Cities Changing Diabetes / Cities for Better Health: Addressing the Urban Diabetes Epidemic 

Funder: Novo Nordisk (Denmark) 

Location: 47 cities globally including Copenhagen, Houston, Mexico City, Tianjin and Shanghai 

Themes: Urban health, diabetes, chronic disease, social vulnerability, health equity 

The Challenge:  

Type 2 diabetes poses an escalating public health threat in urban settings worldwide. The increasing prevalence of this chronic disease in cities is influenced by a complex interplay of factors, necessitating collaborative efforts across sectors to inform effective prevention and management approaches. Understanding the specific drivers of type 2 diabetes within diverse urban contexts, especially the social and cultural determinants that increase vulnerability, is crucial to addressing this epidemic. 

Project Details:  

Launched in 2014 by Novo Nordisk, Steno Diabetes Center Copenhagen, and University College London (UCL), the Cities Changing Diabetes initiative was built on the principle of co-production. This involved actively engaging community members, city governments, academic researchers, and people living with diabetes from the outset. UCL played a key role in providing academic leadership and developing the global study protocol. The initial phase of the program included five partner cities: Copenhagen, Houston, Mexico City, Shanghai, and Tianjin. In 2023, the program entered its next phase as Cities for Better Health, expanding its focus to encompass a broader range of urban health challenges, including childhood obesity, nutrition, and active living. This initiative aims to examine the growing impact of type 2 diabetes, and other urban health issues, in cities globally. To achieve this comprehensive understanding, UCL developed a global study protocol that combines quantitative and qualitative approaches to analyze the urban health burden and its underlying drivers. 

Methodology:  

The global study protocol developed by UCL employed a mixed-methods approach to gain a thorough understanding of diabetes in urban environments.  

Quantitative Analysis: This involved a “rule of halves” analysis to estimate the prevalence of diagnosed and undiagnosed diabetes within participating cities, providing a measure of the overall diabetes burden. A “rule of halves” analysis refers to estimating diabetes prevalence based on known data by repeatedly dividing the population in half. This type of analysis is a method to visualize and quantify the cascade of diabetes burden in a city by estimating the number of people at each stage: undiagnosed, diagnosed but not receiving care, receiving care but not achieving treatment targets, and those achieving targets but not optimal outcomes.  

Qualitative Vulnerability Assessments: In-depth assessments were conducted to identify the social and cultural determinants contributing to vulnerability to type 2 diabetes. This qualitative research involved gathering contextual data through methods such as individual interviews and focus group discussions with community members, including individuals living with or at risk of diabetes. These assessments aimed to explore lived experiences, social networks, cultural practices, and environmental factors that shape diabetes risk in diverse urban settings.  

For example, in Mexico City, data was collected from a sample of 2,500 adults and included detailed information on anthropometry and biomarkers for diabetes and lipidemia. A Diabetes Vulnerability Assessment in Mexico City consisted of 220 individual interviews with people diagnosed with type 2 diabetes. The assessment revealed that socioeconomic vulnerabilities are further exacerbated when individuals are unable to access healthcare services. Moreover, it brought attention to several barriers to care, including limited resources, lack of understanding, and lack of trust in institutions.  

The research protocol was initially implemented in five collaborating partner cities to identify groups at high risk of developing type 2 diabetes. The adoption of this UCL-designed protocol has since expanded to 47 partner cities globally. 

Findings:  

The Cities Changing Diabetes (CCD) / Cities for Better Health initiative has generated crucial insights into the drivers of type 2 diabetes in urban settings by integrating quantitative data on the diabetes burden with qualitative understandings of social and cultural vulnerabilities. This research informs the development of targeted and context-specific interventions and strategies to promote improved health outcomes in cities worldwide. 

• Elevated awareness of diabetes as a major public health challenge in urban areas. The initiative has successfully placed the issue on the agendas of city leaders and policymakers. 

• A strengthened multi-stakeholder approach to addressing diabetes. By fostering collaboration between diverse groups, the program has built capacity for collective action. 

• The development and implementation of over 100 interventions globally tailored to the unique contexts of participating cities. These interventions strategically target key areas such as food systems, physical activity promotion, educational initiatives, and innovative care delivery models, ensuring relevance and effectiveness for the specific populations they serve. In Mexico, for example, based on the research findings, policymakers have introduced the El Médico en tu Casa initiative. This program focuses on conducting diabetes screenings in people’s homes, with the goal of increasing the rates of diagnosis and offering support to those who are at high risk. 

• The project has facilitated thorough local vulnerability mapping and research in 47 cities, providing vital insights into the specific drivers of diabetes within each unique urban context. 

• The rigorous research undertaken by Cities Changing Diabetes has yielded over 70 peer-reviewed outputs, including the development of novel vulnerability indices and insightful foodscape studies, contributing substantially to the scientific understanding of urban diabetes. 

• CCD’s evidence-based approach has driven notable policy wins at both national and municipal levels. Prominent examples include reforms in China, Mexico, and Denmark, where CCD research directly informed impactful legislative changes. 

• The sustained impact of CCD interventions is evident in long-term health gains. For instance, in districts like Tingbjerg, Copenhagen, a remarkable decrease in diabetes prevalence has been observed, bucking national upward trends and highlighting the potential for targeted urban interventions to bend the curve on chronic disease. 

Researchers (The Lived Experience Lab, University College London): 

• David Napier (Lead Investigator & Global Academic Lead) 

• Anna-Maria Volkmann (UCL Research Lead) 

Partners: 

• Novo Nordisk 

• Steno Diabetes Center