October 26-27, 2017; Houston, TX; Highlights – Draft

Executive Highlights

As we fly home from Houston, we’re in awe at the palpable energy that ran like a current through the 2017 Cities Changing Diabetes summit (it was the second one – here’s the report for the inaugural gathering in 2015). From the announcement of a “bold goal” – cut obesity by (a whopping) 25% in cities so that diabetes rates go no higher than one in 10 (currently, prevalence is one in 11 globally up from an estimated 1 in 180 when Kelly was diagnosed in 1986) – to phenomenal interactive exhibits on early progress from the eight current CCD participants, to two different walking tours of Houston where we learned how to assess urban design as well as how to develop a stronger vocabulary to describe built environments (and to convince policymakers to improve them), this meeting virtually never ceased to inspire. Given that Novo Nordisk’s CEO Lars Jorgensen has a fairly new executive team (over half are new in the last two years), this was a fascinating place to hear from the new leadership as well. We interviewed four executives (including two on the new exec team) plus Houston impresario Dr. Faith Foreman – we’ll be back with more on these.  We appreciated the delicate balance between showing that diabetes prevention is possible and showing that much work lies ahead – this is difficult to strike, but it’s the sweet spot where any public health message is most powerful. In our view, this CCD summit presented the right messages, both emotional and practical, very effectively.

The summit concluded with a big reveal: Four new cities are slated to join the Cities Changing Diabetes Program very soon, including Hangzhou (population ~9 million) and Beijing (population ~21.5 million) in China! Yes, you did that math correctly – these two cities alone cover a population upwards of 30 million people. China faces one of the biggest burdens of diabetes worldwide, given the sheer size of its population and the tendency to delay diagnosis and care, and it’s tremendous that Hangzhou and Beijing will join Tianjin and Shanghai to bring this nation’s CCD participant count up to four. Although we thought we understood the magnitude of diabetes in China, we had not understood it nearly as well as we do now.

Read on for 11 key highlights from this Houston gathering, followed by a list of our most pressing questions, all getting at how this effort can be amplified even more. As noted, we were fortunate to sit down with multiple members of Novo Nordisk management, and this report also includes insights from CEO Mr. Lars Jørgensen (on the company’s approach to digital health), CMO Mr. Alan Moses (on the “bold goal”), brand new EVP Ms. Camilla Sylvest (on the need to invest in diabetes care solutions that support great therapeutic molecules), and VP Mr. Neils Lund (on Novo Nordisk’s philosophy for investing in Cities Changing Diabetes).

Top 11 Highlights

1. CCD to Add Four New Cities, Hangzhou + Beijing in China Cover >30 Million People; Novo Nordisk On Track for $20 Million Investment by 2020

Novo Nordisk EVP Ms. Camilla Sylvest announced that CCD is about to welcome four new participants, including Hangzhou and Beijing in China, which together cover a population >30 million – this is incredible momentum for Cities Changing Diabetes. Ms. Sylvest also shared the company’s commitment to support a vulnerability analysis in at least five more global cities in 2018, so that participation can continue to grow. We learned much more about Novo Nordisk’s investment in this prevention initiative in a conversation with VP Mr. Neils Lund. He confirmed that the company is on track to its meet its pledge of investing $20 million by the year 2020 (we suspect this funding has been largely linear, though we’re not sure the precise amount that has been invested to-date). A key difference between this summit in Houston and the one organized two years ago in Copenhagen, according to Mr. Lund, is that Novo Nordisk is now playing the role of facilitator, supporting the communities as they drive forward their own prevention programs, setting up a meeting so that the local public health heroes can exchange ideas. This is the position he foresees moving forward as well. Novo Nordisk will continue to fund research so that cities can map their local diabetes epidemic and can identify optimal strategies, and will then play a supporting role as these interventions are implemented. Why not play a heavy hand in running these interventions? “It’s a duality of being in control while letting go,” Mr. Lund expressed, “so that we can allow local creativity to blossom.”

• Moreover, Mr. Lund and Dr. Moses (in a separate interview) alluded to some popular resistance to a pharmaceutical company getting involved in on-the-ground public health practices (we’re certainly aware of this general inclination to distrust big pharma, which has worsened in recent years, now approaching Big Tobacco,  although we think most of this stems from misunderstanding). As Ms. Sylvest so eloquently stated, “If healthcare systems are overwhelmed with diabetes and obesity in the future, they won’t be able to pay for new products, and then the problem only escalates if we’re not innovating in medicine and patient care. So, we need to find a balance.”
• Further, Mr. Lund suggested that Novo Nordisk could have a larger, broader impact by setting more cities up for success. He described how in many cases, a new prevention effort can be funded by a city re-allocating resources within its budget: Houston using faith-based organizations to spread a diabetes prevention message is one example, and he also quoted Copenhagen’s Mayor, who said “we would have done many of these things, but we’re doing them sooner because of Cities Changing Diabetes” (so nothing new was invented, per se).

2. The Bold Goal: Reduce Obesity by 25% so that Type 2 Diabetes Doesn’t Rise >10%

Dr. Alan Moses, CMO at Novo Nordisk, presented the program’s bold goal – cities should cut obesity rates by 25% between now and 2045, in order to curtail rising type 2 diabetes prevalence and keep it at no more than one in 10. Currently, one in 11 adults globally (9.1%) have type 2 diabetes, and Cities Changing Diabetes is advocating for action now so that worldwide prevalence does not rise above 10% – this means a higher proportion of the urban population will have type 2 in 28 years, but we’ll be “bending the curve,” changing an upward trajectory to point down. Instead of 11.7% prevalence by 2045 (approximately one in nine), which is where we’re headed now, achieving this bold goal will prevent 111 million people from developing type 2 diabetes (800 million fewer people will have obesity). Instead of spending >$1 trillion on type 2 diabetes in 2045, annual expenditures will be $872 billion, saving the healthcare system $200 billion. “This bold goal makes fiscal sense, it makes public health sense, it makes sense for the individual citizen at risk,” Dr. Moses argued – yes, this is certainly very compelling. He explained the laser focus on obesity: This isn’t the only risk factor for new-onset type 2 diabetes, but it does account for 44% of the diabetes burden, and is thus an important target for prevention efforts. At every table in the main conference hall, attendees could view interactive graphs on an iPad to see how obesity rates on a sliding scale will impact diabetes prevalence by 2045 in the first eight CCD cities (Copenhagen, Houston, Mexico City, Vancouver, Shanghai, Tianjin, Johannesburg, and Rome – the eighth city to join this movement, in 2017). For dramatic example, reducing obesity to near zero in Shanghai would bring type 2 diabetes down from affecting 18.2% of the city’s population to 14.3% – more specifically, this would prevent 907,090 new cases and would save $433 million. Obesity currently affects ~18% of the population in Shanghai, and if this was lowered to 8% by 2045, the city would prevent 692,215 new cases of diabetes (keeping prevalence at 15.2%) and would save $330 million. Without a doubt, we see Dr. Moses’ fiscal argument, his public health argument, and his individual citizen argument in this model, and this held true for every participating city. Dr. Moses underscored that solutions to “bend the curve” will be different for every city, depending on sociocultural factors, the current state of the local diabetes crisis, and the main barriers to healthy living. To this end, he reviewed the five steps that Cities Changing Diabetes is asking of local stakeholders: (i) define a goal, (ii) create an action plan, (iii) establish new and innovative partnerships, going beyond your comfort zone to enlist the help of agencies, companies, and nonprofits, (iv) build health into every aspect of your urban strategy (this is so incredibly important), and (v) contribute learnings to the global effort (absolutely – as the legendary Dr. Faith Foreman shared in her closing remarks to this CCD summit, one of her fondest wishes is for a learning collaborative so that insights can be transferred from city to city).

3. Why Cities? Because Cities Get Things Done

Why cities? The decision to target diabetes prevention efforts at this level is not at all arbitrary. Cities feel the direct impact of people’s health and wellness. Or, in Mr. Lund’s words “cities are often the ones that pay the biggest price for health problems.” Local policymakers thus have the most to gain from investing in public health – and the least to lose, because as Dr. Moses put it, there’s less political risk in taking a stand on issues like this with a smaller constituency. Former Philadelphia Mayor Michael Nutter and Houston Mayor Sylvester Turner both underlined the message that “cities get things done.” Local politicians have a closer, on-the-ground view of the people and their priorities, lending them a greater sense of direct responsibility for the daily wellbeing of their constituents. Novo Nordisk EVP Mr. Doug Langa echoed these themes in his Thursday closing remarks, quoting superstar Mayor Michael Bloomberg of New York City: “We’re the level of government closest to the world’s people. While nations talk and too often drag their heels, cities act.” Mr. Langa elaborated on this with a nod to history, recalling that the movements for LGBT rights, HIV, and clean air all began at the city level. This is also exemplified by the ongoing commitment of individual cities to climate responsibility, even when this is not a priority on the national agenda (at least in the case of the US with the recent withdraw from the Paris Climate Agreement). There’s also the fact that effective diabetes prevention programs must take local culture and norms into account. The best strategies are the ones that tackle the tallest hurdles to health within a specific community. And lastly, urban areas show a troubling rise of diabetes and obesity prevalence. Half the world’s population lives in cities, so this call to action is actually quite broad-sweeping in itself.

4. Former Philly Mayor on Philly Bright SPots and Call to Action

Former Philadelphia Mayor Mr. Michael Nutter – a trailblazer in the movement toward healthy, sustainable cities – shared a number of bright spots from his time in office, and issued a five-step call to action. (i) Elevate the issue of obesity and diabetes on the agenda of those responsible for shaping cities; (ii) Inspire cities to drive action and fight diabetes; (iii) Create networks between and among cities to facilitate continued knowledge sharing, share best practices; (iv) Encourage more cities to engage in Cities Changing Diabetes programs by underlining the unmet need, promoting the urban diabetes toolbox, cases that demonstrate impact, and innovative approaches and partnership; and (v) Set goals – “if you can’t measure it, you can’t manage it…Create an action plan.” Though we found these points to be very general, we especially appreciated the messages of spreading awareness/urgency, sharing successes, and measuring outcomes. Then again, one of the major themes of the Summit has been that – as each patient with diabetes is different – each city presents with its own specific set of opportunities and barriers, so a specific guidance may not be globally applicable. In his city of Philadelphia, Mr. Nutter oversaw a 5% reduction in obesity in school children from 2006-2010; partnering with >650 corner stores to increase availability of nutritious foods; the opening of new farmers markets; the Philly Food Bucks program (which increased SNAP redemption by 400%); one of the strongest menu-labeling laws in the US; construction of 100s of miles of new bike lanes; the implementation of  support and resources for smokers, resulting in a 15% drop in smoking rates since 2008, and more. We were utterly blown away by his commitment to health as an investment of the overall health of the city. In his own words: “It’s crystal clear – the evidence is available – that in order for a city to be resilient, economically successful, and livable for its citizens, health must be at the top of the agenda. It requires courage, commitment, and persistence. We are concerned about inequality around the world and obesigenic cities – we know that we can do something positive about both.” In a later conversation with a Novo Nordisk employee who spends time in the Greater Philadelphia area, we learned that Mr. Nutter puts his money where his mouth is; he is frequently seen out and about in the community speaking to people, trying to learn about their unmet needs. We need more mayors like this!

• Mr. Nutter pointed out that there has been a shift in the paradigm of social and health governance from nation-states to cities – as demonstrated by recent conversations he’s had with mayors across the country. “I can assure you as I talk to numerous mayors across the US, notwithstanding an announcement from the president with respect to the Paris agreement, virtually no mayor across the country is paying any attention. Mayors and cities will continue to pave the way to make sure we have a better and safer climate to turn over to our children.”

5. Kelly Close: “What if We Don’t Have to Invent Solutions From Scratch?”… Enter the Anthology of Bright Spots

Highlighting The diaTribe Foundation’s Anthology of Bright Spots, our very own Ms. Kelly Close asked the simple question: “What if we don’t have to invent solutions from scratch?” She followed with an overview of some of the interventions that are working, and called on attendees to devote as much scientific rigor to the questions of “what is working? How can we scale it?” as we do to questions of “does it work? Why or why not?” Download her slides here. The concept of bright spots was pervasive throughout the whole Summit, as the organizers hope that non-participating cities will see the ROI and benefits in the pilot cities and apply the interventions in their own communities. The Anthology of Bright Spots, now in beta – authored by a team from The diaTribe Foundation’s led by Ben Pallant and Amelia Dmowska – details >50 scalable and investable successes that already exist in the areas of prevention, workplace wellness, and healthcare teams of the future, stemming from nearly 100 interviews and just under 1,000 hours of collective work over the last 12 months. We hope the search for programs that are already working results in greater levels of awareness that success is possible, greater investment, and ultimately translation/scaling.

• Ms. Close specifically discussed the Durham Diabetes Coalition (DDC) – a partnership between Duke University, the Durham County Department of Health, and a number of local medical centers and community partners. The DDC took claims info and health records from the partner medical centers, and analyzed this data to create highly-detailed mappings of diabetes risk and the community factors that contribute to it. They used this information to design community health interventions at the neighborhood level and then deployed teams of community health workers to put it into action. They paired this with a clinical team to connect people with diabetes to existing community resources, and even to deliver home care to the very highest-risk individuals. And then, to round it out, they created a “Diabetes Food Pantry” so that their interventions could be actionable for people in the community. In 2013, the DDC entered the scaling phase: With a CMS Innovation Grant and funding from the Bristol-Myers Squib Foundation, it became part of the Southeastern Diabetes Initiative, a three-year effort to compare and coordinate best practices across similar interventions in three different states. The CMS grant predicted a two-to-one cost savings from the initiative. Unfortunately, the grant ended in 2016, the initiative entered what Ms. Close called “program purgatory,” and we eagerly await publication.
• For cities where neighborhood-level disparities aren’t a huge challenge, Ms. Close suggested that major universities and large employers institute the Healthy Beverage Program. Dr. Laura Schmidt pioneered these efforts at her home university, UCSF, where you can no longer find ANY soda sold on campus. Preliminary data suggests there has been 20+% reduction in consumption so far, which has even trickled over to employee/student consumption when they are at home
• Other bright spots include “Agitas Sao Paolo,” “Faithful Families Eating Smart and Moving More,” and “Sunday Streets” in Houston. “Sunday Streets,” where selected roads are blocked in Houston for walking, biking, and other activities, has even now received support from Cigna!
• Notably, many in the audience didn’t realize how far we’ve come in pharmaceutical development. Ms. Close emphasized that this is a transformative time in science and technology and polled the audience: “How any of you know that there are major diabetes medications that reduce the risk of heart disease? Kidney disease? Severe hypoglycemia?” With each question, fewer hands went up … and from a low base. Although many protested to her afterward that “this is not a clinical meeting,” she felt it important to explain the successes in science, particularly if we have any hope of reaching the very ambitious goals set by the Cities Changing Diabetes communities – particularly “no more” than 1 in 10 people with diabetes in any country and a 25% reduction in obesity. She emphasized that an incredible sum of money will be needed to come close to either goal and this funding must come at least in part by countries globally spending less on heart attacks, strokes, kidney disease, and severe hypoglcyemia (the “fatal four” she coined them).  As a community, she implored, we need to do a better job of communicating just how far the science and technology have come – and then executing on this, and putting a major focus on improving access to therapies (especially GLP-1 and SGLT-2s, although she did not specify them) and better technologies (especially CGM, particularly exploration of CGM in diabetes diagnosis and prevention). Many providers, including those who teach young clinicians, came up in the age of “metformin until it fails, then throw your hands up in the air.” The landscape couldn’t look more different today, Close concluded, and though not the primary focus of her remarks, it may have been the most practical.

6. NN CEO Inspires Confidence with DIgital Health Comments in Close Concerns Interview

Novo Nordisk CEO Mr. Lars Jørgensen reinforced in an interview with our team (our first face-to-face meeting) his company’s commitment to digital health. His enthusiasm was measured, but he was eager to tell us about Novo Nordisk’s strategy to conduct pilots to ensure that any deployed technology keeps the human at the center – “too often we focus too much on what technology can do, and don’t focus enough on the patient.” For example, referring to the connected pen pilot in Sweden, Mr. Jørgensen stressed the importance of avoiding a scenario in which providers shame patients for missing a dose (or not taking the right dose). Certainly, new technology – especially that gives a window into patient’s personal lives – calls for extensive provider education. We wonder how Novo Nordisk is approaching this on the ground, how patient and provider feedback has been thus far, and when the pilot will expand. Regardless, hearing this sort of iterative, patient-centered device thinking from the head of a large pharma company inspires confidence. Longer term, Mr. Jørgensen looks forward to the opportunity to collect more data and deploy sophisticated predictive analytics, but again he emphasized that the patient and provider perspectives can’t be lost in the technological fray. We were impressed by the technology chops of other Novo Nordisk high-ups in separate conversations: very impressive new EVP Ms. Camilla Sylvester responded that “we can’t afford to leave anything unexplored” when we asked about deploying CGM in China, and VP Mr. Niels Lund mused on the implications of accuracy in insulin dose capture. We got a look at the company’s vision for the future of digital health at the recent HITLAB Symposium, when VP of US Device Research Thomas Miller shared Novo Nordisk’s compelling future vision of digital health-enabled insulin delivery. Watch the cool 90-second video here (55:40-57:16).

7. CCD Cities Face Unique Challenges –E.g. Diverse, Geographically-Distributed Vancouver; Growing, aging Rome

We enjoyed learning about the unique challenges faced by the Cities Changing Diabetes coalitions in different cities, especially Vancouver, Rome, and Johannesburg. As part of the first phase of Cities Changing Diabetes, participating cities were asked to map and assess the problem, which is a big first step (particularly when it comes to driving smart investment). It reveals where the biggest areas of unmet need lie and what might be the biggest obesity- and diabetes-causing factors. One takeaway may be that generalizability is low – that is, that an intervention that works in one geography won’t work in another. But we’d argue that while each city has its differences, there’s also a lot of overlap, and programs can be tailored to meet a specific community’s needs. We could imagine the formation of “twin cities” or “cohort cities,” where cities that have a lot in common at baseline form sub-committees where they can frequently exchange thoughts about what is working.

• Vancouver, the first city to pilot the Urban Diabetes Risk Assessment, has a very large minority population (11% south Asian; 30% east and south east Asian), a growing immigrant population, a high cost of living, a prominent homeless population (+ mental illness and drug use), and a large urban indigenous population (2.3%) that has a high prevalence of diabetes. Overall, 10% of people live with diabetes, of which 25% are not diagnosed. Prevalence is not homogeneous: On the wealthy and most walkable west side, prevalence is 5%. But there is a west-to-east gradient of increasing prevalence (which also correlates with decreasing income) – South Vancouver, which has a high proportion of south Asians, and the northeast of the city, which has the highest population of indigenous people, face much higher rates (10+%). The program coordinators in Vancouver therefore must figure out how to access and engage these very diverse microcosms within a large city – we might suggest an extension program (“Communities Changing Diabetes”?), engaging local leaders to ensure that needs are met.
• Rome is faced with a skyrocketing population that is highly enriched with elderly people. In the last 50-60 years, the population has doubled. There are a large number of people over 64 years old, 28.4% of which live alone. In the past 8-10 years, diabetes has increased 8-10%. Surprisingly, researchers found no significant correlation between age index (a measure of the age structure of the population) and diabetes prevalence, but did find relationships between prevalence and education level, unemployment rate, use of private transportation, and sustainability/mobility rate. Notably, diabetes-related mortality has decreased over time, though this is possibly an artifact of increased diagnosis – a larger denominator, enriched for “healthier” people.
• In Johannesburg, women are at much higher risk than males, there is significant ethnic diversity (and variability in diabetes prevalence), and poor diet is a major risk factor.

8. Tour of Two CCD Sites in Houston – HOPE Community Clinic and Institute of Spirituality and Health

Upon arriving in Houston, our team got to put on our “investigative journalism” hats as we toured two of Cities Changing Diabetes’ partner sites – two local organizations that are helping to spearhead the efforts on the ground. At HOPE Clinic and The Institute for Spiritual and Health at the Texas Medical Center, we had the opportunity to speak with upbeat, smart, devoted members of the Houston community who are venturing outside the clinic to meet people where they are. We also had the opportunity to interview people with diabetes at both institutions, who expressed gratitude for the work being done for them and others in their own backyards.

• HOPE Community Clinic gave us a first-hand look at the on-the-ground efforts in a low-income, ethnically-diverse neighborhood. We were absolutely floored when we stepped through the doors and some of the first words out of our host’s mouth were, “we speak 29 languages internally; 70 different dialects” (we confirmed that this language capacity is pretty much unprecedented). This is just the tip of the iceberg that is the staff meeting patients where they are, catering to “those that are forgotten” and who may or may not have health insurance. The clinic has received $3-$4 million in grant money, partially from the federal government, allowing it to drastically reduce costs – for example charging ~$20 for a mammogram, pap smear, and HPV test, when mammography alone typically costs upwards of $300. But the healthcare extends well beyond the clinic’s four walls, which was abundantly clear to us when the Director concluded her toast over lunch with: “We don't want to treat more diabetes, we want to invest more in preventative care.” We can assure you their money is where their mouths are: An outreach specialist told us of efforts to reach out to people in the community instead of waiting for them to come in for an evaluation; of a grant to build initiative and community awareness about how to work with policymakers to address issues of walkability, poverty, appropriate lighting at night, of food access; of a Saturday program for staff to go explore the local community – incentivized by time shaved off week work hours; of a 70,o00 square-foot facility recently purchased up the street that will be designed to “lead by example” with an exercise track, lighting, a healthy kitchen, etc.; and of an outreach department that runs information campaigns, provides resources to the community (toothbrushes, vaccines), and is currently gearing up to assist with open enrollment.
  
  • The staff “data geek” (their term, not ours) told us that 9.9% (1,400 people) of the treated population has diabetes (including gestational) or prediabetes. We followed up by asking how much of the cost these patients contribute to the system, but were only given an estimate: “Probably, a lot.” According to the clinic director, everyone gets an A1c screening when they first walk through the door for their free consultation – she notes that there is a lot more diabetes in Asian and Latino populations, due to a litany of cultural, biological, and socioeconomic factors. Anecdotes include Asian parents saying “oh he’s just a little chunky” upon being told that their child has prediabetes, a Latino man who “didn’t prioritize” his diabetes (meanwhile his blood glucose was 500 mg/dl), and Cubans and Colombians who gained 40-50 pounds in their first three months in the US. The director also indicated that when the clinic first started, the diabetes population was actually in very good control – A1cs were on average around 7%. However, the Affordable Care Act opened the doors to the sickest people (patients privately-insured before ACA: 4%; Now: 26%), so in the past two years diabetes prevalence has climbed and percent at target have gone down. Of course, even though the numbers look worse, it’s a positive that people who need care are getting it.
    • HOPE doesn’t use professional CGM – in fact the Director didn’t even know the abbreviation “CGM.” Even the rather cheap Abbott Libre Pro, she said, is probably too expensive. We were disappointed but not wholly surprised to hear this, though we see this population as perfect candidates for intermittent CGM, which could open eyes to the effects of certain behaviors and help providers titrate therapy. Would the federal government designate grant money for professional CGM? How about a philanthropic organization? We imagine that costs would be decreased on the back end thanks to the up-front investment. The same goes for pricey drugs – GLP-1 agonists, SGLT-2 inhibitors, GLP-1 agonist/basal insulin combinations – which would surely boost outcomes and lower cost.
  • We spoke to numerous patients of all ethnic backgrounds and with wildly different stories. A middle-aged Iranian man said that type 2 diagnosis “took him like a storm.” He used to play soccer, but then after getting his knee surgically repaired, could no longer compete. Still, he seemed upbeat, and he actually finds Houston pretty walkable and that healthy foods are easy to get. He didn’t seem to pay much attention to his diabetes – he takes his metformin but doesn’t test, and he doesn’t take advantage of HOPE clinic’s offerings. A petite American woman of similar age was a different story – she found a psychiatrist at HOPE that took Medicare, and has since taken classes on stress management, relaxation, and diabetes education. “They’ve put things into my life which I really didn’t expect to have put I my life. It’s a step up from care I’ve had previously. From the first time I came in, I got a feeling that this place serves a community. I got a feeling that this is awesome.” Notably, she loves to walk, but finds that Houston doesn’t make it easy – in our limited experience, we agree. Crosswalk lights didn’t always work, sidewalks were uncomfortably close to traffic, streets were very wide, etc.
• The Institute of Spirituality and Health at UT Medical Center aims to bridge the gap between spiritual identity/practice and health/wellness. We had an opportunity to sit down with VP Mr. Stuart Nelson and a number of community actors to learn about their specific toolbox. Mr. Nelson and other leaders (including Dr. Stephen Linder) are training teams of two in diabetes 101, religious studies, leadership, prevention, and evaluation/outcomes measurement, with hopes they’ll take the learning back to their congregations. From our discussions, two advantages of addressing the epidemic in a faith-based context surfaced: (i) Places of worship provide a home, where people care about each other; (ii) Religion is a strong belief system that can be leveraged to modify human behavior.
  
  • (i) A preacher from a local church spoke about the “A Better We, a Better Me” initiative, where her pastor asked healthcare professionals in the community to identify themselves. He then interviewed them about their specialties (mental health, diabetes, internal medicine, diet, etc.), one-on-one, in front of the Sunday morning service – “rather than preach from the pulpit and watch us die, he gave us an avenue to find health.” This simple act did wonders to elevate the dialogue surrounding health in the church. As a result, when people came forward with health conditions, they were directed to a member of the community who could help – no small thing considering every local at the table had had a negative experience with healthcare providers. “These people give advice – they care about me, love me, and I love them, I’m comfortable. They come over to me in church and say, ‘you don’t look good, we need to talk.’ Those who love god love me enough to help me take control of my life. At the doctor’s, they give information, but they don’t check in. Doctor’s now call me.”
  • (ii) An ER doctor-turned-pastor explained his efforts to help people live “bible-based health lives.” For example, he’ll give his congregations scriptures that have to do with salt in order to encourage diminished intake. “They’ll be better warriors for Christ if they’re physically fit.” We asked him afterward how long it takes to see behavior change, and he replied, “pretty immediately.” We’d love to see outcomes, but understand the logic – if someone is completely devoted to religion, then there’s probably little they wouldn’t do in the name of that religion. Of course, even if >50% of the Houston population regularly attends a religious service (as Mr. Nelson indicated at the meeting’s outset), a much smaller proportion of them are likely aiming to be “warriors for Christ” or the equivalent. How do you reach the others? Probably through (i) above.

9. A Lesson from Gehl Architects on the Connection between Urban Design and Behavior

The potency with which urban design influences behavior (for better or for worse) was a resounding theme throughout the summit, and we were fortunate to attend an interactive workshop with experts from architecture firm Gehl on how the built environment connects to quality of life. Gehl’s Mr. Jeff Risom led groups on a short walking tour of Houston, asking us to observe both public life (number of people, gender and age split, what activities they’re engaged in, etc.) and public space (sensory experiences, perceived sense of safety, aesthetic quality, etc.) in a number of sites surrounding the conference center. Armed with Gehl’s amazing Field Guide for Studying Public Life and Public Space, which elaborates on these variables in-depth, our eyes were opened to the sheer complexity of the built environment – and, in the case of Houston, how much opportunity exists for more person-centered design choices in urban planning. The sites we toured exemplified precisely the qualities that make spaces uninviting to pedestrians: close proximity to traffic, street noise, lack of aesthetic stimulation, no places to comfortably sit, and in one case, an extremely dangerous intersection with poor crosswalks and a broken traffic light. Despite sidewalks and some slivers of green space (oft-cited factors believed to promote walkability), it was clear that these spaces are unlikely to nudge residents into a more active lifestyle. Mr. Risom characterized this as a distinction between “hardware and software” – that is, physical features of the built environment vs. “life in between” and the way people actually use these things. To this end, he elaborated that putting in more crosswalks doesn’t necessarily ensure that people will use them, emphasizing that these kinds of urban planning decisions should be made more intentionally. To be sure, creating a healthier built environment cannot be a matter of “checking a box” for a policymaker. Urban planning has to take health and human behavior into consideration at every step. Rather than designing a space and having people mold their behavior around its constraints, Ms. Risom offered a hopeful vision of urban planning that operates in the opposite direction, identifying the kinds of behaviors and interactions that we want to promote, and shaping spaces around this. We hope this new way of thinking spurs city governments to more deeply consider the ways spaces are being used and where there is opportunity for improvements to the built environment that will nudge communities into a healthier and more active lifestyle. It has not escaped our notice that design choices that promote greater physical activity also tend to be more environmentally-friendly and foster a greater sense of community – a triple win. 

10. Progress Takes Patience – How Can We Best Measure CCD Success in the Short Term?

A key theme emerging from the summit was that no great prevention program – not even the best – will yield results right away. In fact, on the interactive iPads, graphs didn’t show any downward trajectory for diabetes prevalence until 2025, which is seven years away. Many current mayors will be out of office by then. Political priorities could shift. This has notoriously been a problem in getting policymakers to take a stand on matters of public health, and it reflects a dilemma we hear about often in diabetes care, in that hyperglycemia hurts long-term (micro and macrovascular complications, reduced life expectancy, etc.), but eating well and exercising feel more burdensome short-term. In a similar vein, communities may realize that lowering soda consumption will benefit public health in the long run, but people can still be biased against a sugar-sweetened beverage tax that’s going to hurt their wallets (and maybe their egos) more imminently. Mr. Lund shared some hope on this front: While it is too early to see an impact on population-level health from the existing CCD participants, he described how qualitative interviews have found that policy change is taking place and is setting improvements in motion. Still, we’d love a list of quantitative metrics that can be measured short-term to gauge early progress, as this could be instrumental in maintaining political will and investment from various healthcare stakeholders. Perhaps public surveys, showing satisfaction with more bike lanes in a city or with more convenient/healthy grocery stores, could help sustain and refine citywide initiatives over time. We’ll have to watch closely for this in the years ahead – Mr. Lund even admitted that statistically, CCD will eventually experience a scenario where a new mayor is less motivated than his/her predecessor to bend the diabetes curve, and that will require some troubleshooting. We hope for more insights on this at a future Cities Changing Diabetes summit as well.

11. Interactive Fair Showcases Diabetes Prevention Projects from Eight Cities

A fantastic interactive fair featured exhibits for eight diverse cities in the Cities Changing Diabetes program, showcasing the unique ways each is working to “bend the diabetes curve.” We appreciated this intriguing glimpse at the unique approach each city has taken, and were filled with hope by the multitude of potential diabetes prevention interventions – from doctors visiting patients’ homes in Mexico City, to peer-to-peer mentorship programs in Copenhagen, to leveraging communities of faith as a site for diabetes self-management education programs in Houston, to systemic efforts to train PCPs in diabetes care in Shanghai and Tianjin, just to name a few. Below, we outline learnings from each of these citywide projects.

• Houston: The host city unveiled three impressive interventions: (i) the Faith & Diabetes Initiative, (ii) the Houston Diabetes Resource Center (HDRC), and (iii) the Employer Diabetes Prevention Program. The Faith & Diabetes Initiative will train 30 faith leaders from 15 different places of worship across Houston in a diabetes self-management education curriculum beginning in January 2018. Given that 80% of Houstonians are religious and 50% regularly attend religious services, faith-based organizations represent a promising access point for diabetes education (plus, these congregations have a culture of community engagement and social cohesion already built-in). To complement these educational efforts in an even more broad-reaching way, the HDRC web portal provides diabetes information geared toward patients and providers alike. Finally, the Employer Diabetes Prevention Program aims to increase the availability of the CDC’s Diabetes Prevention Program in workplace settings across the Houston area. A task force consisting of public and private employers, insurance companies, insurance brokers, health systems, and DPP providers convened for a two-day conference, and devised six pilot DPP employer programs to be launched in 1Q18. If successful, the program has the potential to expand statewide (and wouldn’t this be absolutely amazing for Texas?).
• Mexico City:“El Médico en Tu Casa” promotes care for vulnerable and underserved populations by bringing HCPs directly into people’s homes. The program was first introduced in 2014 with a focus on pregnancy and care for the elderly, but has been expanded in scope based on CCD’s research, and now additionally tackles type 2 diabetes. The promise of this program lies in its ability to circumvent common barriers to diabetes care in Mexico City – namely, the cost and time of commuting to a doctor’s office, or in some cases physical inability to do so. Moreover, El Médico en Tu Casa has the potential to foster relationship-building between HCPs and people with diabetes, and by seeing a glimpse into patients’ home lives, providers can better understand how to help them manage the unique challenges of diabetes.
• Shanghai: The city has focused on strengthening local-level diabetes care by (i) equipping community health centers with the capacity for diabetes screening and (ii) training HCPs to better support people with diabetes. To-date, 195 of the 241 participating Shanghai community health centers have implemented diabetes screening programs. As a result, more than 150,000 Shanghai residents have been screened for diabetes since the implementation of this program in 2015, yielding 17,000 diabetes diagnoses and 23,000 prediabetes diagnoses – remember, these are cases that would have gone undiagnosed otherwise, in all likelihood. Novo Nordisk EVP Ms. Camilla Sylvest even cited this as a key diabetes challenge in China, that people are much further along in their disease progression by the time of diagnosis compared to patients in the US or Europe. We hope Shanghai’s program has increased awareness of diabetes in the community as well, even for those not diagnosed. These community health centers have additionally trained 1,531 HCPs in strategies to better empathize with and support people with diabetes. Shanghai’s next step is to expand screening capacity at these community health centers to also encompass diabetes complications.
• Tianjin: The goal here is to reimagine the city’s community health centers as hubs for diabetes care. Nearly 45% of people with diabetes remain undiagnosed in Tianjin, and most citizens seek medical care in overstretched hospitals due to a longstanding lack of trust in primary care physicians. To change this paradigm, Tianjin has implemented 30 training centers throughout the city, with the goal of training one or two “Chief GPs” who are experts in the diagnosis and management of diabetes for each primary care clinic in the city. Over the long term, this project could have the three-fold impact of (i) rebuilding trust in PCPs, (ii) putting patients in contact with providers with deep expertise in diabetes, and (iii) easing the burden on hospital systems.
• Copenhagen: As part of the larger Copenhagen Diabetes Action Plan, the city is piloting a community-based peer mentorship program aimed at empowering lasting lifestyle changes in the city’s most high-risk populations. The first pilot was launched in May 2017, enrolling 100 people from a population in Copenhagen with particularly high diabetes prevalence: men >45 who are unemployed and have a limited social network. This iteration of the program has a particular emphasis on cooking skills and healthy eating, but the city hopes to scale the project to address different vulnerable populations with their own unique needs. If successful, Copenhagen aspires to integrate these peer-to-peer support groups as a component of the city’s standard health offerings. 
• Johannesburg: Since joining Cities Changing Diabetes in 2016, the city has embarked on quantitative research to map the burden of diabetes and its comorbidities across the city. The aim of this project is to understand the principal drivers for diabetes in the city and to gain a sense of which ones are most addressable – a challenging task in a city characterized by rapid population growth, rising inequality, high unemployment, housing shortages, and inadequate healthcare provisions. Key learnings thus far include the need for greater diabetes screening, as well as increased education about diabetes and obesity at the community level. To this end, a majority of the people surveyed in this analysis felt that they eat well and exercise adequately, and yet 66% had overweight/obesity (37% had obesity).
• Rome: To increase physical activity among its citizens, a team mapped out 38 walking routes throughout the city. Taking advantage of the city’s rich history and beautiful monuments, these walking routes – which cover ~162 miles – are designed with sightseeing and safety in mind.
• Vancouver: Already named one of the top 10 healthiest cities, Vancouver is committed to pushing the needle even further with the ambitious goal of getting walking, cycling, and public transit to account for 50% of all trips by 2020, and for 66% by 2040. To meet this target, Vancouver has long-term policy plans that include making more efficient use of road space, building “complete communities” with essentials within walking distance to shorten trips, and designing urban spaces for people of all ages and abilities. We were extremely impressed to learn that Vancouver has in fact already met the 50% target (far ahead of the 2020 schedule!). There is an enormous amount to learn from this city’s success, and Vancouver represents a true bright spot in health-promoting policy work.

Close Concerns Questions

Q: Who’s next? We were thrilled to hear that two new cities from China, Hangzhou and Beijing, are joining Cities Changing Diabetes (with a combined population upwards of 30 million). Now, we’re itching to know the other two cities lined-up, and we’ve love to learn who else around the world and in the US is a contender.

Q: Of the current CCD participants, which city has achieved the best outcomes so far? Who has generated the most data to-date (in this very short time)? What’s the most impressive data we have to show, and could this be used to sway other cities into action, maybe even other unlikely cities? Where is the most transferable learning?

Q: How are cost-savings being recorded and quantified? What are the key municipal finance learnings?

Q: What key elements are needed to convince non-pilot cities to start mirroring the success stories? What are the biggest points of resistance from local politicians?

Q: How much has each city invested in acting to bend the local diabetes curve? How does this compare to Novo Nordisk’s investment in each city?

Q: Which city might benefit the most from extra funding?

Q: What metrics can be used to define “success” in a relatively short term? What do local politicians care about in evaluating a public health initiative?

Q: Do most mayors around the US buy into the idea that diabetes and obesity constitute an epidemic? Is there still a knowledge gap, and how big? How many mayors feel responsibility to act on these public health problems?

Q: What does a city need in its infrastructure to get a program off the ground? What are the biggest barriers?

Q: Have there been any false starts? What obstacles get in the way, between a local policymaker being inspired to take action against diabetes and a prevention program actually taking root?

Q: Who have been the greatest champions of CCD to-date? We’re always eager to hear about impactful leaders. How do we get more bright people engaged in this movement?

Q: What’s the role of impact investing in Cities Changing Diabetes?

-- by Abigail Dove, Brian Levine, Payal Marathe, and Kelly Close