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On Cruyff & NCDs in low-and middle-income countries

There is no escape from the NCD epidemic. In recent weeks, two consecutive papers in the Lancet, to which our colleagues Patrick Kolsteren and Roos Verstraeten  contributed as  members of the NCDRIsC group, underscored this (inconvenient?) NCD truth once again. Among the key messages: 1) quantitatively, the problem of obesity now outweighs that of underweight: the number of overweight or obese people now surpasses the 794 million people who do not have enough calories, and is substantially higher in low-and middle-income countries (LMICs) than in high-income countries (HICs);  2) the burden of diabetes  has increased globally (both in terms of prevalence and adults affected), but much faster in LMICs than in HICs. Of course, the linkage between obesity and diabetes is not as straightforward as the sequence of the Lancet papers – one was published ten days ago, the other one this week – might tempt the average reader to believe, as my colleague Grace Marie Ku already pointed out in this very newsletter, 5 years ago.

The authors of  this week’s Lancet paper give a number of other explanations for the difference in the rise in diabetes between HICs and LMICs. The faster rise in LMICs can partly be explained by differences in genetic susceptibility or phenotypic variations resulting from poor fetal and early postnatal nutrition, they argue. The ‘thrifty phenotype hypothesis’ (Barker 1992)  states that nutritional deficiency during pregnancy – resulting in reduced fetal growth – may be associated with diabetes (and other chronic diseases) in later life. This increased sensitivity is due to adjustments made by the foetus in an environment where the supply of nutrients is limited. When these children then get sufficient  (and more) food, metabolic problems such as obesity and T2D arise. Changes in dietary and physical activity habits also affect the diabetes risk. These changes are fueled by rapid economic, social and cultural changes, previously labelled as the nutrition transition. Various responses to these issues have been formulated in HICs, but rarely in LMICs. The NCDRIsC research group has implemented and evaluated a school-based health promotion program (RCT) aimed at improving dietary and physical activity behaviours among Ecuadorian adolescents aged 11–15 years, called ACTIVITAL. It is an example of a child health promotion success story in a LMIC context, reducing waist circumference and blood pressure.

Another important reason  for regional differences is the variety in resources of health systems. It is particularly this element on which our (i.e. the first author’s) research has focused over the last years. How can health systems in LICs adapt to better respond to the needs of  increasing numbers of people with diabetes? Various forms of diabetes care and self-management programmes have developed within, and in reaction to their surrounding (often resource limited) health system context. “It [is] possible to maintain a diabetes programme with minimal external resources, offering care and self-management support”.  Is it possible to make use of innovative technologies, such as mobile phones, to increase the quality of these programmes? Can we make better use of the potential of community resources and patients themselves to support self-management? Together with our partners, we developed, tested and evaluated interventions, for instance in the TEXT4DSM and SMART2D studies. This being health systems research, we aim to learn lessons across contexts, but also explore how to embed and scale up interventions best into existing health care systems.

Tackling diabetes, obesity, and other related diseases, is complex. It requires a whole-of-society approach and the involvement of multiple actors. In spite of the recent (high-profile) Lancet papers, the challenge is still somewhat underappreciated as a public health issue in LMICs: difficult to understand, and even more difficult to tackle effectively.

One of the trademark “wisdoms” of the first author’s (rather more famous) compatriot, the late Johan Cruyff (who proved to be capable of behaviour change but nevertheless died of a chronic disease recently), went like this: “The truth is never exactly like you think it would be.”   Being less of a genius, we don’t know exactly what he meant by that, but it sure sounds pertinent in the NCD fight!

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