How can we build healthier cities? What city needs the most help? Plus a reader poll!

By Alex Ganninger, Nancy Liu, Manu Venkat, and Kelly Close

Twitter summary: How can we build healthier cities? Novo Nordisk tackles the challenge with an innovative new program. Plus, a reader poll!

Short summary: 64% of the 342 million people with diabetes globally now live in cities. As more people move into cities and the rates of diabetes increase, how can we learn how to build healthier cities? Novo Nordisk aims to do just that by launching what looks to be a very cool and smart “Cities Changing Diabetes” program. Read on for the considerations we believe will be the most important for cities to be able to impact people with diabetes and a reader poll of which city would be your top pick!

Fifty percent of the world’s population, or around 3.6 billion individuals, live in cities, and by 2050, it is estimated that the number will rise to 70% of the global population. So how are our cities doing from a health perspective? Unfortunately, a disproportionately high percentage (64%) of the 342 million people with diabetes live in cities. Of course, this is not to say that type 2 diabetes prevention should focus solely on cities, as it is a severe problem in rural areas as well. However, as both urbanization and the incidence of type 2 diabetes are on the rise, cities are increasingly being looked at as a part of the global diabetes pandemic. It is important to consider why this is the case, and how we can take steps to build healthier cities.

While movements toward cities have long been considered a marker of prosperity due to increased job opportunities and easier access to healthcare and educational resources found in urban areas, the development of cities may also be contributing to the increased prevalence of type 2 diabetes. Drastic lifestyle changes associated with urbanization have led to the rise of unhealthier lifestyles and increased type 2 diabetes. City design in the past half century has largely centered on cars, allowing people to commute from the suburbs instead of walking or taking public transit. Additionally, people who live in cities are more likely to have sedentary office-based jobs. As a result of these two factors, the opportunities for residents of cities to engage in enough physical activity are relatively low. Maintaining a healthy eating plan in cities can also be challenging because of the easy access to fast food restaurants and convenience shops, as well as the decreased availability of fresh produce. Although it might appear on the surface that decisions concerning eating and exercise are a matter of personal choice, they are greatly influenced by the structure and culture of our surrounding environment.

If cities are playing a role in the increase of type 2 diabetes, can they also be part of the solution? Based upon the wide disparity in diabetes prevalence throughout the United States and around the world, there seems to be a connection between a city’s infrastructure and policies and the incidence of tye 2 diabetes and obesity. Though comparisons are usually made between states, cities too display wide differences in diabetes rates like San Antonio, which boasts a 12.7% rate of diabetes, more than double the 6.7% diabetes rate found in Denver.

Although the factors that lead to increased type 2 diabetes rates in certain cities are complex, some smart policies can certainly make some urban areas healthier than others. A major factor in a city’s role in public health is transportation infrastructure. Over the past ten years, cities like Seattle and Denver have significantly upgraded their bicycle infrastructure by dedicating lanes on major roads to bicycles, helping cyclists take back the roads from the dominance of cars. Well-developed public transportation systems encourage individuals to use their cars less and to walk more. The availability of recreational facilities through parks is another factor built into a city’s blueprint that can also have a positive impact on individuals’ average daily physical activity, especially for children (who are a key target in efforts to prevent future cases of type 2 diabetes and obesity).

Cities are also excellent laboratories for policy initiatives to improve public health. Places such as Mexico City have tried to discourage the purchase of sugary soft drinks by imposing a soda tax. Other cities are exploring ways to make healthy foods both more affordable and more accessible to populations that live in “food deserts,” or areas where fresh fruits and vegetables are not readily available. The past few decades have seen an explosion in urban farms and gardens, which help move sources for fresh produce closer to the urban populations that have the least access to healthy food. Promoting physical education in schools and preserving recess would be other ways to help future generations be healthier. However, while local initiatives have demonstrated some success, broader initiatives are needed to combat the urban diabetes epidemic on a global scale.

In collaboration with the University College of London, one of the foremost research institutions on the impact of the built environment on human health, and the Steno Diabetes Center in Denmark, Novo Nordisk is pioneering the Cities Changing Diabetes initiative. This program seeks to combat urban diabetes through study of selected focus cities. Novo Nordisk hopes to identify the unique challenges that cities present and develop solutions for combating type 2 diabetes that can then be replicated elsewhere. Once the company creates agreements with partner cities, it will conduct a period of observation, to learn more about urban diabetes, share best practices, and begin policy conversations. As more people move to cities, the importance of addressing the relationship between type 2 diabetes and urban lifestyles lies not just in making people healthier today, but also in laying the proper groundwork for the future.

With its launch on March 28, the Cities Changing Diabetes initiative announced the partnership with its first regional urban center, Mexico City. Aside from being one of the most populated metropolitan areas in the world, Mexico City, according to the Mexican Minister of Health Dr. Armando Ahued Ortega, views type 2 diabetes as its most significant health problem, making it ideal for this urban experiment. The leaders of the Cities Changing Diabetes program plan to work with additional partner cities in Asia, Europe and North America. Those who are interested in learning more about Cities Changing Diabetes should check out the program’s gripping 75-second introductory YouTube video.

Which cities would be the most promising partners for the “Cities Changing Diabetes” program with Novo Nordisk? The team at diaTribe brainstormed some ideas on what makes a city healthy, how they could change diabetes, and our top picks on future partners.

What makes a city ready to change diabetes?

Acknowledgment that diabetes is an issue - Different groups ranging from the general public to city leaders would need to recognize that diabetes is a problem worth addressing in order to mobilize resources and to engage residents to fight diabetes. There is no room for a halfhearted effort.
High diabetes prevalence - Cities that have a high number of people with diabetes could make a big impact through public health initiatives like improving city design and policy interventions. Examining cities with the highest diabetes prevalence could also help identify the distinctive factors in these areas that make diabetes such a pressing problem. In this regard, cities such as Baltimore and Birmingham, with above average diabetes prevalence (10.5% and 10.7%, respectively), have a particularly high level of unmet need.
Community engagement - Cities with active health movements would be great partners for the “Cities Changing Diabetes” program, as residents would be more willing to assist with the implementation of proposed solutions. These cities may also be able to take advantage of the positive foundation built by public health initiatives. The prevalence of programs like urban gardens and farmers’ markets could be a marker for the enthusiasm and grassroots activism of the cities’ residents. Detroit’s push for urban vegetable gardens and San Francisco’s bicycling movement are compelling displays of communities addressing health problems in their cities and implementing solutions to fix them.
Urban structure and infrastructure - Cities that are physically concentrated and less politically divided could facilitate the implementation of new programs. For example, it would be much easier to implement a public transit system in cities that have a dense urban core and well-defined areas of development (such as Chicago) than in a sprawling city like Houston. There is a wide variety in the way cities are structured politically; for example, St. Louis’s metropolitan area is divided among smaller suburbs, each with its own government, and would require coordination with more local governments than would more politically integrated cities.
Interest and engagement from government leadership - Certainly, it is critical to have the support of local governments when making policy changes in cities. A demonstrated interested in health issues on the part of policymakers could be a good barometer of the support they would offer to type 2 diabetes prevention efforts. Several cities across the US have recently witnessed public health campaigns driven by innovative politicians who have thought creatively about how to improve the health of cities. Former Mayor Michael Bloomberg pushed for regulations on soda size in New York City, Philadelphia Mayor Michael Nutter is working to reduce sugar sweetened beverages in schools and homes, and other leading policymakers have begun to step up to the table (least of all is Michelle Obama and her influential role in the Partnership for a Healthier American (PHA) – learn more about her work here).
Existing healthcare infrastructure - Scalability of type 2 diabetes prevention strategies will require effective use of cities’ healthcare providers and infrastructure. Cities with large and well-respected medical centers can contribute through research or by sponsoring health-related programming. Boston, New York, Chicago, and other large US cities are known for possessing a large number of world-class medical centers. Cities such as Cleveland with its eponymous Cleveland Clinic would also be promising.
Opportunity for public-private partnerships and other collaborations - A comprehensive solution will require the active engagement of multiple stakeholders. Cities with more opportunity for collaboration can pool resources and create broader and more effective outreach. Businesses such as the food and beverage industry as well as pharmaceutical and other healthcare companies, could facilitate the process of designing and implementing public-private initiatives. Partnerships with schools and universities might be useful way to galvanize support and raise awareness for future generations of leaders. Atlanta is an example of a city with great opportunities for a range of partnerships, due to the presence of the CDC, major universities, and a range of corporations.

New York City skyline Novo Nordisk Cities Changing Diabetes Our list is highly speculative, and is intended primary as a starting point for consideration and discussion of the factors that are important for healthy cities. Although we have mentioned a few contenders for the spot as Novo Nordisk’s US partner city, the decision has not yet been announced. What do you think? Vote below for the city you think has the most potential to change diabetes. But don’t stop there – although the Cities Changing Diabetes program will only be able to select one program in the US to begin with, every city in America faces a diabetes problem that can only be solved with active public engagement. You can communicate with your government representatives to advocate for more walkable cities, better access to healthy food, health education programs for center-city schools, and other important programs that can help ensure that the cities of tomorrow are healthy places for future generations.