Strengthening the capacity to tackle noncommunicable diseases (NCDs): meeting of collaborating centres of the WHO European Region on NCDs, with a focus on risk factors and surveillance: Moscow, Russian Federation, 5–6 December 2018

Strengthening the capacity to tackle noncommunicable diseases (NCDs) Meeting of collaborating centres of the WHO European Region on NCDs, with a focus on risk factors and surveillance Moscow, Russian Federation, 5–6 December 2018 Strengthening the capacity to tackle noncommunicable diseases (NCDs) Meeting of collaborating centres of the WHO European Region on NCDs, with a focus on risk factors and surveillance Moscow, Russian Federation, 5–6 December 2018 Abstract As pointed out by experts in the field, there is a real danger that the 2025 targets set by the World Health Organization (WHO) in noncommunicable diseases (NCDs) and the United Nations Sustainable Development Goal target on NCDs will not be reached. If the aspirations of these targets and of the report of WHO’s Commission on NCDs are to have any chance of being achieved, a new approach and strategy are needed. All these global frameworks acknowledge that collaboration is essential in tackling NCDs, which is a complex and systemic health issue. To date, however, collaboration between the WHO Regional Office for Europe (WHO/Europe) and its collaborating centres (CCs) has been bilateral (between WHO/Europe and individual CCs) rather than multilateral (between CCs). While this approach has provided WHO/ Europe with valuable information, it does not tap into the potential for collaboration between the various CCs, which could greatly increase the effectiveness of the guidance that WHO/Europe provides to Member States. In December 2018, WHO/Europe convened a two-day meeting of representatives from various CCs and other academic institutions that focus on NCD risk factors and surveillance. The aim of the meeting was to launch a network of CCs and to tap into the potential for new collaboration between them, with a commitment from WHO/Europe to continue knowledge exchange and to facilitate joint working in the future. This report provides the results of the two-day discussion: an overview of WHO/Europe’s priorities in NCD risk factors and surveillance, proposed research projects identified by CC discussion groups, and next steps. © World Health Organization 2019 All rights reserved. The Regional Office for Europe of the World Health Organization welcomes requests for permission to reproduce or translate its publications, in part or in full. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. 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The views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the World Health Organization. Address requests about publications of the WHO Regional Office for Europe to: Publications WHO Regional Office for Europe UN City, Marmorvej 51 DK-2100 Copenhagen Ø, Denmark Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the Regional Office website (http://www.euro.who.int/pubrequest). iii Contents Foreword iv Acknowledgements v Abbreviations v Executive summary vi Participating institutions 1 Context and aims 2 Format of the meeting 3 Priorities and gaps 4 Diet and physical activity 6 Priority project – Healthy and environmentally sustainable diet 7 Alcohol 8 Priority project – Modelling best buy investment cases for alcohol, tobacco and sugar-sweetened beverages (SSBs) in three countries in the WHO European Region 9 Tobacco 10 Priority project – ENDS and HTPs: regulation and policy implementation 11 Policy implementation 12 Training and surveillance 14 Priority project – A platform for training on NCDs – surveillance, implementation and evaluation 15 Diet – problem definition 16 Priority project – Industrial contribution to data – food sales and composition 17 Looking ahead: building a network 19 Appendix 1. Risk factors mapped against the priority projects 21 Appendix 2. Participant survey 24 Appendix 3. Participating institutions and individuals 26 iv Foreword The World Health Organization (WHO) Regional Office for Europe has worked extensively with the network of WHO collaborating centres (CCs) to support Member States of the WHO European Region in their development of scientific products. As leading research and academic institutions, the WHO CCs are actively making significant and beneficial contributions in the current era to the task of transforming our global programme of work, developing further research on priority interventions, and improving our strategic frameworks in monitoring the risk factors and overall burden of noncommunicable diseases (NCDs). In order to achieve the 2025 NCD global targets and the United Nations Sustainable Development Goal Target 3.4 on NCDs, it is essential to align our activities with the future work of the WHO CCs and to encourage a spirit of collaboration within the network to further support and catalyse our progress. By promoting such awareness, the WHO CCs join efforts and develop collaborative projects that could further address the priorities and research gaps in tackling NCD risk factors and improving surveillance across the European Region. We would like to sincerely thank the network of WHO CCs in the European Region for their ongoing participation and contribution, and we look forward to continuing the knowledge exchange and facilitating joint working in the future. Dr João Breda Head of the WHO European Office for the Prevention and Control of Noncommunicable Diseases Dr Bente Mikkelsen Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course The WHO European Office for the Prevention and Control of Noncommunicable Diseases was es- tablished in Moscow, Russian Federation, in 2014. Its primary remits are to address the risk factors for NCDs and to lead on NCD surveillance across the 53 countries of the WHO European Region. WHO has over 800 collaborating centres around the world, 275 of which are based in the European Region. These collaborating centres have a global remit and, for the most part, operate independently. Each has a memorandum of understanding with WHO and can be drawn on for information on the subjects contained within that memorandum. vAcknowledgements The WHO Regional Office for Europe wishes to thank the following contributors whose knowledge and expertise made this publication possible. The development of this report was guided by Kremlin Wickramasinghe and João Breda (WHO European Office for the Prevention and Control of NCDs). Significant contributions were provided by Kristina Mauer-Stender, Carina Ferreira-Borges, Ivo Rakovac, Tina Kiaer, Stephen Whiting, Julianne Williams and Olga Zhiteneva (WHO European Office for the Prevention and Control of NCDs). Bente Mikkelsen, Director of the Division of Noncommunicable Diseases and Promoting Health through the Life-course, provided further guidance and supervision. We would also like to thank consultants Amélie Schmitt and Lea Nash Castro, and intern Jocelyn Victoria for their contributions. The report is based on materials presented and discussed during the meeting on strengthening the capacity of the network of WHO European collaborating centres in tackling NCD risk factors and improving surveillance. Thanks are due to the staff of the WHO Country Office in the Russian Federation for their contribution to making the meeting possible. We would also like to acknowledge the researchers and staff of various collaborating centres and other academic institutions for their attendance and active participation in the meeting. Our special appreciation is extended to the meeting rapporteur, Katy Cooper, for compiling all the content necessary to draft the report and for her support throughout its subsequent development. We would also like to extend our appreciation to the WHO Collaborating Centre on Population Approaches for NCD Prevention (University of Oxford, United Kingdom) for their assistance in facilitating the participant survey for the meeting and the report. All the activities related to this report were funded through a grant of the Russian Government in the context of the WHO European Office on the Prevention and Control of NCDs. Abbreviations CC collaborating centre ENDS electronic nicotine delivery system(s) EU European Union FCTC Framework Convention on Tobacco Control HFSS high in fat, salt and/or sugar HTP heated tobacco product KAP Knowledge Action Portal NCD noncommunicable disease NGO nongovernmental organization SDG Sustainable Development Goal SSB sugar-sweetened beverage WHO World Health Organization WHO/Europe WHO Regional Office for Europe vi Executive summary In December 2018, in Moscow, Russian Federation, the WHO Regional Office for Europe (WHO/Europe) convened a two-day meeting of representatives of WHO collaborating centres (CCs) that are working on noncommunicable disease (NCD) risk factors and surveillance. It was the first time that the CCs had been brought together; the aim of the meeting was to launch a network of CCs, with a commitment from WHO/Europe to continue knowledge exchange and to facilitate joint working in the future. The meeting was an opportunity both to compare the policy priorities of WHO/Europe with the expertise and capacity of the CCs and to map training and capacity-building in NCDs offered by the CCs. A set of five priority projects was identified and developed (Table 1). The intention is that WHO/Europe will work on these projects with the CCs over the next 3–5 years: a coherent set of actions that, between them, will tackle multiple risk factors and improve surveillance. Table 1. Five priority areas and associated projects Priority area Priority project Diet and physical activity Healthy and environmentally sustainable diet Build evidence in different countries and draw up a WHO/Europe position on healthy and sustainable diets, engaging countries to develop their own guidelines. Alcohol Modelling best buy investment cases for alcohol, tobacco and sugar-sweetened beverages (SSBs) in three countries in the WHO European Region Provide countries with evidence on the financial and health impacts of investing in the best buys; use this knowledge to develop a user-friendly tool that other Member States can use to develop their own case. Tobacco Regulation/policy implementation of ENDS and HTPs Summarize existing evidence and case studies on the health effects and current regulations; develop a policy brief setting out WHO/Europe’s position that Member States can use. Training and surveillance Platform for training on NCDs – surveillance, implementation and evaluation A training platform on NCDs to provide integrated, comprehensive training on surveillance and evaluation methods, both face to face (summer schools and one- day courses) and online. Diet – problem definition Industrial contribution to data – food sales and composition Establish a methodology to assess and analyse sales of HFSS foods (high in fat, salt and/or sugar) and front/back-of-pack nutrient information from major food retailers across the European Region. “Collaborating centres are critical for the implementation of WHO’s healthier populations’ vision: saving and improving the lives of a billion people.” Dr João Breda, WHO/Europe 1Participating institutions In total, 33 collaborating centres (CCs) and other academic institutions (including potential CCs) were represented, drawn from across the WHO European Region (Fig. 1) and beyond.1 Note that, while not all WHO/Europe CCs with an interest in NCD risk factors/surveillance were invited or able to attend, all will be included in future discussions and projects. Fig. 1. Member States with CC representation at the meeting And participants from the World Health Organization (Geneva) and WHO/Europe (Copenhagen and Moscow). 1 An asterisk (*) indicates a collaborating centre (CC); individual participants are listed in Appendix 3. Australia: University of Melbourne* Bulgaria: National Centre of Public Health and Analyses, Sofia Canada: Centre for Addiction and Mental Health, Ontario* Croatia: Croatian National Institute of Public Health Centre, Zagreb Germany: Friedrich-Alexander University Erlangen-Nürnberg, Erlangen*; German Cancer Research Centre, Heidelberg*; Institute for Epidemiology and Prevention Research (BIPS), Bremen* Italy: Istituto Superiore di Sanita, Rome* Kazakhstan: Kazakhstan Academy of Nutrition, Almaty*; National Centre for Problems of Healthy Lifestyles Development, Almaty* Netherlands: Institute for Public Health and the Environment, Bilthoven* North Macedonia: Institute of Public Health, Skopje Poland: Maria Sklodowska-Curie Cancer Centre and Institute of Oncology, Warsaw* Portugal: Institute of Public Health of the University of Porto, University of Porto Medical School; National Institute of Health Dr Ricardo Jorge, Lisbon* Russian Federation: Federal Research Centre of Nutrition, Biotechnology and Food Safety, Moscow; Federal Research Institute for Health Organization and Informatics, Moscow*; V. Serbsky Federal Medical Research Centre for Psychiatry and Narcology, Moscow*; I.M. Sechenov First Moscow State Medical University*; Moscow School of Management SKOLKOVO; National Medical Research Centre for Children’s Health, Moscow; National Medical Research Centre for Preventive Medicine, Moscow*; Plekhanov Russian University of Economics, Moscow; Scientific and Practical Psychoneurological Centre Z.P. Solovyov, Moscow Spain: Catalan Institute of Oncology, Barcelona*; Public Health Agency of Catalonia, Barcelona Sweden: Lund University, Malmö* Switzerland: University of Zurich* United Kingdom: European Association for the Study of Obesity, Teddington; University of Bath; University of Leeds*; University of Oxford*; University of Stirling Created with mapchart.net© 2Context and aims On 5–6 December 2018, the WHO European Office for the Prevention and Control of Noncommunicable Diseases hosted a meeting of WHO CCs to identify ways to support and catalyse progress in tackling the risk factors for NCDs across the European Region. As many of the participants pointed out, there is a real danger that the 2025 targets set by WHO to tackle NCDs and the United Nations Sustainable Development Goal (SDG) target on NCDs will not be reached.2 A new approach and strategy are needed if there is to be any chance that the aspirations of these targets and of the report of WHO’s High-Level Commission on NCDs will be achieved.3 In all these global frameworks, it is acknowledged that collaboration is essential in tackling NCDs, which is a complex, systemic health issue. To date, however (and despite their name), the collaboration between the WHO Regional Office for Europe and the CCs has been bilateral (between WHO/Europe and individual CCs) rather than multilateral (between CCs). While the information provided to WHO/Europe has been valuable, this approach does not tap into the potential of joint working between the different CCs, which could greatly increase the effectiveness of the guidance that WHO/Europe provides to Member States. The meeting brought together the CCs for the first time, to identify and tap into potential new collaborations between CCs, with WHO/Europe acting as a regional hub and catalyst. The aims of the meeting included: 1. to create a network of WHO CCs working in NCD prevention and surveillance and to identify how WHO/Europe could contribute to strengthening them – activating synergies and enabling stronger research capacity in the European Region; 2. to familiarize participants with the WHO best buy actions and other WHO/Europe priority areas; 3. to map the current activities of participating CCs in order to identify gaps in evidence and expertise and to identify mechanisms to address these gaps; and 4. to identify how CCs could contribute to NCD prevention and surveillance activities carried out by WHO/Europe over a period of 3–5 years. Taking this approach – and ensuring that it continues into the future – will facilitate collaboration and exchange of ideas; this will be of mutual benefit to WHO/Europe, to CCs and to Member States. Aligning around a prioritized research agenda will also help to make the case for action to funders, many of which have been slow to recognize the urgency of the NCD crisis and the potential for positive change. This meeting report sets out the results of the two days of discussion, giving an overview of WHO/Europe’s own priorities in NCD risk factors and surveillance, the research projects that were identified by CCs themselves, and the next steps. 2 NCD Global Monitoring Framework. Geneva: World Health Organization; 2013 (https://www.who.int/nmh/global_moni- toring_framework/en). Sustainable Development Goals (Target 3.4 on NCDs) (https://sustainabledevelopment.un.org/sdgs). 3 Time to deliver : report of the WHO Independent High-Level Commission on Noncommunicable Diseases. Geneva: World Health Organization; 2018 (https://www.who.int/ncds/management/time-to-deliver/en). “Thank you for fostering bi-directional dialogue between evidence-generators and evidence-users!” Ms Jessica Renzella University of Oxford, United Kingdom 3Format of the meeting Day 1 • Introduction to the overarching aims and a welcome from the Russian Ministry of Health. • Presentations on the priorities of the WHO/Europe across the four major NCD risk factors and surveillance. • A summary of the survey of participating CCs, providing an overview of the interests and expertise of all in the room (see Appendix 1). • Panel discussion to begin drawing out possible areas for research. • Brainstorming topics of interest across each of six discussion group areas: diet and physical activity; training and surveillance; tobacco; alcohol; diet – problem definition; and policy implementation. • Discussion group session 1 - Participants were each allocated a discussion group (according to their own and their CC’s areas of expertise). Within these groups, each brainstormed list was whittled down to a maximum of five priority issues, three of which were chosen by each group to be developed in more detail. Each group identifies a research gap, suggests a possible project or activity that would address the gap, and provides a brief justification for choosing the topic as a priority. - Each discussion group then presented in plenary on the three chosen ideas. Day 2 • Recap of the first day, including a restatement of WHO/Europe’s desire to take the ideas forward. • Discussion on training/capacity-building already offered by the CCs: how these can be better aligned and how WHO/Europe can help to communicate these opportunities. • Discussion group session 2 - Each discussion group chose one of their three chosen ideas from Day 1 to discuss in much greater detail: aim, project design, outcomes, potential impact, and roles and responsibilities (including WHO support that would be required). - Each discussion group presented its idea in plenary. • Presentation on the new Knowledge Action Portal (KAP) – a tool that could be used by CCs in future to share their expertise. • Discussion to gather final thoughts and to set out the next steps for WHO/Europe. “This is one of the WHO meetings I’ve enjoyed the most – coming from a smaller country, it is important to share experience.” Dr Igor Spiroski Institute of Public Health, North Macedonia 4Priorities and gaps Dr Tedros Adhanom Ghebreyesus, WHO Director-General, has set out “triple billion” targets of 1 billion more people with health coverage, 1 billion more people made safer, and 1 billion more people whose lives are improved. Identifying and acting on clear priorities in NCD risk factors will help to achieve the target of improving a billion lives. Presentations and plenary discussions established the views of WHO/Europe and participants on the priorities and gaps in research into NCD risk factors and surveillance, taking into account the challenges posed by the size and diversity of the European Region.4 Cross-cutting priorities • Turning evidence into policy into action: translating data into policy-relevant materials, policy implementation, and then assessment of the impact of policies once they are in force (which can lead to policy refinement). WHO/Europe is keen to do more to translate data (such as dietary information) into relevant, usable information and materials for policy-makers. • System-level change is needed to tackle the highly complex challenges presented by NCDs. But prevention and treatment must also have the individual at their heart: “We could implement all the beautiful policies, but it won’t be enough if we don’t focus on the whole person” (Professor Hanne Tønnesen, Lund University, Sweden). • Funding for NCDs is wholly inadequate: “We have big problems, big projects and big responsibilities – but we lack big consistent funds” (Ms Jessica Renzella, University of Oxford, United Kingdom). Establishing a set of clear, evidence-based priorities will make a stronger case for action and a better case for improved funding. • Working in partnership across sectors – a whole-of-government, whole-of-society approach – is essential in tackling NCDs. Bringing CCs together in a network could enable information exchange, joint working and harmonization of approach. This will benefit CCs, WHO/Europe and Member States. Physical activity and diet • Taking a life-course approach, from pre-pregnancy through to healthy active aging (for instance, the European Region has the lowest rates of breastfeeding of all WHO regions). This includes surveillance of all risk factors, disaggregated by age. • Tackling inequalities and ensuring that the most vulnerable are enabled to lead healthy lives. • Good nutrition and physical activity across different settings, including cities (which can provide case studies of innovation), local communities (particularly important if physical activity is to be a part of everyday life) and institutional settings (such as prisons and workplaces). • Education – not just in schools, but health literacy more broadly. • Addressing food composition and marketing – devising new ways to study, assess and improve composition and marketing of food by the food industry. 4 Gaps in mental health research and provision – particularly in primary care, among migrant populations and with respect to inequalities in care – were mentioned in the survey that was sent to participants prior to the meeting (Appendix 2); however, they were not a focus of discussion at this meeting. “My wish list for this meeting is to identify and respond to emerging policy opportunities, to target the big contemporary questions, and to address gaps in the evidence base.” Mrs Kristina Mauer-Stender, WHO/Europe 5Tobacco • Avoiding complacency: the WHO European Region still has much to do to tackle tobacco use – 25% of adults are smokers, and it has the highest proportion of women smokers in the world. • Taking on long-standing challenges: making the economic arguments (taxation and the case for investing in tobacco control), addressing the social determinants of tobacco use, and countering the tobacco industry. • Addressing e-cigarettes and novel tobacco products: electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs) – “The second frontier” (Mrs Kristina Mauer-Stender, WHO/Europe). As the industry aligns itself with “harm reduction”, extreme caution is advised: “we need to throw science at this!” (Dr João Breda, WHO/Europe). However, evidence currently lags behind changes in products. Alcohol • A long way to go: the Global Status Report on Alcohol and Health 2018 indicates that the WHO European Region has the highest per capita alcohol consumption in the world, with high levels of heavy episodic drinking. A quarter of deaths among the Region’s young people are alcohol related. • Taking action – including extending screening and brief interventions (SBIs), particularly in eastern countries of the European Region. • Better and extended monitoring is required – including improved mechanisms for reporting on SDG Target 3.5 on substance and alcohol misuse, and monitoring of the European Action Plan to Reduce the Harmful Use of Alcohol 2012–2020. • Making the case: strong arguments (including economic arguments) to address industry interference; an alcohol control “playbook” could collect together evidence-based arguments, case studies and policy interventions and impact from across the European Region. Surveillance • Using existing data more effectively: there are many existing surveys (such as the WHO Country Capacity Survey), but much of this wealth of data is not fully explored. • Risk factor surveys are not harmonized with one another, and measurement is often subjective and of low quality (for instance, in the case of physical activity). • Population-based risk factor surveys are challenging to undertake, with capacity varying significantly across the European Region. • Mixed-methods research is needed to understand the underlying stories behind the data and to ensure that solutions are appropriate to national contexts. • Digital data collection, big data and smartphone-based apps present opportunities to improve surveillance (although privacy concerns must be considered). • Surveillance can be an awareness-raising tool in itself – “surveillance is already the first intervention – at individual and at country level” (Dr Ivo Rakovac, WHO/Europe). • Developing new strands of work – focused on baby food, for example, and digital marketing, particularly to children; the European Region is also the only WHO region looking at prisons and health (including a survey sent to 41 countries). • Engaging the media: CCs can leverage their reputations nationally to engage the media with country- level data by providing interpretation and analysis of the evidence. 6Diet and physical activity Discussion group members: the Netherlands, Portugal, the United Kingdom. Diet and physical activity were grouped together because the survey of participants had indicated that many of the CCs have a strong focus on both of these risk factors. Brainstorm: gaps and opportunities • Lack of data: impact of preconception/pregnancy/postpartum interventions on nutrition and physical activity; need for objective measurements of nutrition and physical activity. • Links with the environment: tackling climate change; setting public health and environmental targets; identifying public health/environmental win-wins (such as reducing meat consumption). • Guidelines: need for revised dietary guidelines, including “individualized” guidelines. • Food composition and marketing: updated food composition data, front-of-pack labelling. • Training: need for an integrated strategy for training of health professionals. • Awareness and involvement: awareness of the health benefits of physical activity; active involvement of young people; engaging the trade/investment community in the conversation. • Social determinants of health. Priority topics The group felt that taking the time to undertake a full prioritization process would be of benefit, as it was not possible to include many other areas of importance (such as food regulation). One priority topic was chosen for each risk factor (diet and physical activity); addressing these as part of maternal health was also clearly identified as essential. 1. Preconception/pregnancy/postpartum surveillance and interventions Research gaps: there is a lack of data on weight status, physical activity level and diet during the preconception, pregnancy and postpartum periods; there is a concurrent lack of evidence on the impact of lifestyle interventions during these three periods, especially preconception. Future projects a. Implement objective measures of weight status, physical activity/sedentary behaviours and diet in pregnant women during the first trimester of pregnancy, before delivery and postpartum. b. Develop and evaluate lifestyle interventions in the preconception period (from the end of puberty). c. Develop guidelines for physical activity/sedentary behaviours and diet during pregnancy and postpartum. Justification: reducing the prevalence of maternal obesity and excessive gestational weight gain and facilitating healthy lifestyles at these times should help to prevent NCDs in the future. 2. Objective measures of physical activity level, built and social environments Research gaps: there is a lack of objective data on physical activity, sedentary behaviour and sleep in children and adolescents. 7Future projects a. Continue to implement objective measures of physical activity/inactivity and sleep patterns of the population, with improved access to these data. b. Develop tools to objectively measure the built/social environments that relate to physical activity. Justification: objective data will allow policy-makers to be fully informed about the impact of interventions to promote integrated physical activity for all. 3. Healthy and environmentally sustainable diet This was selected as the priority project to be discussed in greater detail on Day 2 (see below). The group was not able to cover all foods, so it focused on fat/oil, fish, processed meat, fruit and vegetables, and alcohol. Priority project Healthy and environmentally sustainable diet Research gap What constitutes a healthy and sustainable diet, and how can this be integrated into food-based dietary guidelines? Justification To simultaneously tackle food-related NCD epidemics and the challenges of climate change. Project design 1. Evidence-building • There are many gaps in knowledge of healthy/sustainable diets: what is a healthy diet and a sustainable diet, and what would be the optimal balance between the two (taking gender, age and the local population into account)? Evaluation is needed of the availability of food products in different countries and differences in diet (including, for instance, cultural differences – alternatives to meat products, for example, may vary between countries); and existing national policies on healthy/sustainable diets could be assessed. Optimization modelling in some sample countries could be used to evaluate the impact of changes at country level (for example, the effect of reducing red meat intake on iron intake should be assessed). 2. Implementation • WHO/Europe takes a position on the principles of a healthy and environmentally sustainable diet in the European Region. • An integrative implementation strategy and negotiation strategy is developed at country level. • Countries are engaged to develop healthy/sustainable dietary guidelines for all actors. 3. Communications • A communication strategy should also be developed, to make the case for the health/environment win-wins that are available. Outcomes The outcomes would be the WHO/Europe position on the principles and the implementation strategy; and, in the longer term, there would be a reduction in the risks of NCDs and in the negative impacts of the food system on the environment. “We need to tackle the urgent and important health issues facing our planet today – top amongst which is climate change.” Professor Mike Rayner University of Oxford, United Kingdom 8Suggested collaboration All the participants in the discussion group expressed their willingness to be involved in a steering committee to take this project forward. Other potential collaborators would be other WHO CCs, experts/researchers, nongovernmental organizations (NGOs), funding agencies, foundations and the European Commission. WHO/Europe support would be required to fund the project, as well as to provide contacts, technical knowledge, and negotiation and strategic input. Alcohol Discussion group members: Canada, Italy, the Russian Federation, the United Kingdom. Brainstorm: gaps and opportunities • Data: country-level surveys, data on abstention, alcohol and socioeconomic status (individual and aggregated), social/cultural perceptions of alcohol. • Knowledge: “we monitor but don’t evaluate” – need to bridge gaps between evidence and policy, economic analysis (including return on investment) of alcohol strategies and prevention (including taxation), effectiveness of treatment (including brief interventions), youth prevention, advertising/ promotion/sponsorship. • Making connections: risk factor for many NCDs (cancer, cardiovascular disease, obesity, etc.) and for injury (link with police records), workplace health, integrated substance approach. Priority topics 5 1. A framework for alcohol Research gap: what would the equivalent of the Framework Convention on Tobacco Control (FCTC) look like for alcohol? Future project: the aim would be to produce an international convention equivalent to the FCTC. Justification: to address the lack of internationally binding instruments in alcohol (including treatment). Current global strategies are “toothless” and, while this would not be a panacea, it would be a step in the right direction. 2. Registry for alcohol-related injuries Research gaps: there is a lack of comprehensive, reliable, consistent data on alcohol-related injuries and a “potpourri” of strategies. Future project: to establish registries tracking alcohol-related injuries. 5 Two other priorities were discussed, but in less detail: alcohol intervention co-benefits and a Health Evidence Network review of alcohol guidelines in the WHO European Region. 9Justification: current data are poor and do not provide sufficient justification to change policies – without these data, there will be no evidence-based interventions. Better tracking could lead to better estimates and much clearer injury prevention strategies. 3. The investment case for alcohol policy “Whenever we talk to ministries beyond the Ministry of Health, they want real data on return on investment.” Research gap: there is insufficient country-level data on the return on investment of alcohol policy. Future project: to research and publish country-specific investment cases for alcohol policy. Justification: the models exist to develop the investment case, but it will require a research workforce and input from the countries themselves. The investment case topic was extended to cover other risk factors and discussed as the priority project on Day 2 (see below). Priority project Modelling best buy investment cases for alcohol, tobacco and sugar-sweetened beverages (SSBs) in three countries in the WHO European Region Research aims To develop a comprehensive best buy investment case for alcohol, tobacco and SSBs in three countries in the WHO European Region through a collaborative modelling project. The aim is to provide countries with evidence on the financial and health impacts of investing in the best buys. A further, wider aim would then be to use this knowledge to develop a user-friendly tool, offering training and capacity-building in use of the tool (initially in the three pilot countries and then more widely). Pilot project design 1. Do resource stocktake (using e.g. the OneHealth or WHO-CHOICE tools) and develop project proposal • Already in place: validated models, evidence-based WHO best buys,6 expertise, collaborative infrastructure, and Member State appetite for this information within the WHO European Region. • Required: a concrete proposal and timeline, funding, formal agreement (memorandum of understanding) from pilot Member States, country-specific data and modelling teams. 2. Formalize country participation and CC input • The discussion group suggested that there would be interest from the CCs in Czechia, Germany, Portugal and the Russian Federation. Modelling could be undertaken by a group in Barcelona, Spain, that is currently working to establish itself as a CC. 3. Begin the work! • The first meeting would bring together the CCs to share expertise. • The best buys (e.g. starting with three alcohol best buys) would be modelled in the pilot countries. • A second meeting would allow dissemination of the results and involve a wider group of stakeholders (including Ministries of Health and Finance). 6 Tackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017 (https://www.who.int/ncds/management/best-buys/en). 10 Outcomes The outputs of the pilot project would be strong country-specific cases to invest in the NCD best buys. The process of developing the investment case in the pilot countries would then be used to develop a user-friendly tool that could be rolled out by WHO European Member States to model the investment case for the best buys in their own countries, integrating it into their policy decision-making processes. This assessment tool must be easy to use and replicable – the feasibility of this further phase of the project would need to be carefully assessed. Suggested collaboration WHO/Europe would initially work to confirm Member State appetite for involvement in the project. In addition, WHO/Europe would organize the meetings, write and coordinate memoranda of understanding with participating governments, develop a policy document template, and facilitate publication and dissemination of the pilot results. A team in Barcelona, Spain, would act as the focal point on modelling, requesting data from the in-country CCs (Portugal, the Czechia and Germany were suggested) and then undertaking the analysis and drawing up the results. A CC in the Russian Federation would interpret and analyse the results of the modelling and – if the wider project went ahead – develop the user-friendly tool and engage in capacity-building under the guidance of the Barcelona focal point. Tobacco Discussion group members: Germany, Kazakhstan, Poland, Spain, the Russian Federation. Brainstorm: gaps and opportunities • Regulation: restricting sales outlets, need for clear guidance on regulation from WHO, including on ENDS and HTPs. • Lack of data: health effects of ENDS and novel products (e.g. need for time-limited trials – “quick and dirty evidence”; need for “bulletproof data”, including evaluation of policy measures). • Cessation: cessation in primary health care; impacts on mental health and weight gain; support for vulnerable groups; cessation for health care professionals themselves; affordable cessation; cessation for people with cancer. • Pregnancy: clear messaging, incentives and social support for pregnant women and partners. • Policy implementation: barriers to implementation (including tobacco industry interference); need for smoke-free public places (including prisons). • Knowledge: health literacy; school-based curriculum on tobacco; sharing good practice (including across the risk factors). • Combating the actions of the tobacco industry. 11 Priority topics 7 1. Cessation Research gaps: Many research gaps in cessation were identified during the brainstorm and discussion. Future project: priority actions in cessation were identified as sharing good practice between countries; training and capacity-building; implementation research; strengthening guidelines; tobacco-free pregnancy; and education of health professionals. Cessation should be financed nationwide by national health insurance schemes, with drug reimbursement. Justification: there is a need to tailor cessation to vulnerable groups (such as people living with mental illness and prisoners) and people with specific needs (such as pregnant women, people living with cancer, etc.). 2. Taxation Research gaps: there is much more that can be done to improve systems of taxation of tobacco, particularly in countries in the WHO European Region that are outside the European Union (EU). Future project: priority actions in taxation were identified as sharing good practice between countries; training and capacity-building (including among health professionals and policy-makers); cross-ministerial convening to ensure an integrated approach (e.g. finance, agriculture, education, led from the top by prime ministers); and further work to increase the evidence base on the impacts of taxation, including simulation models and return-on-investment reports. Justification: according to WHO, taxation (increasing the price of cigarettes) is the most effective factor in reducing smoking prevalence at population level. 3. Regulation/policy implementation of ENDS and HTPs This was selected as the priority project to be discussed in greater detail on Day 2 (see below). Priority project ENDS and HTPs: regulation and policy implementation Note: there was significant overlap in the discussions of the tobacco and policy implementation discussion groups on Day 1, and the decision was made to combine efforts and ideas when drawing up a priority project. Research gap There is a lack of a clear set of guidelines on novel tobacco products – ENDS and HTPs. Justification There has been a huge recent increase in prevalence, especially among young people (to whom the products are attractive and aggressively marketed); evidence and guidance are not currently strong enough. 7 Two other priorities were discussed, but in less detail: a need to define future goals in tobacco use (defining the “end- game”) and new forms of tobacco industry interference. 12 Research aims 1. Summarize existing evidence on health effects and current regulatory options and practices relating to novel tobacco products. 2. Assess Member States’ specific needs for information required to develop national evidence-based policies. (There is currently a regulation gap between EU and non-EU countries in the European Region.) Project design This project takes a stepwise, mixed-methods design approach: • review existing reports and reviews; • use case studies to highlight and review Member States’ experiences from across the Region; • summarize existing evidence, including the latest knowledge on health effects, cessation, the potential role of the products as a gateway to nicotine addiction, and second-hand exposure (infographics and fact sheets would be produced to ensure a wider audience); • develop a policy brief outlining WHO’s position, which could be used by Member States. Outcomes The materials will provide guidance to be used by Member States to develop country-specific policies and recommendations and to direct and inform further steps that can be taken in the future. Suggested collaboration The CC in Warsaw, Poland, offered to support the development of materials, which could then be presented to governments by other in-country CCs (WHO/Europe would also assist with dissemination). If CCs positioned themselves as indirectly representing the countries in which they were based, there could be an opportunity for them to put in a request for more support to the WHO regional committee. Assistance from WHO/Europe would be required to identify the countries with existing regulation in novel tobacco products and to assist in coordinating input from the CCs across the Region. WHO/Europe would also write and fund the summary materials using information from CCs. Policy implementation Discussion group members: Bulgaria, Croatia, the Russian Federation, Switzerland. Brainstorm: gaps and opportunities • Integration of policy areas: a process to establish a national approach to addiction. • Research: experimental trials on policies; evidence of impact of agricultural policies on health; reliable data on policy implementation; and qualitative research into how well societies are prepared for change. • Industry: lack of food sales data. • Knowledge: training/education on (a) advocacy for researchers, (b) health policy for people in the media, and (c) policy for schoolchildren; guidance on alcohol in the workplace; a guideline for national nutrition policy implementation in institutions; a database of health laws. 13 Priority topics 1. Improving availability of reliable data on policy implementation Research gap: there is a lack of high-quality data and no established methodology to evaluate public health policy implementation and impact. Future project: a range of approaches could be taken – time-dependent laws that are automatically evaluated, experimental trials on future policy implementation projects, improved access to simulation tools, and improved models for analysing cost–effectiveness. Justification: these measures would greatly improve understanding of policy implementation; they will help to defend policy against criticism and to identify any unexpected consequences, ensuring that the most effective policy options are selected and that improvements can be identified and made as required. 2. Harmonized food composition and sales databases Research gap: there are currently no comparable, widely available databases on food sales and food composition, with a particular lack of data in countries that are in the WHO European Region but outside the EU. Future project: to develop a harmonized database on food composition and reported sales; to require that food composition be included on labelling; and to develop legislation making it mandatory for companies to report on these data. Justification: a food composition and sales database would help to assess dietary intake at a population level (which is important for both food producers and consumers), providing comparable data to identify differences between countries, to monitor the industry and to assess the impact of policy actions. 3. Overcoming loopholes in regulations on new tobacco products This project was selected to be worked out in greater detail in the Day 2 discussion; it was decided to join forces with the discussion group on tobacco to develop the project (see previous section). Research gaps: current legislation refers only to traditional tobacco products, not to heat-not-burn products, water pipes and e-cigarettes. Future project: to organize an expert meeting, held under the WHO umbrella, to set recommendations on what countries should do and to establish what further research is needed and how to manage the industry. Justification: the aggressive behaviour of tobacco companies, combined with the harm done to public health (the products are harmful yet attractive to young people and easily available). 14 Fig. 2. Word cloud drawn from detailed notes of the discussion over the two days of the meeting Training and surveillance Discussion group members: Germany, Portugal, Sweden, the Russian Federation. Brainstorm: gaps and opportunities • Lack of data: insufficient surveillance at local level; lack of data on health behaviours; move from subjectively to objectively measured data. • Collecting data: ensure better harmonization/coordination between different surveys and overcome barriers to data sharing; identify opportunities to use electronic media/records in surveillance. • Understanding data: need to improve (a) health literacy; (b) training on established and innovative research methods and data for health care professionals and researchers (and need to develop a standard curriculum); and (c) presentation of data to policy-makers. Priority topics 8 1. Harmonization and innovative methods Research gap: data are often not harmonized, access to existing surveillance data is inadequate, and there is a lack of innovative methods (such as use of information technology). 8 Two other priorities were discussed, but in less detail: funding for training/surveillance and the barriers to sharing data. 15 Future project: to establish a methods platform that would provide open access to data; stakeholders and experts would be able to propose ideas, such as harmonization of existing surveillance systems. Justification: open access to harmonized data “just makes sense!” 2. Surveillance of new indicators Research gap: lack of data on upstream determinants of health behaviour and on implementation of interventions and policies. Future project: mapping the needs and interests of policy-makers at local level and identifying relevant data sources; a further project could be to look at the impact of the local environment on health, beginning by bringing together local policy-makers to ascertain the data that would help them. Justification: upstream determinants of health are becoming more important, but there are insufficient data on these determinants of behaviour, particularly at local level: “data is collected nationally but action tends to happen locally”. 3. Increasing knowledge of surveillance methods This was selected as the priority project to be discussed in greater detail on Day 2 (see below). Priority project A platform for training on NCDs – surveillance, implementation and evaluation Research gap There is insufficient knowledge of specific NCDs and risk factors, coupled with a lack of understanding both of surveillance techniques and of methods to use in evaluating programmes. Research aims The project has four aims, which will upskill and empower the individuals who undertake in-country surveillance: • to develop a curriculum for a training platform (mapping needs, gaps and current offers), with modules designed by CCs; • to increase the availability and accessibility of training in NCD surveillance, implementation and evaluation; • to increase knowledge of NCDs; • to improve surveillance practice. Project design The WHO/Europe training platform on NCDs would provide integrated, comprehensive training on surveillance and evaluation methods, both face to face (summer schools and one-day courses, perhaps timed to be delivered contiguously with other international meetings) and online (video, webinars and interactive components). Outcomes • A report on needs and gaps in surveillance, including identification of target groups and prioritization of topics. • An inventory of existing training modules and capacities within WHO/Europe and the CCs. • Draft training curriculum on surveillance methods, implementation/evaluation of local interventions, etc. • Course materials, including recordings and slide decks. 16 Suggested collaboration Each participating CC would contribute to the initial mapping and then take the lead in a specific topic and develop material for it (for example, the CCs represented within the discussion group could help to coordinate physical activity surveillance, introductions to statistics/surveillance/quality management, evaluation of local interventions, and nutrition/physical activity). Each CC will provide input on other modules of interest and review the final content. Other organizations could also be invited to be involved in designing the curriculum modules. WHO/Europe support will be required to coordinate the needs assessment and mapping, to establish the platform, to review the content developed by CCs, and to organize face-to-face training workshops. Diet – problem definition Discussion group members: Australia, Kazakhstan, Macedonia, the Netherlands, Portugal, the Russian Federation, the United Kingdom. Brainstorm: gaps and opportunities • Definition: find a definition of “healthy diet” appropriate to populations; combine environmental sustainability and health. • Data: harmonize tools and methods, develop new tools to collect data and improve national surveys, improve data-gathering on food composition. • Guidance: translate population-level evidence into individual recommendations that are culturally appropriate and affordable (balance health and food security); roll out user-friendly labelling. • Industry: assess and monitor industry marketing (experience, effect, regulation); appropriately support/ incentivize food reformulation. Priority topics 9 1. Need for national surveys, nutrient information and harmonizing tools Research gap: there is a need for national surveys across Europe and harmonized methods (including food composition data); the methodology must allow for adequate representative sampling for subgroup analysis. Future project: WHO and CCs to take the lead on a practical, cost–effective approach; this will enrich the data on food composition. Justification: current and past initiatives are intensive and deemed to be unworkable. 9 The discussion group found it challenging to choose just three priorities. The other two topics that were discussed but not presented in plenary were (a) the need for better evidence on diet/healthy diet and specific diseases; and (b) how to translate population-based evidence into consumer information and individual advice on NCD prevention and management. 17 2. Translation of data into policies Research gap: a failure adequately to translate existing data into effective policies. Future project: a concrete project was not identified in the discussion; however, the group agreed that there is a need (a) to monitor where changes in policy have been reflected in data collected through surveillance; and (b) to work with policy-makers to ensure that surveillance data are optimal for their purposes. WHO should lead this approach. Justification: to create policy impact from research and surveillance. 3. Commercial determinants of health and access to new forms of data This was selected as the priority project to be discussed in greater detail on Day 2 (see below). Priority project Industrial contribution to data – food sales and composition Research gap There is a lack of accessible sales/marketing information for use in public health. Justification Rich data on sales and back/front-of-pack information are available but not being used. Working with industry in a trusted environment could lead to the acquisition of data to track progress internationally and help to redress the power imbalance between public health and the food industry. Research aim To establish a methodology to access and analyse food sales and front/back-of-pack nutrient information from major food retailers/producers, for food products high in fat, salt and/or sugar (HFSS), as defined by a nutrient profile model. Project design 1. Establish study protocols suitable for each country under investigation. 2. Select major providers/retailers to include in the study (using defined inclusion/exclusion criteria). 3. Undertake a review of the industry data provision in the European Region. 4. Hold key informant interviews with stakeholders (including consumers, national NGOs, etc.) to identify incentives to share data (for example, to provide ideas on opportunities to sell healthier, more sustainable food – working on positive foods as well as HFSS products). 5. Analyse sales data (a proxy for consumption) and compare the countries; interpretation of the findings must consider country-level differences across the Region. Acquiring data from commercial suppliers was rejected because it is expensive, however; “if the food and alcohol industries claim they want to be part of the solution, this is where they can really contribute – make the data available to WHO, free of charge, now!” (Dr João Breda, WHO/Europe). Working in a trusted environment will facilitate the appropriate provision of data from the companies. Outcomes Initial outputs of the project would be a mapping of data provision in Member States (including gaps and best practice) and an incentive package devised to support the provision of data. A plan for data acquisition, management and use of data from industry would then be developed and carried out. 18 The WHO Knowledge Action Portal (KAP) In November 2018, the WHO Global Coordination Mechanism on the Prevention and Control of Noncommunicable Diseases (GCM/NCD) launched the Knowledge Action Portal (KAP) (http://www. who.int/kap), an online platform and community-driven hub that aims to facilitate information-sharing and collaboration among a wide range of stakeholders: Member States, United Nations agencies, NGOs, academia and the private sector. The KAP includes an extensive database of NCD resources submitted by GCM/NCD members; these include mapping of country-level prevalence and risk factor data, and information on multisectoral and multi-stakeholder country action on NCDs. Users can subscribe to different topics and be notified when new materials are submitted. The KAP ultimately aims to create a community of connected individuals from a variety of backgrounds and with a range of skill sets, providing a central point to access knowledge and information, promote collaboration, and empower global, regional, national and local action against NCDs: “The KAP is a social network for the NCD community … moving beyond information to interaction and inspiration” (Mr Jack Fisher, GCM/NCD, WHO). A feature of the KAP still in development is its “Research Connect” function. Questions such as “Who is working on NCDs?”, “Where are they based?”, “What are they working on?”, “How can we connect?” and “Where can we find money for our projects?” are all too common and currently difficult to answer. In response to such questions, the Research Connect will fill an existing gap – mapping data, linking various stakeholders, fuelling collaboration, reducing research duplication, and maximizing funding opportunities for NCD research. Participants at the meeting were surveyed on their interest in the KAP, using a real-time, online tool that proved easy to use and engaging. (1) What is your level of interest in using the KAP and Research Connect? (2) What data could usefully be included in the Research Connect? Responses included: databases (e.g. food composition); anonymized study data; grants awarded by key funders; an alert system to signal when a funding call is open; the Cochrane Library; scenario model comparison; details of training courses; relevant meetings and events; and data on mortality/morbidity and risk factors at subregional level. 19 Over time, changes will be tracked and analysis of policy/tax approaches supporting reformulation and sales of HFSS foods improved. Such analysis will provide evidence for recommendations to improve diets. Suggested collaboration If the project were taken forward, all members of the discussion group would be willing to use existing students/research assistant staff to collect data on example countries and to identify leads for each step in the project. WHO/Europe support would be required to coordinate CC activity; to approve a harmonized protocol; to assist with contacting ministries and gaining access to key stakeholders; to provide access to country-level data (e.g. on policies); and to support publication and dissemination of the results of the study. Other potential collaboration partners include industry umbrella organizations; chambers of commerce and trade unions; ministries (including finance and health); universities and research centres (including other CCs); nutritionists working in industry; consumer and health organizations; and relevant EU-funded initiatives, such as the Joint Action on Nutrition and Physical Activity (JANPA). Looking ahead: building a network This is the first time that the CCs on NCD risk factors and surveillance have been convened by WHO/Europe and the first time that a set of priorities has been collaboratively developed. The meeting “has allowed us to align collaborating centres’ skills and capacity with the needs of WHO” (Dr Carina Ferreira-Borges, WHO/Europe). There was evident enthusiasm to continue working together – in particular, to improve translation of research into policy and then to monitor and evaluate the impact of policy in practice and to work with policy-makers to refine it. Member States request this assistance from WHO/Europe, and it is through the involvement of CCs that it can be successfully delivered. There has, in the past, been some reticence within WHO to work with external partners; this approach may help to overcome this inhibition. CCs are often at the cutting edge of research and can help to clarify and support WHO or Member State positions on controversial issues. In addition to identifying five priority projects, the meeting articulated the wide range of training that is already offered by CCs or that could be offered in future. Coordinating, extending and disseminating these opportunities could be of significant benefit to those working in NCD prevention and control within and beyond the WHO European Region. The proposed establishment of a network will facilitate the participation of CCs. In-person meetings would be welcome, perhaps organized to be contiguous with other meetings attended by participants in order to minimize travel and cost requirements. Communication by WHO/Europe will also be extended to include sharing “We want this meeting to have consequences. It is not an end in itself – it is the first step of something bigger!” Dr João Breda, WHO/Europe “We must not just elaborate the problem: we need to develop solutions!” Professor Mike Rayner University of Oxford, United Kingdom 20 information about the work of CCs. The CCs were also asked to follow up with ideas for the network or for joint working – and to be both critical and constructive. This meeting has been the start of a process: the beginning of improved, ongoing working between WHO and multiple CCs on common areas of interest: “What you can do as a big group of institutions jointly with WHO is very powerful” (Dr João Breda, WHO/Europe). Fig. 3. Participants at the meeting in Moscow, Russian Federation, 5–6 December 2018 21Ap pe nd ix 1. Ri sk fa ct or s m ap pe d ag ain st th e pr io rit y pr oj ec ts M an y s ug ge sti on s f or fu tu re jo in t w or kin g by th e co lla bo ra tin g ce nt re s ( C C s) a nd W H O to uc he d on m ul tip le ri sk fa ct or s. By w ay o f i llu str at io n, th e ta bl e be lo w se ts ou t t he is su es d ev el op ed on t he fi rs t da y of t he d isc us sio n (t ho se p re se nt ed in m or e de ta il ar e in it al ics ). T he o ne p rio rit y pr oj ec t c ho se n by e ac h gr ou p fo r f ur th er e xp lo ra tio n on th e se co nd d ay o f t he m ee tin g is lis te d in b ol d. A ga in st th es e pr oj ec t s ug ge sti on s a re m ap pe d fo ur m ajo r r isk fa ct or s f or N C D s: di et /n ut rit io n, alc oh ol , p hy sic al ac tiv ity a nd to ba cc o us e. D is cu ss io n gr ou p to pi c P ro je ct s ug ge st io ns D ie t/ nu tr it io n A lc oh ol P hy si ca l ac ti vi ty To ba cc o D ie t an d ph ys ic al ac ti vi ty H ea lt hy a nd e nv ir on m en ta lly s us ta in ab le d ie t Pr e- co nc ep tio n/ pr eg na nc y/ po st pa rt um s ur ve illa nc e/ in te rv en tio ns O bj ec tiv e m ea su re s of p hy sic al a ct ivi ty le ve l, b ui lt an d so cia l e nv iro nm en ts A lc oh ol M od el lin g be st b uy in ve st m en t ca se s fo r al co ho l, to ba cc o an d SS B s in t hr ee W H O E ur op ea n co un tr ie s Co un tr y- sp ec ifi c in ve st m en t c as es fo r a lco ho l p ol icy FC TC e qu iva le nt fo r a lco ho l Re gi st rie s tra ck in g al co ho l-r el at ed in ju rie s Al co ho l i nt er ve nt io n co -b en efi ts H ea lth E vid en ce N et w or k re vie w o f a lco ho l g ui de lin es in th e W H O E ur op ea n Re gi on 22 Disc us si on g ro up to pi c P ro je ct s ug ge st io ns D ie t/ nu tr it io n A lc oh ol P hy si ca l ac ti vi ty To ba cc o To ba cc o G ui da nc e on n ov el t ob ac co p ro du ct s (E N D S an d H T P s) EN D S an d H TP re gu la tio ns Ta xa tio n of to ba cc o pr od uc ts Ce ss at io n N ew fo rm s of to ba cc o in du st ry in te rfe re nc e D efi ni tio n of o ur fu tu re g oa ls Po lic y im pl em en ta ti on [N B co m bi ne d w ith To ba cc o gr ou p on D ay 2 ] O ve rc om in g lo op ho le s in re gu la tio ns o n ne w to ba cc o pr od uc ts Im pr ov in g av ai la bi lit y of re lia bl e da ta o n po lic y im pl em en ta tio n H ar m on iz ed fo od c om po sit io n an d sa le s da ta ba se s Tr ai ni ng a nd su rv ei lla nc e P la tf or m fo r tr ai ni ng o n N C D – s ur ve ill an ce im pl em en ta ti on e va lu at io n La ck o f h ar m on iz at io n an d in no va tiv e m et ho ds in clu di ng in fo rm at io n an d co m m un ica tio ns te ch no lo gy (IC T) Su rv ei lla nc e of n ew in di ca to rs s uc h as d et er m in an ts o f b eh av io ur a nd im pl em en ta tio n of in te rv en tio ns an d po lic ie s Ba rr ie rs to s ha rin g da ta Fu nd in g 23Disc us si on g ro up to pi c P ro je ct s ug ge st io ns D ie t/ nu tr it io n A lc oh ol P hy si ca l ac ti vi ty To ba cc o D ie t – pr ob le m d efi n it io n In du st ri al c on tr ib ut io n to d at a – fo od s al es a nd c om po si ti on Co m m er cia l d et er m in an ts a nd a cc es s to n ew fo rm s of d at a N ee d fo r n at io na l s ur ve ys , n ut rie nt in fo rm at io n, ha rm on iz in g to ol s an d po w er fo r s ub gr ou ps Tr an sla tio n of d at a in to p ol ici es Tr an sla te p op ul at io n- ba se d ev id en ce in to in di vid ua l m an ag em en t/p re ve nt io n ad vic e an d co ns um er in fo rm at io n N ee d fo r b et te r e vid en ce o n di et /h ea lth y di et a nd s pe cifi c di se as es 24 Appendix 2. Participant survey WHO/Europe has Terms of Reference with each collaborating centre (CC), establishing an area of mutual interest, but CCs’ knowledge and interests often go far beyond this relatively narrow scope. To begin to understand the wider expertise of participants, WHO/Europe and the Collaborating Centre on Population Approaches for NCD Prevention in the University of Oxford, United Kingdom, devised a survey for participants. This identified strengths and weaknesses in coverage of the risk factors, gave an overview of existing CC priorities, and formed the basis for the multidisciplinary groups and discussions. It was completed, in whole or in part, by 28 of the participating institutions and was presented and disseminated at the meeting. Survey questions Are you satisfied with the level of communication your collaborating centre (CC) has with WHO? • The average score was 4.4 out of 5. • Suggestions for improvement included: more frequent visits from WHO, regular joint meetings and discussion exchange (including by Skype/online), and more structured communication including updates on CC activities. Which NCDs are the focus of your research? • Cancer is the NCD on which most CCs focus (17), followed by cardiovascular disease (16), diabetes (14), chronic respiratory disease (10) and mental health (9).10 Which NCD risk factors are the focus of your research? • Poor diet is the risk factor on which most CCs focus (16), followed by tobacco (15), alcohol (14), physical inactivity (11) and air pollution (5).10 Which NCD topic(s) are most closely aligned with your CC’s work? • CCs were given a list of NCD topics from which to choose and were given the option of adding further priorities – most CCs are working across multiple topics: people living with NCDs, youth, collaboration/ partnership and political leadership (19 CCs working in each of these areas); healthy cities (18); poverty/ inequality/human rights and health systems (both with 17); and digital health and scaling up action (both with 16). Other areas include health literacy (15), industry interference (13), climate change (13) and financing (13). What types of research does your CC undertake? • Most CCs (24) undertake monitoring/evaluation and primary data collection, while 23 do quantitative research and 19 qualitative research. Other areas include implementation research (19), longitudinal studies (16) and modelling (13). Just 10 undertake economic analysis. In the past three years, has your CC conducted research relating to the WHO best buys? • 12 CCs have conducted research into the best buys on NCD management and unhealthy diet, 10 on tobacco use, and 8 on physical activity or alcohol. However, only half of the CCs that research the best buys provided evidence to support their assertion, and only a third are working with WHO on this. What does your CC do? • The CCs undertake a wide range of activities. Research – unsurprisingly – was the top response from the CCs (25). This was followed by training/education, providing technical advice to WHO, and 10 In addition to its established 4 x 4 framework, WHO is increasingly recognizing air pollution as a fifth risk factor and men- tal health as a fifth NCD. 25 collection/collation of information (20). Other areas include product development (e.g. guidelines) (19), information dissemination (18) and organizing events (16). Have you collaborated with other CCs? • The CCs were asked whether they already collaborate with other CCs: 16 CCs had collaborated with at least one other CC, while one (based in Moscow) had collaborated with four other CCs. The survey also asked participants for their thoughts on areas on which they would like to work in the future. Many of these were reflected in the subsequent discussions at the meeting (e.g. healthier diets, active populations, and policy impact). Developing the survey Not all the CCs from the WHO European Region working on NCD risk factors were invited or able to attend the meeting, so the survey will be sent to all relevant CCs to extend the knowledge on coverage of risk factors and NCDs, with a view to involving them in projects that are taken forward over the next 3–5 years. Participating CCs will also be given a chance to add to their survey responses, particularly with reference to projects of relevance on which they are working. 26 Appendix 3. Participating institutions and individuals Australia University of Melbourne (WHO Collaborating Centre on Implementation Research for Prevention and Control of Noncommunicable Diseases), Melbourne • Ms Emilia Janca, Researcher, Noncommunicable Disease Control Unit Centre for Health Equity, School of Population and Global Health Bulgaria National Centre of Public Health and Analyses, Sofia • ProfesSor Plamen Dimitrov, Deputy Director • Professor Vesselka Duleva, Head, Department Foods and Nutrition Canada Centre for Addiction and Mental Health (WHO Collaborating Centre for Addiction and Mental Health), Ontario • Dr Kevin Shield Croatia Croatian National Institute of Public Health Centre, Zagreb • Assistant Professor Krunoslav Capak, Director • Dr Ivana Pavić Šimetin, Deputy Director Germany Friedrich-Alexander University Erlangen-Nürnberg (WHO Collaborating Centre on Physical Activity and Public Health), Erlangen • Professor Karim Abu-Omar, Head of the Collaborating Centre and Faculty Member, Department of Sport Science and Sport German Cancer Research Centre (WHO Collaborating Centre for Tobacco Control), Heidelberg • Dr Ute Mons, Head, Unit Cancer Prevention • Dr Katrin Schaller, Science Communication, Unit Cancer Prevention Institute for Epidemiology and Prevention Research – BIPS (WHO Collaborating Centre for Obesity Prevention, Nutrition and Physical Activity), Bremen • Professor Wolfgang Ahrens, Deputy Director Italy Istituto Superiore di Sanita (WHO Collaborating Centre for Research and Health Promotion on Alcohol and Alcohol-related Health Problems), Rome • Professor Emanuele Scafato, Head of the Collaborating Centre, National Centre for Epidemiology, Surveillance and Health Promotion (CNESPS) Kazakhstan Kazakhstan Academy of Nutrition (WHO Collaborating Centre in Kazakhstan for Nutrition), Almaty • Professor Gaukhar Datkhabayeva, Executive Director, Institute of International Projects 27 National Centre for Problems of Healthy Lifestyles Development (WHO Collaborating Centre for Promoting Healthy Lifestyles), Almaty • Dr Assel Abakova, Head, International Cooperation Department • Dr Dana Abeldinova, Chief Specialist Netherlands Institute for Public Health and the Environment (RIVM) (WHO Collaborating Centre for Nutrition), Bilthoven • Dr Ivon Milder, Head of the Collaborating Centre • Dr Elisabeth Temme, Head of the Collaborating Centre, Division of Nutrition and Health • Dr Wanda Wendel-Vos, Investigator, Division of Nutrition and Health North Macedonia Institute of Public Health, Skopje • Dr Igor Spiroski, Head, Department of Physiology and Monitoring of Nutrition Poland Maria Sklodowska-Curie Cancer Centre and Institute of Oncology (WHO Collaborating Centre for Tobacco Control), Warsaw • Dr Magdalena Cedzyńska, Director, Smoking Cessation Clinic, Cancer Epidemiology and Prevention Department • Dr Irena Przepiorka, Coordinator, National Quitline, Cancer Epidemiology and Prevention Department Portugal Institute of Public Health of the University of Porto (ISPUP), University of Porto Medical School, Porto • Professor Henrique Barros, President, Department of Public Health, Forensic Sciences and Medical Education • Dr Romeu Mendes, Researcher, Department of Public Health Nutrition • Dr Patrícia Padrão, Nutritionist National Institute of Health Dr Ricardo Jorge (INSA) (WHO Collaborating Centre for Nutrition and Childhood Obesity), Lisbon • Professor Jose Maria Albuquerque, Member of the Executive Board • Dr Maria Antónia Calhau, Coordinator, Food and Nutrition Department • Dr Ana Rito, Researcher, Food and Nutrition Department Russian Federation Federal Research Centre of Nutrition, Biotechnology and Food Safety, Moscow • Professor Dmitry Nikityk, Director • Professor Victor Tutelyan, Scientific Supervisor • Dr Antonina Starodubova, Deputy Director for Scientific and Medical Work Federal Research Institute for Health Organization and Informatics (WHO Collaborating Centre on Health Information Systems, Health Statistics and Analysis), Moscow • Dr Anna Korotkova, Deputy Director for International Affairs, Department of Health Statistics and Analysis • Dr Elena Varavikova, Leading Researcher, Department of Health Statistics and Analysis V. Serbsky Federal Medical Research Centre for Psychiatry and Narcology (WHO Collaborating Centre on Primary Care Competence in Mental Health and Psychiatric Crisis Interventions in the Community), Moscow • Professor Kekelidze Zurab, Director • Dr Irina Moroz, Deputy Director 28 I.M. Sechenov First Moscow State Medical University (WHO Collaborating Centre on Training and Education of Health Policy-makers in Prevention and Control of NCDs), Moscow • Professor Andrey Demin • Professor Artyom Gil Moscow School of Management SKOLKOVO, Moscow • Dr Irina Svyato, Strategic Consulting Team Leader, Centre for Health Economics and Management in Healthcare National Medical Research Centre for Children’s Health, Moscow • Professor Svetlana Makarova, Head, Preventive Paediatrics Department • Professor Irina Belyaeva National Medical Research Centre for Preventive Medicine (WHO Collaborating Centre on Development and Implementation of NCD Prevention Policy and Programmes), Moscow • Professor Oxana Drapkina, Director • Ms Marine Gambaryan, Leading Researcher Plekhanov Russian University of Economics, Moscow • Dr Ilya Solntsev, Director, Centre for Strategic Studies in Sport Scientific and Practical Psychoneurological Centre Z.P. Solovyov, Moscow • Professor Alla Guekht, Director • Dr Renat Akjigitov, Deputy Director Spain Catalan Institute of Oncology (WHO Collaborating Centre for Tobacco Control), Barcelona • Dr Angel Esteve Fernandez Munos, Director, Tobacco Control Unit Public Health Agency of Catalonia, Barcelona • Professor Jürgen Rehm Sweden Lund University (WHO Collaborating Centre for Implementation of Evidence-based Clinical Health Promotion focusing on Alcohol besides Tobacco, Drugs, Nutrition, Physical Activity and NCD), Malmö • Dr Cecilia Gravin, Technical Officer, Clinical Health Promotion Centre • Professor Hanne Tønnesen, Clinical Health Promotion Centre Switzerland University of Zurich (WHO Collaborating Centre on Physical Activity for Health), Zurich • Dr Anja Frei, Senior Researcher, Epidemiology, Biostatistics, and Prevention Institute United Kingdom European Association for the Study of Obesity, Teddington • Dr Nathalie Farpour-Lambert, President University of Bath, Bath • Dr Nick Townsend, Senior Lecturer, Department for Health University of Leeds (WHO Collaborating Centre for Nutritional Epidemiology), Leeds • Professor Janet Cade, Nutritional Epidemiology Group, School of Food Science and Nutrition • Dr Jayne Hutchinson, Research Fellow, Nutritional Epidemiology Group, School of Food Science and Nutrition 29 University of Oxford (WHO Collaborating Centre on Population Approaches for NCD Prevention), Oxford • Ms Lauren Bandy, Researcher • Professor Mike Rayner, Professor of Population Health • Ms Jessica Renzella, Researcher University of Stirling, Stirling • Dr Andrea Mohan, Public Health Researcher, Institute for Social Marketing World Health Organization Headquarters • Mr Jack Fisher, Consultant, Global Coordination Mechanism Secretariat for NCDs WHO European Office for the Prevention and Control of Noncommunicable Diseases • Dr João Breda, Head • Dr Luigi Migliorini, Senior Advisor • Mrs Kristina Mauer-Stender, Programme Manager, Tobacco Control • Dr Carina Ferreira-Borges, Programme Manager, Alcohol and Illicit Drugs Programme • Dr Ivo Rakovac, Technical Officer • Ms Tina Kiaer, Communications Officer • Dr Kremlin Wickramasinghe, Technical Officer • Mr Stephen Whiting, Technical Officer • Dr Julianne Williams, Technical Officer • Dr Olga Zhiteneva, Technical Officer • Mr Jo Jewell, Technical Officer, Nutrition, Physical Activity and Obesity, WHO Regional Office for Europe • Ms Anna Mezentseva, Programme Assistant • Ms Alena Stepanova, Assistant • Ms Liza Villas, Programme Assistant, Nutrition, Physical Activity and Obesity • Dr Amélie Schmitt, Consultant • Ms Natalia Fedkina, Consultant • Mr Sergey Bychkov, Consultant • Ms Olga Oleinik, Consultant • Ms Marina Bykova, Consultant • Ms Anna Polunina, Consultant • Ms Lea Nash Castro, Consultant WHO Country Office in the Russian Federation • Dr Melita Vujnovic, WHO Representative to the Russian Federation • Dr Elena Yurasova, Technical Officer • Meeting rapporteur: Ms Katy Cooper World Health Organization Regional Office for Europe UN City, Marmorvej 51, DK-2100 Copenhagen Ø, Denmark Tel.: +45 45 33 70 00 Fax: +45 45 33 70 01 Email: eurocontact@who.int Website: www.euro.who.int The WHO Regional Office for Europe The World Health Organization (WHO) is a specialized agency of the United Nations created in 1948 with the primary responsibility for international health matters and public health. The WHO Regional Office for Europe is one of six regional offices throughout the world, each with its own programme geared to the particular health conditions of the countries it serves. Member States Albania Andorra Armenia Austria Azerbaijan Belarus Belgium Bosnia and Herzegovina Bulgaria Croatia Cyprus Czechia Denmark Estonia Finland France Georgia Germany Greece Hungary Iceland Ireland Israel Italy Kazakhstan Kyrgyzstan Latvia Lithuania Luxembourg Malta Monaco Montenegro Netherlands North Macedonia Norway Poland Portugal Republic of Moldova Romania Russian Federation San Marino Serbia Slovakia Slovenia Spain Sweden Switzerland Tajikistan Turkey Turkmenistan Ukraine United Kingdom Uzbekistan