- Email: [email protected]
Turning the tide on NCDs by engaging the next generation
Correspondence
Type 2 diabetes in youth is a disease of poverty
actively engage adolescents with type 2 diabetes and their family members in the design of novel approaches to care. Empirical testing of patient-centred interventions that move beyond diet and exercise are warranted, considering the low efficacy of existing therapeutic options and low adherence rates to self-management behaviours among adolescents living with type 2 diabetes.10
We commend the Review by Russell Viner and colleagues (June 3, p 2252)1 on the topic of type 2 diabetes in adolescents. We were pleased that the authors acknowledged the crucial importance of the psychological and social challenges that adolescents with type 2 diabetes face. However, few clinical guidelines or expert recommendations acknowledge that these challenges might be grounded in the social conditions in which these adolescents live.2 Specifically, a sub stantial proportion of young people with type 2 diabetes live in poverty or socially disadvantaged households (table).3–7 Factors that typically coexist with poverty, such as food in security, disparities in access to care, and related mental health challenges, make the adoption of behavioural lifestyle changes, a cornerstone in clinical management of type 2 diabetes, challenging. Viner and colleagues1 also did not specify the “resilient” factors that promote wellness, positive mental health, and higher quality of life that could enhance self-management of type 2 diabetes. For example, the stigma associated with type 2 diabetes is a barrier to wellbeing and can be reduced with greater social support.8 Finally, we feel this field is ready for patient-oriented research9 and shared decision-making models. Clinicians and scientists should
We declare no competing interests.
*Jonathan McGavock, Brandy Wicklow, Allison B Dart [email protected] Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, Children’s Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3E 3P4, Canada 1
2 3
4
5
6
Viner R, White B, Christie D. Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden. Lancet 2017; 389: 2252–60. American Diabetes Association. Children and adolescents. Diabetes Care 2017; 40 (suppl 1): S105–13. Dabelea D, Stafford JM, Mayer-Davis EJ, et al. Association of type 1 diabetes vs type 2 diabetes diagnosed during childhood and adolescence with complications during teenage years and young adulthood. JAMA 2017; 317: 825–35. Copeland KC, Zeitler P, Geffner M, et al. Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline. J Clin Endocrinol Metab 2011; 96: 159–67. Klingensmith GJ, Connor CG, Ruedy KJ, et al. Presentation of youth with type 2 diabetes in the Pediatric Diabetes Consortium. Pediatr Diabetes 2016; 17: 266–73. Khanolkar AR, Amin R, Taylor-Robinson D, Viner R, Warner J, Stephenson T. Ethnic minorities are at greater risk for childhoodonset type 2 diabetes and poorer glycemic control in England and Wales. J Adolesc Health 2016; 59: 354–61.
Sample size SEARCH for Diabetes in Youth3
1589
Prevalence of poverty 44%*
TODAY cohort4
704
41%*
Pediatric Diabetes Consortium5
503
43%*
38
56%*
Pediatric Diabetes Consortium, age <10 years5 UK cohort6
391
32±16†
Canadian cohort7
342
59%‡
*Using percentage of household income of
Table: Prevalence of poverty among children and adolescents with type 2 diabetes in cohort studies
www.thelancet.com Vol 390 October 21, 2017
7
Dart AB, Martens PJ, Rigatto C, Brownell MD, Dean HJ, Sellers EA. Earlier onset of complications in youth with type 2 diabetes. Diabetes Care 2014; 37: 436–43. 8 Huynh E, Rand D, McNeill C, et al. Beating diabetes together: a mixed-methods analysis of a feasibility study of intensive lifestyle intervention for youth with type 2 diabetes. Can J Diabetes 2015; 39: 484–90. 9 Petit-Zeman S, Firkins L, Scadding JW. The James Lind Alliance: tackling research mismatches. Lancet 2010; 376: 667–69. 10 Berkowitz RI, Marcus MD, Anderson BJ, et al. Adherence to a lifestyle program for youth with type 2 diabetes and its association with treatment outcome in the TODAY clinical trial. Pediatr Diabetes 2017; published online June 30. DOI:10.1111/ pedi.12555.
Turning the tide on NCDs by engaging the next generation In The Lancet (July 22, p 346),1 Richard Horton asked why the global health community is failing to effectively respond to the global rise of noncommunicable diseases (NCDs). A number of opportunities for pro gress were highlighted. Our two organisations, NCDFREE and the Young Professionals Chronic Disease Net work (YP-CDN), are firmly committed to tackling the global challenge of NCDs through advocacy and collab oration that leverages the power of young people. We fully support the recommendations outlined by Horton, and these two organisations represent the beginnings of the bold social movement that is so urgently needed. Our organisations actively engage with actors both within and outside the health sector. We communi cate with and foster communication be tween medical professionals, acad emics, students, activists, lawyers, artists, civil society, and business people working in climate change, sustain able development, urban development, essential medicines, universal health coverage, human rights, and more. We aim to foster trans disciplinary and multidisciplinary problem-solving approaches early in people’s careers. In line with Horton’s call to learn from
For more on NCDFREE see www.ncdfree.org For more on YP-CDN see www.ncdaction.org
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1829
Correspondence
the AIDS movement, YP-CDN, inspired by a need to apply a social justice and human rights frame to NCDs, has worked closely with traditional access to medicines activists and technical experts to add nine essential medicines for NCDs to the WHO Essential Medicines List.2 YP-CDN currently advocates, through its grassroots chapters in east Africa, for this global policy to be reflected at national levels. NCDFREE and the YP-CDN are preparing the next generation to lead on preventing and treating NCDs. Through NCDFREE’s bootcamps, hundreds of young people from varying personal and professional backgrounds in Australia, America, Canada, Denmark, Egypt, Germany, and the UK have gained awareness and advocacy skills to ignite systemic and sustainable change. NCDFREE is actively working toward a wider reach in all regions. YP-CDN’s NextGen Leaders programme, a partnership with RTI International, has trained more than 100 young people in east Africa since September, 2016, to advocate for local and national change on tangible country-specific NCD priorities set by young people, and to hold their governments accountable to their NCD commitments. While YPCDN’s chapter in Kenya is championing the cause of rheumatic heart disease, the chapter in Uganda is working with a civil society network on improving access to radiotherapy. “Be human. Be specific. Be vivid.”1 By communicating with our audiences in a comprehensible manner through visual and engaging means—infographics, short films, social media, campaigns, and events—we can take our message to new and existing audiences, and most importantly, share the stories and voices of people living with NCDs. In 2013, NCDFREE’s #theface campaign collected personal NCD stories from around the world via social media. In 2016, the #feastofideas campaign again harnessed the power of social media to crowdsource 10 000 food system solutions from 56 countries. 1830
These campaigns demonstrate the power of low cost, wide-reaching, intersectoral, and innovative activities in informing and empowering the NCD movement. The NCD tide is turning and we all have a part to play in driving positive change. Our organisations do not have all the answers, but we believe that engaging with young people and people living with NCDs through new and engaging media, as well as developing hard and soft skills to influence policy and hold governments accountable, are crucial steps. All authors are either employees or volunteers for NCDFREE or YP-CDN. IK is also an employee of RTI International (India).
*Prachi Bhatnagar, Jack Fisher, Jessica Renzella, Ishu Kataria, Jordan D Jarvis [email protected] NCDFREE, Northcote, VIC 3070, Australia (PB, JF, JR); Young Professionals Chronic Disease Network, Boston, MA, USA (IK, JDJ) and RTI International, India Country Office, New Delhi, India (IK) 1 2
Horton R. Offline: NCDs—why are we failing? Lancet 2017; 390: 346. Young Professionals Chronic Disease Network. Essential medicines. http://www.ncdaction.org/ essential_medicines (accessed Sept 7, 2017).
From (re-)framing NCDs to shaping public health policies on NCDs and communicable diseases A senior adviser to the Global Fund taught Richard Horton (July 22, p 346)1 some lessons that were drawn from the struggle against three communicable diseases—tuberculosis, malaria, and AIDS—that keep scourging global health. To raise funds to combat noncommunicable diseases (NCDs), one should “translate [one’s] evidence into clear and simple political (not technical) messages”, “articulate why [one] need[s] money—what exactly will [one] spend it on and what will be the results of that investment”, “break down [one’s] broad global demands into tangible country-specific needs”, and “connect [one’s] case to the big political picture—give it meaning”.
What proposals can we formulate to meet these requests? First, the Global Burden of Disease (GBD) has repeatedly highlighted the growing importance of NCDs.2 There is no further need to demonstrate the relevance of a public health approach. Moreover, as the debate initiated by Luke Allen and Andrea Feigl3,4 in The Lancet Global Health illustrates, socioenvironmental factors identi fied at the onset or aggravation of NCDs must be taken seriously to also fight communicable diseases more efficiently.5 Second, as these socioenvironmental causes, cofactors, and triggers of both NCDs and communicable diseases lie in living and working material conditions, money is needed to implement transdisciplinary research that would combine an in-depth clinical approach to the frequent diverse presentations of the diseases at stake, an epidemiological inquiry into the socioenvironmental sources of exposure to hazards, and social data collected through general population surveys, in association with thorough qualitative interviews, on people’s life trajectories, social habits, and daily practices. The results expected from such collaborations will not only provide a detailed description of environmental risk factors, 6 but also a better know ledge of social determinants of health that are still unknown.7 Third, according to a cost-benefit approach, the resource breakdown should prioritise the situations that remain the most unreadable through the general pattern of the epidemiologic transition.8 In this respect, countries like South Africa would be on the front line, to understand the terrible combination of high prevalences of communicable diseases and grow ing prevalences of NCDs, and to provide preventive tools against socioenvironmental hazards in a context of large health inequalities. Finally, is it necessary to draw a “big political picture”?1 As Richard Horton reminds us, a lot has been done to www.thelancet.com Vol 390 October 21, 2017
Type 2 diabetes in youth is a disease of poverty
actively engage adolescents with type 2 diabetes and their family members in the design of novel approaches to care. Empirical testing of patient-centred interventions that move beyond diet and exercise are warranted, considering the low efficacy of existing therapeutic options and low adherence rates to self-management behaviours among adolescents living with type 2 diabetes.10
We commend the Review by Russell Viner and colleagues (June 3, p 2252)1 on the topic of type 2 diabetes in adolescents. We were pleased that the authors acknowledged the crucial importance of the psychological and social challenges that adolescents with type 2 diabetes face. However, few clinical guidelines or expert recommendations acknowledge that these challenges might be grounded in the social conditions in which these adolescents live.2 Specifically, a sub stantial proportion of young people with type 2 diabetes live in poverty or socially disadvantaged households (table).3–7 Factors that typically coexist with poverty, such as food in security, disparities in access to care, and related mental health challenges, make the adoption of behavioural lifestyle changes, a cornerstone in clinical management of type 2 diabetes, challenging. Viner and colleagues1 also did not specify the “resilient” factors that promote wellness, positive mental health, and higher quality of life that could enhance self-management of type 2 diabetes. For example, the stigma associated with type 2 diabetes is a barrier to wellbeing and can be reduced with greater social support.8 Finally, we feel this field is ready for patient-oriented research9 and shared decision-making models. Clinicians and scientists should
We declare no competing interests.
*Jonathan McGavock, Brandy Wicklow, Allison B Dart [email protected] Department of Pediatrics and Child Health, Rady Faculty of Health Sciences, Children’s Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, MB R3E 3P4, Canada 1
2 3
4
5
6
Viner R, White B, Christie D. Type 2 diabetes in adolescents: a severe phenotype posing major clinical challenges and public health burden. Lancet 2017; 389: 2252–60. American Diabetes Association. Children and adolescents. Diabetes Care 2017; 40 (suppl 1): S105–13. Dabelea D, Stafford JM, Mayer-Davis EJ, et al. Association of type 1 diabetes vs type 2 diabetes diagnosed during childhood and adolescence with complications during teenage years and young adulthood. JAMA 2017; 317: 825–35. Copeland KC, Zeitler P, Geffner M, et al. Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at baseline. J Clin Endocrinol Metab 2011; 96: 159–67. Klingensmith GJ, Connor CG, Ruedy KJ, et al. Presentation of youth with type 2 diabetes in the Pediatric Diabetes Consortium. Pediatr Diabetes 2016; 17: 266–73. Khanolkar AR, Amin R, Taylor-Robinson D, Viner R, Warner J, Stephenson T. Ethnic minorities are at greater risk for childhoodonset type 2 diabetes and poorer glycemic control in England and Wales. J Adolesc Health 2016; 59: 354–61.
Sample size SEARCH for Diabetes in Youth3
1589
Prevalence of poverty 44%*
TODAY cohort4
704
41%*
Pediatric Diabetes Consortium5
503
43%*
38
56%*
Pediatric Diabetes Consortium, age <10 years5 UK cohort6
391
32±16†
Canadian cohort7
342
59%‡
*Using percentage of household income of
Table: Prevalence of poverty among children and adolescents with type 2 diabetes in cohort studies
www.thelancet.com Vol 390 October 21, 2017
7
Dart AB, Martens PJ, Rigatto C, Brownell MD, Dean HJ, Sellers EA. Earlier onset of complications in youth with type 2 diabetes. Diabetes Care 2014; 37: 436–43. 8 Huynh E, Rand D, McNeill C, et al. Beating diabetes together: a mixed-methods analysis of a feasibility study of intensive lifestyle intervention for youth with type 2 diabetes. Can J Diabetes 2015; 39: 484–90. 9 Petit-Zeman S, Firkins L, Scadding JW. The James Lind Alliance: tackling research mismatches. Lancet 2010; 376: 667–69. 10 Berkowitz RI, Marcus MD, Anderson BJ, et al. Adherence to a lifestyle program for youth with type 2 diabetes and its association with treatment outcome in the TODAY clinical trial. Pediatr Diabetes 2017; published online June 30. DOI:10.1111/ pedi.12555.
Turning the tide on NCDs by engaging the next generation In The Lancet (July 22, p 346),1 Richard Horton asked why the global health community is failing to effectively respond to the global rise of noncommunicable diseases (NCDs). A number of opportunities for pro gress were highlighted. Our two organisations, NCDFREE and the Young Professionals Chronic Disease Net work (YP-CDN), are firmly committed to tackling the global challenge of NCDs through advocacy and collab oration that leverages the power of young people. We fully support the recommendations outlined by Horton, and these two organisations represent the beginnings of the bold social movement that is so urgently needed. Our organisations actively engage with actors both within and outside the health sector. We communi cate with and foster communication be tween medical professionals, acad emics, students, activists, lawyers, artists, civil society, and business people working in climate change, sustain able development, urban development, essential medicines, universal health coverage, human rights, and more. We aim to foster trans disciplinary and multidisciplinary problem-solving approaches early in people’s careers. In line with Horton’s call to learn from
For more on NCDFREE see www.ncdfree.org For more on YP-CDN see www.ncdaction.org
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1829
Correspondence
the AIDS movement, YP-CDN, inspired by a need to apply a social justice and human rights frame to NCDs, has worked closely with traditional access to medicines activists and technical experts to add nine essential medicines for NCDs to the WHO Essential Medicines List.2 YP-CDN currently advocates, through its grassroots chapters in east Africa, for this global policy to be reflected at national levels. NCDFREE and the YP-CDN are preparing the next generation to lead on preventing and treating NCDs. Through NCDFREE’s bootcamps, hundreds of young people from varying personal and professional backgrounds in Australia, America, Canada, Denmark, Egypt, Germany, and the UK have gained awareness and advocacy skills to ignite systemic and sustainable change. NCDFREE is actively working toward a wider reach in all regions. YP-CDN’s NextGen Leaders programme, a partnership with RTI International, has trained more than 100 young people in east Africa since September, 2016, to advocate for local and national change on tangible country-specific NCD priorities set by young people, and to hold their governments accountable to their NCD commitments. While YPCDN’s chapter in Kenya is championing the cause of rheumatic heart disease, the chapter in Uganda is working with a civil society network on improving access to radiotherapy. “Be human. Be specific. Be vivid.”1 By communicating with our audiences in a comprehensible manner through visual and engaging means—infographics, short films, social media, campaigns, and events—we can take our message to new and existing audiences, and most importantly, share the stories and voices of people living with NCDs. In 2013, NCDFREE’s #theface campaign collected personal NCD stories from around the world via social media. In 2016, the #feastofideas campaign again harnessed the power of social media to crowdsource 10 000 food system solutions from 56 countries. 1830
These campaigns demonstrate the power of low cost, wide-reaching, intersectoral, and innovative activities in informing and empowering the NCD movement. The NCD tide is turning and we all have a part to play in driving positive change. Our organisations do not have all the answers, but we believe that engaging with young people and people living with NCDs through new and engaging media, as well as developing hard and soft skills to influence policy and hold governments accountable, are crucial steps. All authors are either employees or volunteers for NCDFREE or YP-CDN. IK is also an employee of RTI International (India).
*Prachi Bhatnagar, Jack Fisher, Jessica Renzella, Ishu Kataria, Jordan D Jarvis [email protected] NCDFREE, Northcote, VIC 3070, Australia (PB, JF, JR); Young Professionals Chronic Disease Network, Boston, MA, USA (IK, JDJ) and RTI International, India Country Office, New Delhi, India (IK) 1 2
Horton R. Offline: NCDs—why are we failing? Lancet 2017; 390: 346. Young Professionals Chronic Disease Network. Essential medicines. http://www.ncdaction.org/ essential_medicines (accessed Sept 7, 2017).
From (re-)framing NCDs to shaping public health policies on NCDs and communicable diseases A senior adviser to the Global Fund taught Richard Horton (July 22, p 346)1 some lessons that were drawn from the struggle against three communicable diseases—tuberculosis, malaria, and AIDS—that keep scourging global health. To raise funds to combat noncommunicable diseases (NCDs), one should “translate [one’s] evidence into clear and simple political (not technical) messages”, “articulate why [one] need[s] money—what exactly will [one] spend it on and what will be the results of that investment”, “break down [one’s] broad global demands into tangible country-specific needs”, and “connect [one’s] case to the big political picture—give it meaning”.
What proposals can we formulate to meet these requests? First, the Global Burden of Disease (GBD) has repeatedly highlighted the growing importance of NCDs.2 There is no further need to demonstrate the relevance of a public health approach. Moreover, as the debate initiated by Luke Allen and Andrea Feigl3,4 in The Lancet Global Health illustrates, socioenvironmental factors identi fied at the onset or aggravation of NCDs must be taken seriously to also fight communicable diseases more efficiently.5 Second, as these socioenvironmental causes, cofactors, and triggers of both NCDs and communicable diseases lie in living and working material conditions, money is needed to implement transdisciplinary research that would combine an in-depth clinical approach to the frequent diverse presentations of the diseases at stake, an epidemiological inquiry into the socioenvironmental sources of exposure to hazards, and social data collected through general population surveys, in association with thorough qualitative interviews, on people’s life trajectories, social habits, and daily practices. The results expected from such collaborations will not only provide a detailed description of environmental risk factors, 6 but also a better know ledge of social determinants of health that are still unknown.7 Third, according to a cost-benefit approach, the resource breakdown should prioritise the situations that remain the most unreadable through the general pattern of the epidemiologic transition.8 In this respect, countries like South Africa would be on the front line, to understand the terrible combination of high prevalences of communicable diseases and grow ing prevalences of NCDs, and to provide preventive tools against socioenvironmental hazards in a context of large health inequalities. Finally, is it necessary to draw a “big political picture”?1 As Richard Horton reminds us, a lot has been done to www.thelancet.com Vol 390 October 21, 2017