Introduction: Globalization and the Non‐communicable Disease Epidemic

A new World Health Organization (WHO)1 report, Preventing Chronic Diseases: A Vital Investment (1), shows that non-communicable diseases (NCDs) dominated by diabetes are causing double the deaths that are caused by infectious diseases, maternal/perinatal conditions, and malnutrition combined. The report states that without action, 388 million people globally will die from chronic diseases like diabetes and heart disease in the next decade. It is against this background that we are facing a global threat from the spectacular rise in the global prevalence of type 2 diabetes and obesity and their consequences (2). In terms of diabetes, the number of cases has reached pandemic proportions and will continue to increase sharply. The International Diabetes Institute prepared the data for the International Diabetes Federation's Diabetes Atlas 2003 report (3), which predicted that the number of people with diabetes will almost double within just one generation, from the present 190 million to 335 million in 2025. The linkage between obesity and type 2 diabetes is very strong, in fact, so strong that the term diabesity is being used frequently to better describe the current twin epidemic (2). Unfortunately, most nations are poorly prepared to tackle this twin epidemic effectively. Governments remain largely unaware of, or are complacent about, the existing magnitude of the NCD challenge. More important is the fact that they ignore the future increases in obesity and diabetes and their serious complications such as cardiovascular disease (CVD). Failure to act now on the direct costs of healthcare and the indirect costs from loss of productivity and from premature morbidity and mortality is very likely to cripple the health budgets of many nations, both developing and developed. With this major international challenge in mind, in May 2005, the Monash University-affiliated International Diabetes Institute, in conjunction with the Monash University Institute of Global Movements and the United Kingdom-based Nuffield Trust, held a meeting of 25 leading world experts from a number of disciplines at the Nuffield Trust headquarters in London. The objective of the meeting was to assess the impact of globalization on health in both developed and developing countries with respect to NCDs such as CVD, diabetes, and obesity. The London conference focused on how the world has come by a chronic disease health calamity that rivals or even exceeds the emergence or reemergence of devastating communicable diseases including severe acute respiratory syndrome (SARS), acquired immune deficiency syndrome (AIDS), the Ebola virus, and our old enemy, tuberculosis (4). While governments around the world are busy preparing for an avian influenza pandemic, they ignore the equally insidious threat of diabetes and other NCDs! In the brief period of several decades, many developing nations are faced with a double burden of communicable diseases and NCDs, placing enormous pressure for solutions on WHO and other international and regional non-governmental agencies. The NCD burden has now become one of the major threats to human health in the 21st century (1,4). A report on the London meeting's discussions and conclusions is published in this issue of Obesity. Globalization of the world economy has become a fashionable subject for the international economic community. We are constantly reminded that we are all members of the global village, but this means very little to people in areas subject to natural disasters and in sites of major political tension and poverty. In fact, globalization may afford a weak disguise for a movement that attempts to integrate developing nations into the Western socioeconomic and health care models. This scenario was one of the recommendations of a World Bank report a decade ago (5). Many in the public health arena felt very strongly that this strategy was quite inappropriate for most developing nations. We could have hoped for improved health outcomes in many developing nations after so many years of public health research. Unfortunately, in most instances, the research findings have not been translated into improved health outcomes. There are no better examples than those of obesity and type 2 diabetes (2,4). They are epidemic in the peoples of many developing nations and in the economically disenfranchised minorities of many developed countries including the United States, Canada, and Australia (2,4). Globalization does not apply just to economic change but also to the human diet and lifestyle (4). So, tragically, the diabesity epidemic is linked to the socioeconomic revolution and its impact on the traditional way of life, including nutritional and physical activity patterns. This means that the solution, that is, the prevention and control of these NCDs, is not entirely in the hands of individuals and the medical community. It is, as stated by the 1999 WHO report, a major responsibility of public and social planners, private enterprise, economists, and politicians (6). We might ask that, given the rather poor record of implementation of a whole chain of international agreements and declarations, can we trust them to meet the NCD challenge? From a historical perspective, until the latter part of the 19th century, the main causes of morbidity and mortality in all countries of the world have been epidemics of communicable diseases including typhoid, cholera, smallpox, diphtheria, and influenza (4). Although some of these diseases remain epidemic in Third World countries, industrialization and progressive modernization of many communities have resulted in major improvements in housing, sanitation, water supply, and nutrition. The discovery and availability of antibiotics and vaccines have radically changed the profile of diseases, initially in developed countries and later in many developing countries. Consequently, these improvements in public health have led to dramatic reductions in mortality from infectious diseases. Paradoxically, there has been a remarkable increase in the prevalence of risk factors for NCDs such as type 2 diabetes, CVD, hypertension, and strokes. These diseases have become major contributors to morbidity and mortality along with certain cancers. This new health paradigm needs to be understood in the light of the phenomenon described as epidemiological transition (7). In his book “The Call Girls,” the late Arthur Koestler coined the term “Coca-colonization” to describe the impact of the Western way-of-life on developing countries (8). The devastating results of Western intrusion into the lives of traditional-living indigenous communities can now be seen from the jungles of Brazil to the remote and idyllic atolls of the Pacific Ocean. Quite apart from the socioeconomic aspect, the health impact is disastrous; there are epidemic rates in most Pacific Island populations, where type 2 diabetes now affects up to 30% of adults, whereas, before World War II, it was virtually unknown (9,10). This picture is mirrored in disadvantaged communities in developed nations, e.g., Native Americans, African Americans, and Mexican Americans in the U.S., Native Canadians, Australian Aborigines, and Torres Strait islanders, and in the Maori community in New Zealand. Although the global NCD epidemic has become a matter of enormous concern to public health authorities in both developed and developing nations and WHO, the resources applied to meet this challenge are miniscule; for example, the WHO budget is less than 5%. Globally, type 2 diabetes accounts for more than 90% of all cases of diabetes. Type 1 (insulin-dependent) diabetes is relatively uncommon in many populations, particularly Asian, Middle Eastern, the Pacific Islands, and African. Not only is the prevalence of type 2 diabetes increasing, but the age of onset is becoming younger with an increasing number of children and adolescents now being diagnosed (11). One of the factors driving the creation of the London meeting was the urgency to highlight the need for strategies to prevent the emerging global epidemic of diabesity and its cardiovascular consequences. Evidence-based interventions include lifestyle and behavioral change and tobacco control. The prevention and control of type 2 diabetes and the other major NCDs can be cost- and health-effective through an integrated (i.e., horizontal) approach to NCD disease prevention and control (12,13). The areas covered at the London globalization and health meeting at the Nuffield Trust included a wide range of issues, as discussed in the report of the meeting. The participants reached agreement that the NCD epidemic was already straining health budgets in developed countries, and the impact in developing countries could be disastrous, highlighting the need for a switch from treatment to prevention. It was also agreed that giving individuals good information on the health risks of overweight and obesity and how they could be avoided through proper diet and exercise had to be a principal component of an effective preventive strategy that alone was most unlikely significantly to reduce the expected continued rise in prevalence. More active intervention at governmental, and supragovernmental, levels was essential, and this meant governments ceasing to take what had often been the traditional stance that these matters had to be left to individual choice. There was an urgent need for economic analysis of the full health consequences of overweight and obesity and the cardiovascular consequences to see whether increased levels of investment on prevention now would lead to long-term savings. There is an immediate call for the international diabetes, obesity, and cardiovascular and public health communities to lobby and mobilize politicians, other international and regional agencies such as the United Nations Development Programme (UNDP), the United Nations Children's Fund (UNICEF), WHO, and the World Bank, and other international non-governmental agencies dealing with the NCDs to address the socioeconomic, behavioral, nutritional, and public health issues that have led to the NCD epidemic. A multidisciplinary approach by governments that involves multiple ministries such as health, finance, education, sports, and agriculture can all contribute to a reversal of the underlying socioeconomic causes of the problem. Coupled with cigarette smoking and alcohol abuse, the main constituents of what we call the metabolic syndrome or “The New World Syndrome,” including hypertension, obesity, and dyslipidemia, and type 2 diabetes with its devastating CVD complications will cause havoc. The socioeconomic cost through family disruption, loss to the work force, and premature mortality coupled with the public health burden on primary, secondary, and tertiary health care services in poor nations is already extracting a high economic toll. The world community has been very slow to react to the problem of the NCD epidemic and the urgent need to address the prevention issues. This has been further complicated by the recent reemergence of devastating communicable diseases mentioned earlier. The NCD explosion will not be prevented by diet and exercise alone! We need to see new imaginative strategies and major and dramatic changes in the socioeconomic and cultural status of people in developing countries and disadvantaged and minority groups in developed nations. Global concern about our ecosystem culminated with an international talk-fest, The United Nations Conference on Environment and Development in Rio de Janeiro in 1992. This resulted in The Rio Declaration on Environment and Development. The conference participants were particularly conscious of the much-feared impact of global warming on the future of humanity. The London participants concluded that there was an urgent need for a similar international meeting (e.g., a Kyoto Health) to consider the impact of globalization on health along the lines of meetings that have looked at the impact of globalization on the environment.

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