges. On the one hand, people are drawn to the social and economic possibilities of urban life. It also brings people closer to health services, meaning there’s the potential for greater health service delivery and equity.

On the other hand, urban development is putting massive strain on services and infrastructure. And it’s creating new tensions and social challenges, not least as a third of urban residents in the developing world live in urban slum conditions.3 The UN estimates that by 2050 the number of people living in urban slums might triple to 3 billion unless decisive actions are taken.10

All this means that managing and running cities is one of the great challenges of this century.

DIABETES IS A CHALLENGE AFFECTING MORE PEOPLE AND RISING UP AGENDAS GLOBALLY, AND THE SOLUTIONS TO IT MUST BE FOUND AT A LOCAL LEVEL.

According to the International Diabetes Federation (IDF), 387 million people around the world had diabetes, diagnosed or undiagnosed in 2014.2 By 2035, that number will have risen to 592 million.2

What’s significant about this trend is the link to urbanisation. Already, 65% of those with diabetes live in urban areas, the equivalent to around 252 million urban dwellers.2

The number of people with type 2 diabetes is increasing in every country.2 The majority – some 77% – of people living with diabetes live in low and middle income countries2, where cities are also growing fastest.1

The way that cities are designed and run influences how people live and can be an enabler of, or a barrier to, diabetes prevention and management.11 There is evidence that aspects of urban living may drive a significantly higher risk of diabetes, especially in low and middle income countries.11,12 These drivers play out differently in the developed and the developing world, from city to city and across different areas in cities. They span barriers to physical exercise13 to fast-paced working environments11 and poor diet,14 through to consequences of urban development such as air pollution15 and living beside noisy roads.16

This means we simply cannot tackle global diabetes unless we take on the problem in cities. Yet we believe that urban diabetes is not inevitable. To tackle it, more needs to be known about what is driving the problem.

This means we simply cannot tackle global diabetes unless we take on the problem in cities.

OF PEOPLE WITH DIABETES LIVE IN CITIES2

2/3OF URBAN DWELLERS IN THE DEVELOPING WORLD LIVE IN URBAN SLUM CONDITIONS3

1/3

UN GLOBAL ESTIMATES OF PEOPLE IN URBAN AREAS1

2000 2035

5.39 BILLION

2.85 BILLION

592 MILLION

387 MILLION

194 MILLION

2003 2014 2035

IDF GLOBAL ESTIMATES OF PEOPLE WITH DIABETES2

Across the world, studies are beginning to expose the links between urban development and the prevalence of diabetes. Although the data and understanding is incomplete, some alarming findings show the scale and rapid growth of urban diabetes in all regions of the world.

The mortality rate from diabetes is higher in MEXICO CITY compared to other Mexican states17

In SHANGHAI the prevalence of type 2 diabetes grew 30% from 2003 to 200923

53% of people with diabetes in CHINA are living in urban settings26

Over 45% of residents in TIANJIN are overweight or obese28

Diabetes prevalence in JAKARTA more than doubled between 1993 and 2001 to 12.8%24

In BOGOTA 8.1% of adults have diabetes25

32% of adults in HOUSTON are obese18

8 in 10 of people with diabetes in the US live in urban areas2

Type 2 diabetes in LONDON has increased by 75% over a decade19

In COPENHAGEN diabetes prevalence ranges from 2.5% to 7.4% across different parts of the city20

Urban dwellers in SUB-SAHARAN AFRICA have 2–5 times increased risk of diabetes compared to rural dwellers21

Urban dwelling is associated with a 70% increased risk of diabetes in OMAN compared to rural living22

THE RISE OF

URBAN DIABETES

THE AMBITION FOR CITIES CHANGING DIABETES

THE PROGRAMME STRUCTURE

Cities Changing Diabetes is a response to the dramatic rise in urban diabetes across the world. It is a first-of-its-kind partnership platform for cross-disciplinary, cross-sector collaboration.

No one organisation and no one company can solve the challenge alone, so the programme is built on public-private partnerships between businesses, city leaders and planners, architects, healthcare professionals, academics, community leaders and others with a stake in the outcome. Working together we are setting out to create cities which help us live more healthily, and where people with diabetes can live life to the full.

Cities Changing Diabetes is a global fight against urban diabetes. The work in the study cities will act as a platform for the programme to grow globally. It will provide a basis to connect and learn around the challenge of urban diabetes, and to enable and inspire many more cities to join in the global fight.

CITIES CHANGING DIABETES AIMS TO

Put urban diabetes at the top of the global healthcare agenda.Experience has shown that it is possible to have great impact on the rise of a potentially devastating disease when healthcare systems are mobilised to see it as an urgent priority. By putting the spotlight on the scale and urgency of the issue in many cities across the world, we can help health systems to prioritise the challenge of urban diabetes.

Put it on the agenda of those designing and managing cities for the future. Urban planning has an important role to play in delivering health improvements in the way it designs and reshapes our cities.28 By helping those who design and manage cities to understand the dynamics of urban diabetes, we can equip them to develop healthier cities for the future.

We have set out to map the problem in a number of ‘study cities’ across the world. We have decided to start the programme by generating a body of collective knowledge about urban diabetes: what’s working today, where are the challenges and the priorities for the future.

MAPPINGWe will share the results from these cities in order to drive wider action around the world. We will continuously share what is learnt and connect the dots between cities, so that everyone involved can gain from the experience and knowledge of others – and create solutions for their own local needs. We will use our influence and global networks to drive the issue of urban diabetes up the agenda worldwide.

SHARING

We will work with partners to identify and scale up solutions to tackle diabetes in cities. The programme will enable us to catalyse action. In the study cities, we will play our part in helping to develop action plans. And across the world the learnings will equip a wide range of partners in taking concerted and focused action on the ground in cities through health promotion and urban design.

ACTION

The programme is structured to understand the driving factors behind the rise of diabetes in urban areas, and to share that knowledge and apply it to real-world solutions. The programme has three interconnected elements:

Today, not enough is known about the dynamics of how urban development can drive diabetes, and how to deliver the potential health benefits that city living can bring.29,30 Much is being done on the ground in urban areas to tackle diabetes. The opportunity is to bring together learning from that activity to get a clearer understanding of what needs doing and to underpin future strategy and action.

MEXICO CITY became one of the world’s first megacities forty years ago.30

Government of Mexico City

Ministry of Health, Government of Mexico City

Mexico National Institute of Public Health

TIANJIN boasts the highest per capita GDP of any Chinese city 32

Tianjin Health & Family Planning Commission

Tianjin Medical Association

Tianjin Diabetes Society

Community Health Association of Tianjin

Tianjin Medical University

COPENHAGEN was named most liveable city in the world in 2014.33

City of Copenhagen

University of Copenhagen

Danish Diabetes Association

Steno Diabetes Center

SHANGHAI is the largest urban area in china, the third largest in the world.34

Shanghai Diabetes Institute

HOUSTON is the number one large metropolitan area for job growth increase.31

Houston Department of Health & Human Services

University of Texas School of Public Health

American Diabetes Association, Houston

Clinton Health Matters Initiative

Harris County Healthcare Alliance

BUILDING THE

PARTNERSHIP

NOVO NORDISKNovo Nordisk is at the forefront of one of today’s great health challenges: diabetes. As specialists in diabetes treatment, we’re committed to finding the next generation of medicines through long-term investment in innovation. Our key contribution is to discover and develop these medicines, manufacture them to scale and make them accessible wherever they are needed.

But living with chronic disease is about more than getting the right medicine. That’s why we’re working on helping people to receive the right treatment and achieve the right outcomes. We are committed to playing our part in the global fight against diabetes, and Cities Changing Diabetes is at the heart of this commitment.

The first year of the programme, 2014, saw the launch of Cities Changing Diabetes in five study cities around the world: Mexico City, Copenhagen, Houston, Tianjin and Shanghai. Together, these cities account for nearly 60 million people, of which over 6 million may have diabetes. Initiated by Novo Nordisk, University College London and the Steno Diabetes Center, the programme now has many partners involved in the research phase across the world.

STENO DIABETES CENTERSteno Diabetes Center is a world leading institution in diabetes care and prevention, with a focus on the early stages of the disease. Established by Novo Nordisk A/S in 1932, we are a not for profit organisation working in partnership with the Danish healthcare system. We treat around 5600 people with diabetes.

As a partner in Cities Changing Diabetes we draw on our experience in creating innovative and sustainable approaches to tackling diabetes at the community level, our work training healthcare professional in cities across the world and our expertise in providing care in Copenhagen. We believe we can make a significant contribution to the fight against urban diabetes.

UNIVERSITY COLLEGE LONDON Over the last few years, UCL has put its weight behind understanding the impacts of urbanisation. Under the banner of its ‘Grand Challenge’ commitments to Global Health, Sustainable Cities, Intercultural Interaction, and Human Wellbeing, a cross-disciplinary group has sought to contribute to urban sustainability by identifying health vulnerabilities and addressing the modifiable risk factors that can reduce the impact of NCDs globally.

We are delighted to bring our expertise to bear through supporting research that will underpin Cities Changing Diabetes. More than that, our approach is aimed at making an impact that is sustainable into the future, giving new momentum to this global initiative.

In each study city, partnerships are being built involving business, city authorities, local health leaders, academic institutions and city experts. These partnerships are designed to take on the global challenge of urban diabetes through establishing local research networks and building on existing areas of expertise. We will begin with a local diabetes mapping for each city and deepen our findings through extensive qualitative research. University College London is guiding the global academic research, working with a set of distinguished research partners in each city. The programme also draws on the global experience of the Steno Diabetes Center to better understand the challenge and to design future interventions.

A combination of quantitative and qualitative research will help cities understand diabetes risk factors and provide evidence-based recommendations to inform decisions about prevention and intervention.

The first step is to produce a quantitative Rule of Halves Analysis. This helps us to understand any major gaps in relation to diabetes diagnosis and care in each city. It will indicate where efforts should be placed to have the highest impact.

The second step is to conduct a qualitative vulnerability assessment. This helps us to understand what makes certain people in

each city more vulnerable to diabetes and its complications. It allows us to go beyond the quantitative findings of the Rule of Halves analysis and will emphasise the behavioural and cultural drivers of urban diabetes.

Together, these two steps will unearth what can be done to improve the way diabetes is prevented, treated and managed in the cities.

The Rule of Halves35

This diagram shows a simplified overview of the Vulnerability Assessment process carried out in each partner city.

MAPPING THE CHALLENGE

Of the estimated 387 million people with diabetes

Diabetes

About 50% are diagnosed

Diagnosed

Receive care

Of whom about 50% receive care

Achieve treatment targets

Of whom about 50% achieve treatment targets

Achieve desired outcomes

Of whom about 50% achieve desired outcomes

QUANTITATIVE DATARule of Halves analysis, household surveys

VULNERABILITY ASSESSMENTSSemi-structured interviews conducted

by trained field workers

QUALITATIVE DATALocal data contributes to global

archive of interviews

ANALYSISQuantitative and qualitative data analysis

CASE FILTERSKnown or suspected vulnerabilities. E.g. high BMI, living alone,

from urban area in nutrition transition

NEW KNOWLEDGE Insight for Intervention

CASE DEFINITIONSIdentify participants for vulnerability assessment

THE RULE OF HALVES Today, many people with diabetes are not diagnosed, many who are diagnosed do not receive treatment and many who are treated do not get the best outcomes. The Rule of Halves is a framework which outlines the five hurdles to overcome to get diabetes successfully under control.

According to the Rule of Halves, on average around the globe today only around 6% of people who have diabetes live their lives free of diabetes related complications. Actual rates vary in different cities across the world, so this model can be used to understand the barriers specific to tackling urban diabetes in each city. This means that the particular set of solutions to tackle urban diabetes effectively in each city will need to be localised.

THE VULNERABILITY ASSESSMENTThe Vulnerability Assessment identifies the presence of social and cultural risk factors for developing diabetes and for suffering from diabetes and its complications.

We will carry out Vulnerability Assessments in each of the Cities Changing Diabetes partnership cities to create a global archive of detailed interviews. Importantly, in this process we also want to identify better ways of getting to those who do not (or cannot) for various reasons engage with health services.

On World Diabetes Day 2014, Novo Nordisk made a rallying cry for uniting to fight urban diabetes. Across social media channels and through events all over the world, people came together to raise awareness of diabetes in urban settings.

We hope the steps we took in 2014 to launch Cities Changing Diabetes in a global partnership with take off in 2015 in a global movement against urban diabetes.

JOINING THE

GLOBAL FIGHT

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25. Escobedo J et al. High prevalence of diabetes and impaired fasting glucose in urban Latin America: the CARMELA Study. Diabet Med 2009; 26(9):864–871

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27. Zhang YIW et al. An epidemiological investigation on overweight and obesity in adults from Tianjin city, Chinese J of Epidemiology, 2009 30(11):1147–51

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35. Hart JT. Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. British Journal of General Practice. 1992; 42(356):116–119 and Smith WCS, Lee AJ, Crombie IK, Tunstall-Pedoe H. Control of blood pressure in Scotland: the rule of halves. Br Med J. 1990;300:981–983