The debate opened up through the article by Allen and Freigl (Lancet, February 2017 and July 2017) is timely and welcomed.

This has been an on going challenge for those working on NCD prevention and one that has not been fully addressed or resolved.

This is probably because it is not possible, given the broad scope of NCDs and the historical bio-medical epistemological basis for defining diseases. This limits the use and development of more accurate, appropriate and useful descriptive possibilities.

To date, no one has succeeded in coming up with an alternative description. I suggest that there is a particular group of NCDs that could be better described and propose three key questions and possible answers that may be helpful to the debate. This group of NCDs is the highest burden of diseases globally and were the focus of the discussions at the high level meeting on NCDs at the UN in 2011. They include cardiovascular disease, diabetes, dementia, cancer, and chronic respiratory diseases.

The term NCDs has become the main parlance for this group of these diseases as a consequence of that high level UN meeting. The UN framework was built around diseases caused and linked by the four main primary risk factors – tobacco, alcohol, energy-rich processed foods high in sugar, fat and salt, and physical inactivity and “sedentarism.” This group of linked NCDs could be much better described and framed, which could help with increasing wider understanding of these diseases; the focus on their causes; and constructing a more productive, prevention-orientated research and development and evidence-based social policy.

Essentially this is a group of diseases linked by common risk factors/determinants/protective factors, common aetiologies and pathologies, which can cause a variety of end organ and organ systems damage which manifest as multi-stage diseases which themselves can become risks for multiple morbidities. They are caused by the duration and dosage of exposure to these risk factors, usually over several decades.

They can theoretically be defined by any stage along the pathway of their distal and proximal causes from the social, environmental and economic determinants of health determining behaviours to physiological risk factors and the diseases themselves.

Probably no overall description can cover the bandwidth of the causes so the logic would be to define by the root cause(s) which could, in turn, lead to a greater focus on high impact interventions.

Historically, as scientists have progressively studied and understood the development and causes of these diseases, where the main focus has been biomedical, the discourse is dominated by terms such as “lifestyle diseases.” This is now rapidly changing as the “causes of the causes” are seen as being determined at a population level by social determinants.

To date, most commentators, particularly politicians and those with vested interests, have unfortunately described these diseases as “lifestyle diseases” which essentially frames them for many as being caused by individuals responsible through rational and conscious ways making good or bad health decisions. This is wrong, reductionist, pejorative and unhelpful.

The reality is, we now know, that these diseases are a relatively new range of diseases and conditions with anthropogenic causes and are better described by the root social population level cause(s) as “industriogenic” diseases (new word!). They are caused by the consumption of health-harming products – the vectors of the disease risks being the ready availability and marketing of these products.

Indeed the main discourse on their prevention should be around health protection as these products are very harmful to human and planetary health. The behaviour change debate should be about the behaviour of health-damaging corporations who should no longer ignore or deny the science.

Further, we now know that 90% of human behaviour is governed by unconscious behaviour which is socially and environmentally patterned. For example, inactivity and sedentary behaviour are significantly influenced by the engineering out of physical activity by the human made physical environment for urban development and private vehicle road transport. New and emerging risks such as air pollution are also “industriogenic.”

If this description was ever adopted then some other diseases may also need to be reclassified. Generally if people use the term then there is more prospect of its adoption.

The term proposed may be criticised for being ideologically framed but language, as with knowledge, can never be truly objective. I would argue that it is a better, more objective fit to the world as we now understand it.

Over time the developing science has changed the discourse from individual to population level causes so this is a welcome debate. The public health world needs to upgrade definitions and descriptions as the term NCDs is now anachronistic and possibly harmful to the progression of effective and efficient public policy.

A short version of this blogpost is at: Lincoln, P. (2017) Renaming non-communicable diseases. e654

Paul Lincoln
UK Health Forum

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