To mark World Diabetes Day 2024, we spoke with Elsa Morandat, WDF's Head of Policy and Programmes, about the impactful role of health promotion in diabetes prevention and well-being, and our collective responsibility to ensure healthier futures for the next generations.
13 November 2024 Andreea Enea
When it comes to tackling the global diabetes burden, prevention isn't just the best option—it's the only sustainable one.
That's the message at the heart of World Diabetes Day on 14 November, the world's largest diabetes awareness campaign reaching over 1 billion people in 160 countries. This year's theme, 'Diabetes and Well-being', resonates with our mission: we're dedicated to harnessing the power of prevention efforts to combat diabetes and its complications.
To mark this special day, we had an insightful dialogue with Elsa Morandat, WDF's Head of Policy and Programmes, on the meaningful role of health promotion in diabetes prevention and well-being – and the collective responsibility we all share in the mission to shape a healthier future for forthcoming generations.
We explore the barriers to health in low- and middle-income countries, and how multi-stakeholder and multisectoral partnerships are key in tackling the burden of diabetes and its complications.
The importance of disease prevention cannot be overstated. By improving the ability of the population to make healthier choices, the incidence of non-communicable diseases (NCDs) like diabetes can be significantly reduced, particularly important in low- and middle-income countries (LMICs). This involves enhancing the accessibility of healthy food options, creating a conducive environment for physical activities, and increasing opportunities for healthy pregnancies.
The impact of prevention is also profound. It nurtures individual well-being and cultivates a healthier society. It allows people to lead fulfilling lives, free from chronic illnesses. On a larger scale, prevention reduces healthcare costs, and its ripple effects extend far beyond health, touching every aspect of life.
That is why it requires a multi-level approach, with interventions that support people in making their own informed health decisions, improve access to healthy food and physical activities, and ensure the availability of a trained healthcare workforce delivering affordable screening and care.
At a systemic level, they strengthen the enabling policy environment and resources for NCD prevention.
However, prevention is a broad term.
The World Health Organization (WHO) distinguishes between disease prevention, which involves specific interventions for avoiding diseases and facilitating early detection – primarily a health sector responsibility –, and health promotion, which empowers individuals to manage health through multisectoral actions addressing broader health determinants.
'Health is more than just the absence of disease, it is a holistic concept that encompasses overall well-being. That's why prevention should be viewed more broadly as health promotion.', Elsa Morandat, WDF’s Head of Policy and Programmes, explains.
This perspective aligns with the Sustainable Development Goal target 3.4 to reduce premature mortality from NCDs and promote mental health and well-being – an aspiration of all societies.
Prevention is crucial also from an economic perspective. Many governments, especially those in low-resource countries where NCDs are on the rise and populations are ageing, struggle to shoulder the burden of healthcare costs.
'In these contexts, prevention isn't just a health strategy, it's a sound economic investment. It's about helping people live longer, and better lives.', adds Elsa.
The primary prevention projects supported by WDF emphasise promoting two key behaviours: healthy eating and physical activity, reflecting the broader emphasis on health promotion rather than solely focusing on diabetes prevention.
These behaviours also address risk factors for hypertension and other NCDs. 'That is why we say we do more than diabetes prevention; we do NCD prevention.'
In care-focused projects, primary prevention is carried out through culturally appropriate awareness activities. On the other hand, secondary prevention, an integral part of NCD care, focuses on reducing the risk of complications, including through nutritious diets and regular exercise. These behaviours not only help manage the condition better but also enhance the overall well-being of the individuals affected.
WDF’s prevention projects address societal and environmental factors contributing to diabetes, which is particularly crucial in low- and middle-income countries (LMICs). The focus on these factors highlights the systemic changes necessary for effective prevention.
At the same time, there are significant barriers that affect both people who are at risk and those living with NCDs that need to be acknowledged and addressed.
Access to affordable healthy food options, crucial for both care and prevention, presents another barrier. 'We cannot address that alone because it involves the food systems'. The complexities of these systems, which encompass everything from production and distribution to consumption and waste, not only affect the availability and affordability of nutritious food but also have significant implications for the livelihoods of those involved in the food supply chain.
LMICs in particular grapple with a significant global health challenge: the triple burden of malnutrition, which includes overnutrition, undernutrition, and micronutrient deficiencies. Physical inactivity further compounds this issue, leading to a high risk of developing diabetes or other NCDs.
Moreover, while the economic costs of inaction are significant, convincing policymakers remains challenging due to short mandates and limited resources. This asks for a long-term, multi-sectoral approach to be able to create health-promoting environments offering access to healthy food, safe spaces for physical activity, and affordable healthcare services.
Cultural barriers also exist, such as the consumption of traditional high-carbohydrate or high-sugar foods, stigmatising perceptions of illness and treatment, and language barriers. 'We often talk about addressing the socioeconomic determinants that play a significant role in the health outcomes of individuals – but this can be said about any other condition, not just diabetes'.
That is why the efforts towards universal health coverage and WHO’s Health in All Policies (HiAP) approach advocate for a holistic approach. 'Health is not just a concern that can be solely addressed by health ministries. It is a societal issue involving various sectors, including the food industry. All sectors must work together and align their policies to promote health and well-being for all.'
To address all these interconnected barriers to health and make a lasting difference in the health outcomes of those vulnerable to diabetes and related NCDs, interventions must address all levels - individual, organisational, and systemic. At the same time, it is crucial to adapt such interventions to the unique settings and challenges of each context.
'Our focus is on creating health-promoting environments that empower people to make healthier choices. We work with local partners to adopt a healthy-setting approach founded on community participation, partnership, and equity, using schools and health facility settings as entry points.'
A key requirement is multi-sectoral collaboration, extending beyond healthcare to include agriculture, food systems, and education. 'It is a whole-of-society approach'.
Secondly, health equity is vital. 'We cannot rely solely on individual willpower, especially in vulnerable settings where resources are very limited and people are more focused on making ends meet', Elsa remarks. 'People may adopt healthier behaviours but struggle to sustain them. It is a societal responsibility to create environments conducive to healthy behaviours. Governments play a crucial role in making systemic changes that promote and sustain healthy lifestyles.'.
Community involvement is another key aspect often overlooked. 'Instead of dictating what to do, we should recognise the skills and competencies of local communities. People are agents of change, but their environment must also be conducive to change.'. Access to healthier food and safe local spaces for physical activity are essential.
Cultural sensitivity is equally important, as a successful model in one community may not work in another. 'We need to understand health from a cultural perspective, integrating traditional health systems with western ones in a way that values diversity and inclusiveness.'. This involves adapting public health messages to resonate with diverse populations, even at the smallest scale, using culturally appropriate language and imagery that fit their context, working with local leaders and valuing their cultural beliefs.
While this holistic approach is also important in care, it is even more crucial in prevention because it requires all the different pieces of the puzzle, as seen above.
Prevention has been embedded in WDF’s work since its inception. For example, awareness-raising campaigns have been part of both diabetes care and prevention projects. While not typically behaviour-changing, WDF’s Head of Policy and Programmes stresses that 'awareness-raising campaigns are vital in upholding people’s right to access accurate health information'.
WDF-funded prevention projects target specific groups of people who are not yet patients, deeming it essential to address health determinants, risk factors, and health inequities, particularly during critical windows of opportunity for NCD prevention.
Pregnancy presents a unique opportunity for prevention. By promoting healthy pregnancies and managing Hyperglycemia in Pregnancy (HIP), prevention interventions not only strengthen the opportunities for pregnant women and their children to live a life free of diabetes and related NCDs, but also have the potential to create positive health impacts that can be passed down to future generations.
'We see the importance of integrating maternal health and early-life nutrition into our prevention strategy. The first 1,000 days from conception are crucial for long-term health benefits. By integrating maternal and child care with NCD prevention, we have a golden opportunity to provide preventive services for women and children visiting clinics, ensuring the best possible start in life.'
Childhood is another critical window for prevention. Past WDF reviews have highlighted the strong potential of school-based health promotion interventions and the added value of initiating preventive measures in childhood. Health and risk behaviour are strongly related to habits formed in childhood. Studies suggest that to maximise the effectiveness of these interventions, they should engage not only the children but also their parents and the larger community, adopting a whole school approach.
'By focusing on these critical stages of life, we aim to lay a strong foundation for healthier future generations', Elsa explains, ' and when these interventions lead to changes at a broader level, they can create a ripple effect that benefits other groups as well'.
In the podcast episode below, WDF’s Chair, Dr Anil Kapur, discusses pregnancy as a critical stage for prevention, and the impact of nutrition and healthy behaviours on the mother and child's lives.
Our partners implement projects that are locally formulated, owned, and tailored to the specific contexts of the communities they serve. These projects aim to promote overall health and well-being, with a focus on preventing NCDs and their complications.
For instance, promoting healthy eating and regular exercise not only improves physical health but also boosts mental well-being. Care projects focus on managing diabetes effectively to prevent complications. This includes promoting physical activity and healthy diets, which serve dual roles in both prevention and care by helping manage blood sugar levels.
Moreover, locally established patient support groups enhance mental health by reducing feelings of isolation and improving coping strategies. These efforts also serve to challenge societal norms, potentially leading to broader changes in lifestyle and overall health.
The theme for World Diabetes Day 2024-26 underscores the importance of physical, societal and mental well-being in relation to managing diabetes and preventing its onset and complications.
Next, we explore how health promotion interventions can synergistically address these aspects:
Food choices are deeply personal, complex, and often influenced by cultural and unconscious factors. This means that awareness campaigns alone may not change behaviour. However, by adopting a multi-setting approach and acknowledging these complexities, we can significantly increase the likelihood of successfully helping people make healthier choices and effectively manage their diabetes.
When it comes to food, our partners focus on school and community settings.
In schools, promoting healthy eating can involve updating the curriculum, but the priority is changing the offer on food.
'By providing healthy food for children, we are doing more than just promoting healthy eating – we are actively contributing to their health'. In community settings, our projects may promote community gardens and support people in using their small parcels of land to grow their own food, a practice that has been part of their lifestyle for a long time.
The challenges are different when it comes to promoting physical activity.
'In rural areas, children often walk long distances to go to school, so promoting exercise could be more relevant in urban areas. Cultural barriers also exist, such as families preferring their children to focus on studying rather than engaging in physical activities, and norms that discourage physical activity among pregnant women.', Elsa explains.
We find inspiration in stories like Tikaram’s that speak to the role of education and a healthy diet in managing diabetes and having a fulfilled life. Tikaram (70) lives in Pokhara, Nepal. 'I was living a carefree life before. After the diagnosis, I started eating healthy', he shares, looking at his family's vegetable garden. Moreover, he added yoga, brisk walks and dancing to his daily life. 'I had no idea how to dance, now I do it every day', he smiles. His active lifestyle and advice have not only motivated his family, including his son living with diabetes, to adopt healthier habits, but also his community where he is fondly referred to as the 'knowledgeable grandfather'. Tikaram was part of a WDF pilot training female community health volunteers in diabetes care and prevention in Nepal A scale-up launched this year to expand its positive outcomes.
Learn more about Tikaram’s story
Moving to Cambodia, where an ambitious project is taking root, targeting 150 schools and their communities to ensure healthy nutrition for children. This new project responds to the increased access to unhealthy foods in the country, which exacerbates the triple burden of malnutrition and the risk of NCDs in adulthood. The goal is to create sustainable health-enabling environments with the participation of everyone – parents, children, teachers, authorities, school food vendors. Building on a pilot that led to a school directive banning six categories of unhealthy foods and drinks, the scale-up also aims to connect local farming families with school food vendors. The key focus areas are the school environment, the communities' settings, and national policies to support healthier lifestyles and NCD prevention, including updated guidelines for antenatal care and HIP prevention.
See the full story of Cambodia's sprouts of change
Societal well-being depends on the active involvement of governments in health promotion efforts. However, the challenge lies in the competing priorities on their agenda. Yet, these efforts are not one-sided, as citizens too are creating demand for healthier products and lifestyles.
For those living in vulnerable settings, where their next meal is uncertain, mere instruction is insufficient.
As Elsa points out, 'We must enable a healthy environment for them.' This is where the need for Health in All Policies comes into play. High-level decisions profoundly impact individuals, and governments worldwide grapple with these decisions.
'To increase health equity, we need to shift our focus from individual to societal responsibility and make it easier for the most underserved to change their behaviour. This is the health-enabling environment we aim to foster.'.
Our partners' multi-setting intervention for healthy nutrition among adolescents and pregnant women in Cameroon illustrates this. It shifts from school-only efforts towards a holistic approach involving schools, health facilities, and communities. The project unites civil society, healthcare providers, academia, and the government – a key partner in sustaining the outcomes – to make systemic changes supporting healthier behaviours. It provides access to community gardens, offers tax incentives for vegetable vendors, regulates food labelling, and establishes water points and health clubs in schools. A focus is also on nutritional education in antenatal care clinics and monitoring women with HIP. By engaging communities in building such health-promoting environments, the well-being of children and pregnant women and their right to health can be protected.
Explore the story of change in Cameroon
Our partnership for the 2023 fundraiser empowering Lebanese and refugee children and youth through sports to prevent NCDs is another great example. In Beirut, where public spaces are scarce, GAME Lebanon has collaborated with municipalities, schools and the government to transform public spaces into GAME Zones. This project promotes well-being and a sense of belonging by ensuring access to free, safe public spaces to children and youth living in vulnerable settings, in major cities. Asmaa, one of the Playmakers who train the children, believes that sports are very important to them: 'They need to spend their energy and destress from studying or being bullied... They connect no matter their background and this reduces racism or prejudice.' Twelve Playmakers were also trained as Health Promotion Ambassadors to help educate more children on nutrition, empowering them to bring healthy habits to their communities.
Explore the story of our fundraiser in Lebanon
The aftermath of the COVID-19 pandemic has intensified the global focus on mental health, especially in relation to the prevention and management of NCDs. The importance of mental health is particularly evident in care projects.
In our projects enhancing diabetes management, peer support groups often play a crucial role. Patients meet, share their challenges, and exchange tips on healthy eating or even help each other with practical resources to manage their diabetes.
However, the issue extends beyond this. In certain cultures, individuals living with NCDs often face social stigma and discrimination. Managing such conditions can become burdensome, especially without an enabling environment that provides access to necessary medication, proper care, and social support.
We've seen many stories in the communities we serve that illustrate this (the names have been changed to protect the privacy).
Consider Mr Chandan with type 1 diabetes who, to avoid drawing attention to his condition at work, injects insulin over his shirt, compromising the effectiveness of his insulin delivery.
Or Mrs Rani, a member of the Bodo tribe in Assam. Despite suffering from diabetic neuropathy, she refuses to wear footwear due to cultural norms in her agrarian community, working barefoot in the paddy fields to avoid standing out.
Or Miss Pooja, a young girl with type 1 diabetes who was not allowed to bring her diabetes care essentials to an exam hall because the supervisor believed she could use them to cheat.
The same goes for protecting the mental well-being of children and youth with type 1 diabetes. Our partners in dedicated care projects often organise camps to provide a safe and accepting environment where young patients can connect with peers facing similar challenges, significantly reducing feelings of isolation and stigma. These camps offer experiential learning opportunities where children gain practical skills in diabetes management, boosting their confidence. They also teach the importance of physical activity and healthy eating through engaging activities and games for self-management. The camps offer support to their caretakers as well, which is often neglected.
'It was necessary to form an association. Why? So we could go and motivate our own,' says Luckson, a member of the diabetes self-support group at Chikombedzi Hospital, Zimbabwe. Composed solely of men, the group is challenging societal norms and breaking down barriers that delay men from seeking healthcare. They meet regularly, share information, and promote health education in their communities. 'If you are alone, it is painful. But if you have friends and colleagues, it is easier', Luckson adds, highlighting the importance of their unity. Their efforts have indeed led to improved health outcomes among them. More than that, the group is now a valuable resource for other men with diabetes. They advocate for acceptance, challenging the perception that a diagnosis means a shortened lifespan, in rural areas where such misconceptions are more harmful. The group was formed under a project to improve diabetes care in rural Zimbabwe, which was scaled up this year.
Follow their emotional journey here
In Georgia, diabetes care and education for children and youth with type 1 diabetes is a major issue. School staff often lack the expertise to manage diabetes and, for many children, regular travel to major cities for proper care is not accessible. Lack of education and support systems further complicates the caregivers' ability to manage the condition. Our 2024 fundraiser has stepped in, aiming to reach 1,500 children and youth across all Georgian regions through camps and digital education. The camps welcome children and their caregivers to cultivate a supportive and informed community. They offer them the chance to learn diabetes management skills and receive psychosocial support, fostering their well-being and sense of belonging. The project is also developing a digital education platform, co-created with families, parent organisations, and healthcare professionals.
Read more about the fundraiser in Georgia
Marshall Islands
Since 2010, our local partners, representing both the education and health sectors, have created sustainable change in a small country dealing with high rates of obesity and chronic diseases. Among the outcomes, the partnerships have challenged the food culture and influenced legislation on school food. This year, a WDF-supported scale-up was launched as a response to an urgent need to integrate physical exercise and nutrition literacy into the national school system and broader communities.
Challenging the food culture in Marshall Islands
Bangladesh
Leveraging the influence of religious leaders, our partners in Bangladesh used sermons to promote healthy habits for diabetes prevention, recognising the respect and trust Imams have nationwide. Imams not only promoted healthy lifestyles but also monitored community members' health, guiding people on where to seek help. Building on past WDF projects, including one introducing pre-conception counselling, this initiative has made a significant impact on diabetes awareness and prevention.
Preventing diabetes through sermons
As we look into the future, investments and governmental support of prevention-only projects are pivotal to ensure a focus on non-patients and reach a wider range of stakeholders otherwise excluded with access to care projects. Addressing systemic issues is key, as knowledge alone is not enough.
Focus on malnutrition: 'The first thing I would argue for is to get the nutrition donor community to look more broadly at malnutrition in all its forms. Undernutrition is still a global issue, but we need a broader perspective and a bigger lens on food systems'.
Leveraging nutrition and maternal health actors: 'We need a greater focus on systemic interventions and comprehensive programmes with strong advocacy, led by stakeholders suitable for health promotion', WDF’s Head of Policy and Programmes explains. This approach is critical to reach people who live in the most vulnerable settings. 'Given the extent of the challenges, we need to work with sectors that are already working on building health-promoting environments and lift that agenda that we alone cannot'.
Prevention as health promotion: 'It's important to reaffirm our perspective around health promotion rather than diabetes prevention. Health promotion contains a wider range of activities and includes the protection of mental well-being, healthy lifestyles, and supportive environments for health.'
HIP standards: 'We also want to see more global maternal health programmes that move towards making HIP prevention and care a standard', Elsa adds.
. . .
The fight against NCDs is a complex and multifaceted challenge that requires an integrated, comprehensive approach.
It is clear that prevention strategies are not just about interventions in health facilities, but also about addressing the broader social, economic, and environmental factors that contribute to these diseases.
Overcoming barriers to quality care, healthy food options, and physical activity spaces is not just a health issue, but a matter of equity.
It is crucial that we focus our efforts on those stages of life that are most critical, such as adolescence and pregnancy, and on those communities that bear the greatest burden of NCDs.
Our interventions need to be broad and far-reaching, targeting multiple settings and levels of society. In particular, the prevention of diabetes would greatly benefit from a stronger focus on food systems and health promotion.
Finally, it is evident that tackling NCDs in low-resource settings, which are disproportionately affected by these diseases, requires a concerted effort from all sectors of society.
Only by working together, breaking down barriers, and focusing on health promotion can we hope to make a significant impact on the global NCD burden.