Research Priorities for NCD Prevention and Climate Change: An International Delphi Survey

Climate change and non-communicable diseases (NCDs) are arguably the greatest global challenges of the 21st Century. However, the confluence between them remains under-examined and there is little evidence of a comprehensive, systematic approach to identifying research priorities to mitigate their joint impact. Consequently, we: (i) convened a workshop of academics (n = 25) from the Worldwide Universities Network to identify priority areas at the interface between NCDs and climate change; (ii) conducted a Delphi survey of international opinion leaders in public health and relevant other disciplines; and (iii) convened an expert panel to review and advise on final priorities. Three research areas (water security; transport; conceptualising NCD harms to support policy formation) were listed among the top 10 priorities by >90% of Delphi respondents, and ranked among the top 12 priorities by >60% of respondents who ranked the order of priority. A fourth area (reducing the carbon footprint of cities) was ranked highest by the same >60% of respondents. Our results are consistent with existing frameworks on health and climate change, and extends them by focusing specifically on NCDs. Researching these priorities could progress understanding of climate change and NCDs, and inform global and national policy decisions for mitigating associated harms.

• Healthy placesdesigning towns, cities and rural areas, which are smoke-free, and where it is easy to walk, cycle and play, with unpolluted open spaces and safe local areas that foster social interaction.
• Healthy foodmaking healthy food affordable, and available to all.
• Healthy businessengaging business in the agendas promoting healthy people, healthy places, healthy planet and making good health good business.
• Healthy public policy -formulating comprehensive, innovative and 'joined-up' legislation and social and economic policies that promote health.
• Healthy societiesaddressing equity and socio-economic disadvantage. Rationale Non-communicable diseases (NCDs) are not only a health problem, they are a sustainability and human development disaster. They are inextricably linked to the global environmental and economic crisis. Their impact on human capital is inexorable.

Oxford
The United Nations General Assembly's unanimous decision in 2010 to hold a UN High Level Meeting on NCDs in September 2011 signals growing government recognition and concern about the impact of the global emergency arising from diabetes, heart disease and stroke, cancers and chronic respiratory diseases and their modifiable antecedent risks. These diseases are closely associated with mental illness and result in untold personal suffering and grave social and economic hardship. Individually and collectively they are major causes of poverty and lost productivity and pose a significant barrier, not only to human development, but also to global economic stability and prosperity.
These diseases form a substantial component of a broader global sustainability predicament that threatens economic and environmental sustainability and human capital. Their modifiable causes, particularly physical inactivity and under-or over-nutrition, go hand in hand with social inequality and with vectors of climate change such as over-urbanisation, poor urban design, sedentary automated work and play, and unhealthy food grown or manufactured through carbon intense food production methods. Many aspects of these things can be mitigated or ameliorated through laws. Yet, despite the obvious direct and indirect links between NCDs and climate change, the confluence remains under-examined in both global health and climate change research. Consequently, the Global Health Justice Network of the Worldwide Universities Network (WUN) met in Sydney on 5-7 May 2011 to consider how these issues might be addressed.

Purpose
The meeting brought together academic researchers from a range of disciplines including law, medicine and public health, the social sciences, environmental science, nutrition, psychology, policy, politics, and philosophy from academic institutions in the UK, the USA, Canada, the West Indies, and Australia. Its purpose was to explore, debate and identify key research deficits and priorities at the interface between NCDs and climate change to which the law might be applied to mitigate current and/or future harms and achieve co-benefits.

Process
Drawing on the 2008 Sydney Resolution (www.oxha.org) which called for urgent action on NCDs and their environmental vectors, delegates considered knowledge and evidence deficits that currently hinder progress on NCDs and climate change and exacerbate social injustice. The debate was anchored in the elements and components of optimally healthy and environmentally friendly:  Places  Food  Business  Public policy  Societies Page 1 of 2

Agreed priority areas
Five overarching research areas were identified as priorities on the basis of their i) capacity to impact positively one or more aspects of the intersect between climate change and NCDs, ii) amenability to mitigation through legal and ethical frameworks and governance systems and, iii) potential to contribute to addressing critical deficits in our knowledge and understanding of how to mitigate the current NCD and climate change crisis. They are:

Global and national policy
Can NCDs and climate change be integrated at the global and national level and how are NCD interventions justified by (and to) governments to assist them in balancing health and environmental gains versus restrictions on personal/corporate freedoms? This would require engaging all levels of government, civil service and civil society in systematically 'visioning' the goals of society globally and in determining which overarching principles have supremacy over others. For example, should health and/or climate change take precedence over economic growth or vice versa.

Food systems
How can food systems from 'paddock to plate / farm to fork' be re-engineered to maximise nutrition and minimise environmental harm. This would require researching: -the magnitude /extent of food waste the utility of using food waste to make biofuels the intergenerational safety and/or harms of genetically modified food the impact on human health of food manufactured or produced with nanotechnology the benefits and harms for NCDs, the environment and local economies of localising food production and consumption the relative effectiveness of various strategies for averting the anticipated global food crisis eg containing population growth versus reducing overconsumption.

Corporate social responsibility (CSR)
How can corporations be incentivised and enabled to deliver an integrated approach to improving health (specifically with regard to measures of NCD risk) and reducing carbon emissions and environmental damage more broadly? -do CSR principles and rhetoric match what corporations do in reality? -can/should governments and agencies such as the International Standards Organisation set stricter obligations for corporations to integrate and report on environmental and health impacts/outcomes as a condition of their registration? -should international trade law agreements include more specific exceptions allowing and protecting public and environmental interest regulation?

Health in all policies
How effective is a 'health in all policies approach' in mitigating NCDs and climate change? How do various government sectors understand, address, operationalise considerations of climate change and NCDs within their mandate? What influences them to do so? This would include the development of reliable audit tools to monitor each sector's response to health and climate change.

Regulatory interventions
What is the impact on behaviour change of specific regulatory interventions eg: -would mandatory labelling of foods with their carbon footprint change people's purchasing behaviour in favour of health and environmental considerations? -does mixed density housing reduce vectors of climate change and NCDs?
Additional critical issues were identified around urbanisation, social inequity /distributive justice, adaptation to climate change and dwindling natural resources. These, together with the areas above, are being refined into specific research questions through an international Delphi Process designed to canvass the expertise, insights and professional wisdom of researchers from the broad spectrum of disciplines working at the interface between NCDs and climate change.

ROUND 1 -OCTOBER 11, 2011
Dear Colleague Thank you for participating in this Delphi process which aims to expand on and complete the list of research priorities around the interface between climate change and non-communicable disease (NCD) prevention which was identified at the Worldwide Universities Network (WUN) Global Health Justice Network workshop held in Sydney, Australia, in May of this year. These five research priorities are shown in the WUN Communiqué on Combining Climate Change and NCD Prevention (see Appendix 1: page 2 of this survey document). We are seeking your views on additional areas of importance which may have been overlooked at the May workshop -particularly those which may be amenable to modification through the application of laws and regulatory processes.
To undertake the survey please read and consider the 5 research priority areas identified in the May 2011 WUN Communiqué (Appendix1) and: 1  The United Nations General Assembly's unanimous decision in 2010 to hold a UN High Level Meeting on NCDs in September 2011 signals growing government recognition and concern about the impact of the global emergency arising from diabetes, heart disease and stroke, cancers and chronic respiratory diseases and their modifiable antecedent risks. These diseases are closely associated with mental illness and result in untold personal suffering and grave social and economic hardship. Individually and collectively they are major causes of poverty and lost productivity and pose a significant barrier, not only to human development, but also to global economic stability and prosperity.
These diseases form a substantial component of a broader global sustainability predicament that threatens economic and environmental sustainability and human capital.
Their modifiable causes, particularly physical inactivity and under-or over-nutrition, go hand in hand with social inequality and with vectors of climate change such as over-urbanisation, poor urban design, sedentary automated work and play, and unhealthy food grown or manufactured through carbon intense food production methods. Many aspects of these things can be mitigated or ameliorated through laws. Yet, despite the obvious direct and indirect links between NCDs and climate change, the confluence remains under-examined in both global health and climate change research. Consequently, the Global Health Justice Network of the Worldwide Universities Network (WUN) met in Sydney on 5-7 May 2011 to consider how these issues might be addressed.

Purpose
The meeting brought together academic researchers from a range of disciplines including law, medicine and public health, the social sciences, environmental science, nutrition, psychology, policy, politics, and philosophy from academic institutions in the UK, the USA, Canada, the West Indies, and Australia. Its purpose was to explore, debate and identify key research deficits and priorities at the interface between NCDs and climate change to which the law might be applied to mitigate current and/or future harms and achieve co-benefits.

Process
Drawing on the 2008 Sydney Resolution (www.oxha.org) which called for urgent action on NCDs and their environmental vectors, delegates considered knowledge and evidence deficits that currently hinder progress on NCDs and climate change and exacerbate social injustice. The debate was anchored in the elements and components of optimally healthy and environmentally friendly:  Places  Food  Business  Public policy  Societies Page 1 of 2

Agreed priority areas
Five overarching research areas were identified as priorities on the basis of their i) capacity to impact positively one or more aspects of the intersect between climate change and NCDs, ii) amenability to mitigation through legal and ethical frameworks and governance systems and, iii) potential to contribute to addressing critical deficits in our knowledge and understanding of how to mitigate the current NCD and climate change crisis. They are:

Global and national policy
Can NCDs and climate change be integrated at the global and national level and how are NCD interventions justified by (and to) governments to assist them in balancing health and environmental gains versus restrictions on personal/corporate freedoms? This would require engaging all levels of government, civil service and civil society in systematically 'visioning' the goals of society globally and in determining which overarching principles have supremacy over others. For example, should health and/or climate change take precedence over economic growth or vice versa.

Food systems
How can food systems from 'paddock to plate / farm to fork' be re-engineered to maximise nutrition and minimise environmental harm. This would require researching: -the magnitude /extent of food waste the utility of using food waste to make biofuels the intergenerational safety and/or harms of genetically modified food the impact on human health of food manufactured or produced with nanotechnology the benefits and harms for NCDs, the environment and local economies of localising food production and consumption the relative effectiveness of various strategies for averting the anticipated global food crisis eg containing population growth versus reducing overconsumption.

Corporate social responsibility (CSR)
How can corporations be incentivised and enabled to deliver an integrated approach to improving health (specifically with regard to measures of NCD risk) and reducing carbon emissions and environmental damage more broadly? -do CSR principles and rhetoric match what corporations do in reality? -can/should governments and agencies such as the International Standards Organisation set stricter obligations for corporations to integrate and report on environmental and health impacts/outcomes as a condition of their registration? -should international trade law agreements include more specific exceptions allowing and protecting public and environmental interest regulation?

Health in all policies
How effective is a 'health in all policies approach' in mitigating NCDs and climate change? How do various government sectors understand, address, operationalise considerations of climate change and NCDs within their mandate? What influences them to do so? This would include the development of reliable audit tools to monitor each sector's response to health and climate change.

Regulatory interventions
What is the impact on behaviour change of specific regulatory interventions eg: -would mandatory labelling of foods with their carbon footprint change people's purchasing behaviour in favour of health and environmental considerations? -does mixed density housing reduce vectors of climate change and NCDs?
Additional critical issues were identified around urbanisation, social inequity /distributive justice, adaptation to climate change and dwindling natural resources. These, together with the areas above, are being refined into specific research questions through an international Delphi Process designed to canvass the expertise, insights and professional wisdom of researchers from the broad spectrum of disciplines working at the interface between NCDs and climate change.
Delegates The results of Round 1 are presented below and we now seek your assistance in reducing and ranking these research questions and ask that you complete the survey form (below) and return it by February 3, 2012 to Dr Sinead Boylan at sinead.boylan@sydney.edu.au In deciding which questions you wish to exclude and how the remaining questions should be ranked we ask that you keep in mind that we are primarily looking for research questions that: -are of central importance to the global response to NCD prevention and climate change -address a knowledge or evidence deficit that is preventing progress in area of high importance to the overlap between mitigating or adapting to climate change and preventing or significantly reducing the impact of NCDs and/or which focus in social and health justice issues -address problems at the interface between NCDs and climate change which may be amenable to modification through legal interventions -have some urgency or immediacy Food systems and food security 1. What is the difference in nutritional properties between grass-fed and intensively reared livestock? 2. How can food needs be defined to meet optimal nutrition within an environmentally sustainable agricultural program? 3. What climate resilient fruits and vegetables crops could be promoted in different types of environments?
4. How does climate change affect gene expression and production of functional food products in crops?

5.
How can we effectively predict crop production changes due to climate change and affects on food security (crop adaptation in regions most likely affected)? 6. How does monoculture farming affect ecosystems health and the diet of local population in developing countries? 7. Compared to confined animal feeding operations, do other agricultural practices have less impact on climate change? How are they brought about to a high production-level scale?

8.
What are the benefits of GM food?
9. Which strategies are the most appropriate to improve food security through small-scale farming and environmentally sustainable food production?
10. What impact does climate change have on the possibility that people have to eat fruits and vegetables?
11. Should people eat fish -yes or no?

12.
General evidence that food security is not attainable without decreasing demand for unhealthy cropintensive environmentally-damaging food. 13. Access to potable water for human consumption and agriculture: what current best practices are needed to provide equitable access to water between geographic regions and usage demands? Are new best practices needed given climate change?

WUN Research Priorities for Non-Communicable Disease Prevention & Climate Change: Delphi Survey Round 2`
Instructions: Please tick (√) the options that most appropriately reflect your opinion noting that you do not need to rank priorities for any questions you exclude. 3

Research question
Exclude Include Priority High Med Low 14. How do national agricultural policies affect urban food security in different regions?

15.
Should there be national guidelines to enable a diet good for both human and environmental health?

16.
What metrics, policies and governance structures are needed to address tough trade-offs needed in shifting agricultural patterns underway, especially aimed at reducing long term demand for meat and palm and developing a more diverse diet? 17. What are effective incentives and disincentives for healthy and unhealthy food consumption which also promote low-carbon solutions? 18. How does urban food security relate to the effectiveness of local transportation networks and market functioning in a country? Urban design, transport and housing 19. What are the health impacts of a low carbon environment? 20. How can housing policies contribute to climate change adaptation and mitigation?

21.
How can car-dependent cities shrink their carbon footprints in a way that reduces health inequalities?

22.
What are the health effects of innovative approaches to transport pricing?

23.
Does re-designing the built environment and transport systems to promote activity minimise the effects of climate change while promoting health? 24. What role does walking or cycling to work have in reducing key NCD and what kinds of reductions in GHG would be expected? 25. Quantify health co-benefits of alternative transportation plans for expanding cities, taking account both of air quality-related and physical activity related health benefits. 26. What is the role of place in the determination of NCD prevention -is it additive, or independent of various other influences? (national and global contexts, policy food etc.) 27. How can the health and climate change agendas be better aligned with those of urban planners and real estate developers? Round 2` Instructions: Please tick (√) the options that most appropriately reflect your opinion noting that you do not need to rank priorities for any questions you exclude.

Research question
Exclude Include Priority High Med Low

28.
Urban environment -what are the 'sweet spots' where economic success, climate mitigation and health promotion overlap? 29. How does sustainable urban development and transport impact public health? What are the externalities that impact public health that have not been measured as of today? How do we measure these externalities? 30. What are the methodologies to measure the impact of sustainable urban development and transport on health? 31. How do patterns of urban land ownership and related land law impact on sustainable/healthy land use/transport policies and performance? 32. As people are being encouraged to walk more in their communities, are they being exposed to CO2 and other pollutants from automobiles? Is there an ethical imperative here? 33. Natural experimental analyses of how changes in physical living patterns and facilities have been reflected in behavioural and biomedical indicators of NCD risk. 34. How can we integrate commitments to climate change prevention and mitigation into ongoing chronic disease prevention activities such as bikable/walkable communities, complete streets, and urban infill developments? 35. Development and evaluation of the role and impacts of standards based on air quality guidelines, including standards/testing (for improved cook stoves, etc), and associated regulation. 36. What are the most appropriate policies to shift from private motorized transport to healthier and cleaner transport alternatives? 37. What comparative benefits for GHG emissions and prevention of NCD can a shift in motor sports to physical sports? What kind of regulation could be put forward to encourage such a shift? 38. What are the political dynamics of shifting responsibility for land use planning from local to regional or state governments given the impending climate change crises? How successful could this be in a) changing practice on the ground when it comes to implementation and enforcement, and b) incorporating public health goals into regional plans? 39. What are the relative effects of different policies on health in different urban locations with a range of disease burdens and transport infrastructure?

WUN Research Priorities for Non-Communicable Disease Prevention & Climate Change: Delphi Survey Round 2`
Instructions: Please tick (√) the options that most appropriately reflect your opinion noting that you do not need to rank priorities for any questions you exclude.

Research question
Exclude Include Priority High Med Low 40. What is the relative importance of the health argument for influencing urban planning?
Economics, trade and business 41. What are the cost-benefits of fiscal policies such as a fat tax/ healthy subsidies, taking into account the potential benefits or costs that they might have in terms of environmental effects? 42. How can econometric models that provide information about food prices be amended to incorporate information from environmental sensors that are used to warn of local food production declines? 43. Valuation of the economic benefits of reduced NCD burdens (welfare and costs to health sector), of policy options that also reduce greenhouse gas emissions).

44.
What is the share of GDP in low middle income countries from car sales and FDI on food?

45.
What are the economic options for low middle income countries to promote healthy options?

46.
What are the economic options for major car industries to reduce their sales in low middle income countries? 47. What is the economic impact related with health reported as: a) gains when a good policy/program/project is implemented; b) losses when no policy/program/project is implemented or when those implemented cause detrimental results? 48. How does climate change and an increasing population affect urban economic growth and the affordability of food? 49. Is it possible to describe or characterise the environmental costs (in terms of carbon emissions) of EU or US agricultural subsidies? This might need to be done at the level of individual commodities (e.g. oils, milk, fats etc) 50. Is it possible to quantify the environmental costs (in terms of carbon emissions) or specific kinds of production subsidies? 51. Is it possible to produce a combined analysis that analyses production subsidies in terms of both its impact on diet and on disease outcomes, and in terms of its impact on carbon emissions? Round 2` Instructions: Please tick (√) the options that most appropriately reflect your opinion noting that you do not need to rank priorities for any questions you exclude.

Research question
Exclude Include Priority High Med Low 52. How connected are developing country capital city and regional markets to the international commodity markets? 53. How can countries best evaluate the common impacts of climate change and NCDs of national and international trade? 54. What joint mechanisms can countries put in place to reduce the negative impacts of trade on climate change and NCDs? 55. What are some of the specific areas where the drivers of industry conduct are such that voluntary, CSRled responses to the "problem" (which would need to be defined specifically) won't go far enough? What are some of the areas where incentives and a greater alignment between the interests of industry and the specific policy goal (which would need to be defined specifically) mean that voluntary, CSR-led responses could work effectively? 56. Can we develop a model of the areas where engagement with industry, and incentives, could yield effective CSR-led initiatives with a low regulatory cost? What are some of the areas where progress towards specific desired outcomes is likely to require regulation? Social justice 57. Which are the best practices to combat indoor pollution in poor populations? 58. Which are the technological, cultural and economic challenges for replacing bio-mass and coal stoves in poor populations of developing countries? 59. Testing production, finance and delivery of technologies and solutions for the prevention of NCDs and climate change in issues that affect only the poor and the disenfranchised? 60. The relationship between poverty, NCDs and climate change with macroeconomics and fiscal policy at the intersection between poverty and climate change. 61. Research on the scenario as fiscal constraints increase as population ages and NCDs increase with limited capacity to address climate change. Decreased welfare transfers and increasing income inequality. What will be the regulatory mechanisms necessary to address such situations?

62.
Who bears the biggest burden of NCDs and climate change and why?

65.
Do the small island countries in the Pacific represent some weight in the process or do they have to wait on big countries to change the rules? 66. What is the capacity of people living in low socioeconomic conditions to address issues related to climate change and NCD prevention? Will they experience more of a burden? 67. Will initiatives such as social marketing campaigns to educate the public about NCDs and climate change create knowledge gaps between low and high socioeconomic groups and thus contribute further to health inequities? 68. How do women's gender roles related to climate change (e.g. use of solid fuel cooking stoves) increase their vulnerability to NCDS? 69. Which policy and regulatory interventions to reduce indoor air pollution (use of solid fuels) can help achieve reduction in child mortality, promote gender equality/empower women and contribute to extreme poverty? 70. How does climate change-driven famine/malnutrition increase the toll on the unborn/newborn to NCDs in adulthood? 71. What statistical and process model frameworks can best capture the life chances and outcomes for individuals given early life events that are measurable? 72. If all vegetables and fruits are produced locally, what could be the consequences on small island countries (economical, social and environmental)?
Behaviour, communication and information systems 73. What are the most effective ways to shift consumer demand from the 'western' diet to a more diverse predominantly plant-based diet? 74. What incentives could be developed to encourage people to choose living locations that allow them to walk or cycle to work? What kinds of incentives could be used to encourage them to do so when they can?