Shifts in society, demography, technology and the environment are significantly impacting the global burden of disease, with non-communicable disease (NCD) on the rise. Almost half of all deaths attributable to NCD have nutrition as the predominant risk factor (cardiovascular diseases and diabetes). This briefing provides an overview of policy options that have been or could be adopted across a number of sectors, specifically health systems, social protection, food, agriculture and nutrition, and governance. It recommends that the international development community pay greater attention to the undermining effect of NCD, and develop cross-sectoral policy responses to respond to this growing threat.UK Department for International Developmen

Knezovich, J

MacGregor, Hayley

English

IDS OpenDocs

Despite decreased fertility rates in many parts of the 
world, the total population continues to grow, in 
part because of ageing populations in low- and 
middle-income countries (LMICs). Cities are getting 
bigger and more populated. Great strides in 
preventing deaths and disability from infectious 
diseases have helped people to live longer.
 
These changes have prompted technological 
advances. The agri-food system continues to 
intensify production but also to experiment with 
ways of providing healthier processed foods. 
Manufacturers are also exploring how to provide 
these foods at lower costs. At the same time, within 
the health sector, new technologies for tracking, 
diagnosing, treating and sharing information about 
a variety of health conditions have advanced 
significantly.
These interconnected shifts in society, demography, 
technology and the environment are having a huge 
impact on the global burden of disease, with NCD 
on the rise (see Figure 1). Almost half of all deaths 
attributable to NCD result from diseases that have 
nutrition as a significant behavioural risk factor 
(namely cardiovascular diseases and diabetes). While 
the global public health community has long been 
calling attention to this issue, policy solutions often 
target individual-level behaviour change and risk 
prevention interventions without giving sufficient 
consideration to broader social, economic, 
environmental and political approaches. Nor do they 
tend to consider the broader systemic interactions 
such as the relationship between food systems and 
under- and over-nutrition.
www.ids.ac.uk
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ISSUE 65 • MAY 2014
Shifts in society, demography, technology and the environment are significantly 
impacting the global burden of disease, with non-communicable disease (NCD) 
on the rise. Almost half of all deaths attributable to NCD have nutrition as the 
predominant risk factor (cardiovascular diseases and diabetes). This briefing 
provides an overview of policy options that have been or could be adopted across 
a number of sectors, specifically health systems, social protection, food, agriculture 
and nutrition, and governance. It recommends that the international development 
community pay greater attention to the undermining effect of NCD, and develop 
cross-sectoral policy responses to respond to this growing threat. 
 Responding to the Threat 
 of Nutrition-related 
 Non-communicable Disease
Understanding non-
communicable disease 
Non-communicable disease (NCD) cannot 
be passed from one person to another. 
According to the World Health Organization 
(WHO), there are four main types of NCD: 
‘cardiovascular diseases (like heart attacks and 
stroke), cancers, chronic respiratory diseases 
(such as chronic obstructive pulmonary 
disease and asthma) and diabetes’. Other 
definitions of NCD include congenital 
conditions, like sickle cell anaemia, and 
mental health conditions, which may have 
both genetic and environmental risk factors.
A clearer definition derives from the common 
risk factors for NCD. At a physiological level, 
these include: increased blood pressure, 
elevated levels of glucose and/or fat in the 
blood, and carrying excess body fat. These 
physiological risks are influenced by individual 
genetic make-up but also by behavioural and 
environmental factors. Individual behaviours 
that increase the risk of NCD include tobacco 
usage, lack of physical activity, poor diet, and 
alcohol misuse. Environmental factors thought 
to be driving the increased levels of NCD 
include: urbanisation, ageing, and globalisation, 
along with other common social determinants 
of health. This briefing focuses only on NCD 
where the predominant behavioural risk factor 
is nutrition, which limits the discussion to 
cardiovascular diseases and diabetes.
In this context, experts working across a number 
of development sectors – health systems, social 
protection, food, agriculture and nutrition, and 
governance – have reviewed existing policy 
responses across several LMICs to draw lessons 
for a wider development response to nutrition-
related NCD. This briefi ng provides an overview 
of these policy options.
Understanding the relationship 
between NCD and poverty
The WHO suggested in 2011 that approximately 
63 per cent of global annual deaths (36 million) 
are attributable to NCD and that 48 per cent 
of the healthy life years lost (or disability 
adjusted life years – DALYs) worldwide are due 
to NCD. Of those deaths, almost 80 per cent 
occurred in LMICs. Recent data from the 2010 
Global Burden of Disease study confi rms this
(see Figure 1).
IDS POLICY BRIEFING RESPONDING TO THE THREAT OF NUTRITION-RELATED NON-COMMUNICABLE DISEASE ISSUE 65 • MAY 2014 www.ids.ac.uk
“Deaths are 
increasingly 
caused by NCD, 
in developed 
and developing 
countries alike.”
This presents a serious challenge to health 
systems around the world, especially because, 
unlike many communicable diseases and 
accidents, NCD treatment is often chronic in 
nature. For example, a person suffering from 
diabetes will require regular doses of insulin for 
the rest of his or her life. Compared with rich 
countries, poor countries generally have larger 
out-of-pocket health expenses and higher 
fractions of health costs borne by patients 
themselves. Thus, in LMICs – even for those 
who have escaped severe poverty – 
impoverishment can reoccur when people are 
faced with large, lifelong out-of-pocket 
expenses. For those living close to the poverty 
line, the high cost of NCD care can plunge 
households into impoverishment, if care is 
sought at all.
In India, for example, Mahal et al. in 2010 found 
that about 40 per cent of household 
expenditures for treating NCD were fi nanced 
by households, with distress patterns such as 
borrowing and sales of assets suggesting that 
the economic burden at the household level is 
increasing. The same study found that the 
amount of out-of-pocket expenditures 
attributable to NCD treatment during 12 months 
in 1995–6, and again in 2004, increased from 32 
per cent to 47 per cent, suggesting a growing 
importance of NCD in terms of its fi nancial 
effect on households.
There is not yet enough evidence about NCD 
prevalence rates across wealth quintiles globally 
to suggest that they are either diseases of 
poverty, or wealth, or both. However, it is clear 
that the impact of NCD on households in the 
lower wealth quintiles is signifi cant, especially 
in contexts where people lack health insurance 
and other social protection mechanisms. This 
has the distinct potential to reinforce 
intergenerational transmission of poverty.
Figure 1 Global deaths by cause and 
geographic category 
Source: Based on data from the Institute for Health 
Metrics and Evaluation (2013).
Figure 2 Deaths in developing countries in 2010 by cause
Deaths are increasingly caused by NCD, in 
developed and developing countries alike. 
Moreover, NCD that has nutrition as a signifi cant 
risk factor accounts for about half of all deaths 
from NCD. Put bluntly, cardiovascular diseases 
and diabetes caused more than three times 
more deaths in developing countries in 2010 
than HIV/AIDS, malaria, and tuberculosis 
combined (see Figure 2).
Nutrition-related NCD (developing countries)
Nutrition-related NCD (developed countries)
Other NCD (developing countries)
Other NCD (developed countries)
Other diseases and injuries (developing countries)
Other diseases and injuries (developed countries)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1990 1995 2000 2005 2010
Nutrition-related NCD HIV/AIDS Malaria TB
Source: Based on data from the Institute for Health Metrics and Evaluation (2013)
11,262,454
1,370,061 1,169,610 1,148,877
IDS POLICY BRIEFING RESPONDING TO THE THREAT OF NUTRITION-RELATED NON-COMMUNICABLE DISEASE ISSUE 65 • MAY 2014 www.ids.ac.uk
“A more 
integrated 
policy response 
to nutrition-
related NCD 
must be 
developed.”
Health system responses
The majority of health systems have been 
designed to respond to communicable disease 
and accidents. This means that they are well 
placed to deal with short, and sometimes 
intense, periods of care. The long-term and/or 
expensive treatment implied by NCD, 
particularly in the later stages of disease, has the 
potential to cripple health systems around the 
world, owing to lack of human resources (trained 
doctors and nurses) and/or financial resources. 
Health system responses, then, look to 
alternative care pathways that reduce the 
potential burden on the formal care sector.
The following health system responses could be 
adopted to reduce this potential burden:
• Providing better integrated care, where NCD 
is diagnosed at early stages during routine 
health visits rather than by adding on special 
programmes designed specifically to combat 
NCD.
• Focusing on early detection and education 
to prevent people acquiring NCD in the first 
place through behavioural change. 
• Re-prioritising primary care services, where 
trained health workers have the opportunity 
to identify and deal with health concerns before 
they develop into serious NCD.
• Scaling up low-cost drug distribution 
networks in combination with prevention 
strategies and with awareness of potential 
conflicts of interest.
• Implementing a patient self-management 
model, where those who have contracted NCD 
control it through personal monitoring of 
disease status, assuming responsibility for risk 
factor mitigation through behavioural change 
and drug adherence.
Each of these responses has its own advantages 
and drawbacks. Quality of care is of particular 
concern; access to formal health services and 
providers, as well as community-based initiatives 
and civil society organisations, will remain 
necessary.
Social protection responses
Aside from the health system, social protection 
strategies have a role to play in both preventing 
people contracting NCD and mitigating the 
financial consequences when they do – 
particularly people in the lower wealth quintiles.
Effective social protection policies have an 
important role to play in helping tackle nutrition-
related NCD. They can:
• Improve the poorest people’s access to healthy 
foods and encourage them to adopt healthy 
behaviours – for example, through the provision 
of cash and food transfers. As transfers have, 
in some cases, been found to have perverse 
effects (i.e. food being sold for cash), programmes 
should be carefully designed and implemented 
to ensure that they lead to positive outcomes; 
• Help break down barriers to people accessing 
health services – for example, through 
integrated health financing and insurance, 
such as community-based health insurance 
schemes, cash transfers, preventing large out-
of-pocket expenditures, and enabling people 
to meet the costs of user fees;
• Encourage health-seeking behaviours, as was 
done in Mexico’s Oportunidades programme. 
In order for a social protection response to be 
sustainable in light of the growing NCD burden 
and its ongoing costs, there needs to be greater 
integration of social, health and preventive 
programmes. Example initiatives include free or 
subsidised school meals, or community care 
committees.
Agri-food system responses
The rapid change in diets, patterns of work and 
leisure over the past 30 years – referred to as 
the ‘nutrition transition’ – is already contributing 
to the causal factors underlying the increasing 
burden of NCD, even in the poorest countries. 
Influencing these patterns requires a number of 
regulatory approaches. These could include:
• Facilitating consumer choice by stipulating 
transparent food labelling, coupled with 
education campaigns to ensure that consumers 
are able to make informed decisions;
• Restricting marketing of ‘unhealthy’ foods. 
This could be achieved through:
 – Introducing compositional standards 
for specific products – for example, 
limits on the amount of sodium or trans 
fats in processed products; 
 – Advertising controls that prioritise 
consumers’ health, such as those that have 
been applied in the case of nicotine products;
 – Pricing controls to influence food 
markets. This might include ‘taxes’ on 
unhealthy nutrients, ingredients or 
products. These controls must be 
accompanied by careful monitoring to 
avoid circumvention and to ensure that 
poor people do not bear the brunt.
Governance responses
Effective policy responses to NCD should be 
articulated at multiple levels: international, 
national, state/district and local levels. In all 
cases, a clear argument has to be made as to 
why governments need to intervene to address 
IDS POLICY BRIEFING ISSUE 65 • MAY 2014 www.ids.ac.uk
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Further reading
Institute for Health Metrics and 
Evaluation (2014) GBD Compare 
Data Visualisation and Download, 
http://viz.healthmetricsandevaluation. 
org/gbd-compare/ (accessed 2 
May 2014)
MacGregor, H.; Lally, S.; Bloom, G.; 
Davies, M.; Henson, S.; Mejía 
Acosta, A.; Roelen, K. and Ulrich, 
M. (forthcoming) Non-Communicable 
Disease and Development: Future 
Pathways, IDS Working Paper, 
Brighton: IDS
Mahal, A.; Karan, A. and Engelgau, 
M. (2010) The Economic Implications 
of Non-Communicable Disease for 
India, Washington DC: The 
International Bank for Reconstruction 
and Development/The World Bank 
Popkin, B.M.; Horton, S.; Kim, S.; 
Mahal, A. and Shuigao, J. (2001) 
‘Trends in Diet, Nutritional Status, 
and Diet-Related Noncommunicable 
Diseases in China and India: The 
Economic Costs of the Nutrition 
Transition’, Nutrition Reviews, 
59.12: 379–90 
World Health Organization (WHO) 
(2011) Global Status Report on 
Noncommunicable Diseases 2010, 
Geneva: WHO 
Credits
This IDS Policy Briefing is based on 
the IDS report Non-Communicable 
Disease and Development: Future 
Pathways, and was written by Jeff 
Knezovich and Hayley MacGregor 
and edited by Carol Smithyes. It 
was part of a broader project that 
also included ideas and input from 
Steven Lally, Gerry Bloom, Mark 
Davies, Spencer Henson, Andrés 
Mejía Acosta, Keetie Roelen, and 
Martina Ulrich. It was produced as 
part of the IDS Policy 
Anticipation, Response and 
Evaluation Programme, Horizon 
Scanning sub-theme. The 
programme is funded by UK aid 
from the UK Department for 
International Development. 
The opinions expressed are those 
of the authors and do not necessarily 
reflect the views of IDS or the UK 
government’s official policies. 
Readers are encouraged to quote 
and reproduce material from the 
IDS Policy Briefing series. In return, 
IDS requests due acknowledgement 
and quotes referenced as above.
AG Level 2 Output ID: 248
© Institute of Development Studies, 2014 
ISSN 1479-974X
Policy recommendations
In order to tackle nutrition-related NCD more effectively:
 • The international development community must recognise the potential for 
nutrition-related NCD to undermine development progress. Evidence is 
emerging that the assumptions that NCD is driven by excess wealth and 
therefore are not relevant to poverty alleviation are inaccurate. NCD also 
affects the poorest groups in society and has a disproportionate impact on 
them, which can reinforce intergenerational transmission of poverty.
 • A transdisciplinary focus on nutrition-related NCD needs to be embraced. Risk 
factors for NCD are diverse, ranging from environmental factors to food systems.
 • Global frameworks must create an enabling environment for national 
policymakers and private sector actors to tackle nutrition-related NCD and 
help foster partnerships between government, business and civil society. Global 
goals, such as those that emerge post-2015, should include targets for tackling 
nutrition-related NCD to provide focus and bolster political will. New types of 
political coalition are needed to address the major changes in food systems that 
are occurring in the context of rapid urbanisation and changing lifestyles.
 • Greater cross-country learning should be facilitated. There are a number of 
innovative approaches to tackling NCD in LMICs across the globe that might be just 
as relevant to high-income countries. At the same time, high-income countries 
have a head start of several decades in responding to increased prevalence of NCDs.
 • A more integrated policy response to nutrition-related NCD must be developed. 
It is unlikely that any single ministry will be able to act alone to tackle the 
challenges posed by nutrition-related NCD. Individual or uncoordinated policy 
responses, such as the Mexican ‘soda tax’, are easily circumvented.
a public health issue, as opposed to leaving 
it as a private or individual concern. 
• International governance must create an 
enabling environment for national-level 
policymakers to focus on NCD control. This 
could be about setting high-level targets, 
or by raising awareness about the social 
and economic costs associated with NCD. 
International donors can also influence 
national governments through dedicated 
funding to support action to tackle NCD.
• At the national level, governance 
interventions might be most effective if 
organised around a coordinating function. 
Given the wide-ranging issues that influence 
the risk factors for NCD, national 
governments can establish cross-sectoral 
fora to coordinate activity across ministries 
and with civil society and the private 
sector. National governments can also 
advance research and development by 
securing and investing funding in relevant 
areas.
• Local policymakers at state or district level 
have a role to play in translating government 
policies into context-specific benefits for 
citizens. Local-level policymakers have 
perhaps the greatest scope to effect 
immediate changes that have huge impacts 
on people’s health – for example, through 
closing streets at certain times of the day 
to create public exercise spaces.


Responding to the Threat of Nutrition-related Non-communicable Disease

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Responding to the Threat of Nutrition-related Non-communicable Disease

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