Title: NIHR Global Health Research Group on Diet and Activity, MRC Epidemiology Unit, University of Cambridge
Funder: Department of Health and Social Care

Abstract: Alignment with the Strategic Objectives of the Cambridge University. Cambridge University is committed to pursuing excellence in research to address the health needs of populations in low and middle income countries (LMICs), and doing so through equitable partnerships. Examples include the Cambridge-Africa programme [1], Training Health Researchers in Vocational Excellence [2], and the Wellcome Trust-Cambridge Centre for Global Health Research [3]. This proposal builds on this commitment, and would substantially enhance Cambridge’s ability to contribute to research and capacity building for the prevention of NCDs in LMICs. Institutional Strengths and Partnerships The proposed Global Diet and Activity Research (GDAR) Group and Network will build on the Centre for Diet and Activity Research (CEDAR) which is internationally recognised for its research in the UK on: population-level determinants of diet and physical activity; evaluation of natural experiments and planned interventions; and the use of public health modelling to estimate the long-term health effects of changes in determinants. The work of the Centre is transdisciplinary with social and behavioural sciences, economics, geographical information science, epidemiology and biostatistics. It has 6 main research groups [4], and includes a strong knowledge exchange strategy with pathways to impact through links with national policy makers. It has developed to a stage where it is ready to broaden its focus to LMICs. CEDAR is part of the MRC Epidemiology Unit, which is globally recognised for its work on the genetic, developmental and environmental determinants of obesity, type 2 diabetes and related metabolic disorders [5]. Unit strengths include objective and subjective assessment of physical activity and diet. This, together with the newly established platform for measuring diet, nutrition and physical activity in the NIHR funded Cambridge Biomedical Research Centre (BRC) [6], will support the proposed GDAR Group and Network in robust and feasible approaches to diet and physical activity assessment in LMICs. As described in the section on collaborations and partnerships, this proposal builds on a growing portfolio of studies on the determinants of diet and physical activity in LMICs. This includes two recently funded Foundation Awards from the MRC Global Challenges Research Fund, one of which is concerned with the determinants of diet and the other with physical activity and active transport. This proposal builds on two broad groups of institutional partnerships. We will establish the Network by consolidating current partnerships with institutions in Africa (i.e. University of Yaounde, Kenyan Medical Research Institute, University of Witwatersrand, University of Cape Town) and in the Caribbean (i.e. University of the West Indies, headquarters in Jamaica and serving 10 LMICs). In the second year after the Network is established, additional partnerships will be developed extending the geographical scope of the Network. This will involve institutions who are collaborators on the Foundation Awards referred to above: University of Sao Paolo, Brazil; Universidad Peruana Cayetano Heredia, Peru; Indian Institute of Technology, Delhi; and the University of the South Pacific, Fiji. In addition, we will develop a partnership with the Indian Diabetes Research Foundation, Chennai, with which the MRC Epidemiology Unit has previous collaborations. Goal, Aims, Proposed Work Programme. The goal of GDAR is to support sustainable development and the prevention of NCDs in LMICs by establishing a research Network that will investigate the determinants of diet and physical activity, develop and evaluate interventions and inform policy. In pursuit of this goal, we will: 1. Build on the expertise of CEDAR and the MRC Epidemiology Unit to create a GDAR Group 2. Consolidate collaborations with institutions in Africa and the Caribbean to establish a GDAR Network 3. Agree prioritised research and capacity building agendas 4. Establish studies to provide evidence to support population level interventions 5. Broaden the geographical scope of the Network and ensure its sustainability. Our approach to establishing the Network is informed by guidance on successful approaches to transboundary research [7] and research capacity building [8]. Key to this is joint agenda setting for research, capacity building and knowledge exchange, grounded in a thorough understanding of local contexts and needs. This requires equitable governance arrangements, and monitoring and evaluation from the start. Another principle is that capacity building needs are driven by the agreed research agenda, and takes place simultaneously with research. This is the successful approach, for example, of the International Tobacco and Health Research and Capacity Building Program [9]. The programme of activities is summarised in the uploaded Gantt chart and described below. 0-6 months: We will establish the research Network by consolidating partnerships with the institutions in Africa and the Caribbean. This will consist of: (i) Undertaking a detailed assessment of research activities and capacity in each partner institution relevant to the goal of GDAR; identifying key national and regional stakeholders, and current engagement with them. An assessment framework and data collection tools will be developed, using ESSENCE guidance [10] as a starting point. Data collection will include visits from Cambridge to partner institutions. (ii) Producing with each partner a report summarising the findings from (i) (iii) Collating the reports as the basis for a two-day meeting in Cambridge of the partners (16-17 September 2017). The aims of this meeting will be to agree: Network governance arrangements; a prioritized research, capacity building agenda and budget; plans for monitoring and evaluation. 7 to 12 months: The GDAR Group and Network will be fully established, including recruitment to new posts in Cambridge: one to lead investigation of the determinants of diet and physical activity, the other to lead work on the design and evaluation of interventions (a 3rd appointment to a post to lead impact modelling will be made in year two). Appointments will also be made in LMIC partner institutions, in line with the agreed research and capacity building agendas set in month 6. Governance arrangements for the Network will be implemented, including monthly Network Steering Group meetings, with internet conferencing facilities strengthened as needed (see Structure and Governance). 13 to 24 months: By the start of this period new research activities linked to capacity building in the partner countries will be fully established. Given the commitment to joint research agenda setting which will take place in month 6, we cannot state exactly what these will be at this stage. Examples, based on initial discussion with partners of the types of studies likely to be established are: (i) Assessing the impact of recently announced taxes on sugar sweetened beverages and high sugar products in South Africa, St Vincent & the Grenadines, and Dominica (ii) Establishing ‘data platforms’ in Jamaica, South Africa and Cameroon to facilitate the evaluation of changes in the built environment / transport infrastructure on physical activity levels (iii) Objective assessment of physical activity and its socio-economic and environmental determinants in nationally representative nationwide NCD surveys in Kenya and Jamaica (iv) Establishing a study in a South African Township to examine the determinants of diet and physical activity in adolescents, including the influence of school environments. During this 12-month period work will also be undertaken to further develop partnerships with the institutions described above in Brazil, Peru, India and the South Pacific. This will include assessment of their research capacity and stakeholder engagement, plus enabling pilot work to help inform Network plans for the next 5 to 10 years. 25 to 36 months: Three objectives will be met in this phase: (i) An evaluation of how well the Network is meeting its aims, following the monitoring and evaluation plan agreed at the end of the first 6 months. In addition, an independent evaluation will be commissioned to take place between months 25 and 30. This will focus on key aspects of Network functioning, including equity between partners in decision making, satisfaction with the governance arrangements, communication between partners, and engagement with stakeholders. An independent review should enable each partner to properly express their experience of the Network. Such a review will be an investment towards a well-functioning Network for the following 5 to 10 years. (ii) The dissemination of Network activities and findings to date, including to stakeholders, through conference presentations and initial peer reviewed publications. (iii) To agree and implement plans for the sustainability and growth of the Network. Sustainability will be a concern of the Network Steering Group throughout the life of the proposal. It will be planned for in detail at a two-day workshop in months 30 to 33. The workshop will include the new partners, and the findings from the independent review will be considered. By the end of this initial 3-year period we will have established a well-functioning Network with each partner benefitting and contributing. Further funding support for the Network as a whole will be sought. In addition, the aim is that each partner will be committed to the Network and will also be involved in seeking resources to help support their participation.

Lay abstract: The goal of the Global Diet and Activity Research (GDAR) Group and Network is to help prevent non-communicable diseases (NCDs), including type 2 diabetes, heart disease, and cancers, in low and middle income countries (LMICs). These diseases are a growing cause of death and disability, driven in large part by unhealthy diets and physical inactivity, both of which are associated with rapid economic development. The GDAR Group and Network will generate evidence on the factors that lead to poor diet and inactivity in LMICs, design and evaluate interventions to change these factors, and use mathematical modelling to investigate the long-term health and economic effects of such interventions. Although NCDs are often thought of as diseases of affluence, they are more common in LMICs than in high income countries. They affect primarily those of working age, and cause financial destitution among those in poorer sections of society. NCDs are, therefore, limiting the ability of LMICs to develop socially and economically. In response, the United Nations has developed Sustainable Development Goals committing countries to reducing mortality from NCDs in adults aged 30 to 70 years by one third by 2030. Our work will contribute to meeting this target, by finding solutions that are affordable and are created through engagement with local communities. GDAR is building on the expertise of the Centre for Diet and Activity Research (CEDAR) and the MRC Epidemiology Unit, and that of research partners in Kenya, Cameroon, South Africa and the Caribbean. The priorities for research and capacity building have been set jointly with our partners and informed by consultation with their stakeholders. GDAR projects include: - reviewing the existing literature on the determinants of diet and physical activity in African and Caribbean settings - identifying, appraising and analysing existing datasets for investigating the determinants of diet and physical activity in African and Caribbean settings - using ethnographic techniques to understand people’s ‘lived experience’ of their households, neighbourhoods and communities, and how it relates to food choice and physical activity - mapping policy environments for diet and physical activity across Africa and the Caribbean, including understanding policy context, the viewpoints of decision makers and barriers to effective policy - assessing a pledge by Coca-Cola in South Africa to stop supplying primary school outlets with sugary drinks - discovering the impacts of a new hypermarket on dietary behaviours, activity patterns and health in Kenya - identifying and adapting tools to assess the quality of environments within and around schools with respect to physical activity and diet. Findings from these studies can support health interventions in these countries leading to benefits for people, communities and economic development. We are working with our partners to strengthen existing links with communities and policymakers, building understanding and trust, and identifying methods of communication that are appropriate for the diversity of settings, contexts and cultures. To measure whether what we do is working, we have agreed a monitoring and evaluation plan and will commission an independent evaluation of GDAR’s progress. Setting up a Network in this way is the key foundation in creating long term sustainability and the clarity of focus required to promote public health and development in LMICs.

Research activity codes: 3.5 RESOURCES AND INFRASTRUCTURE (PREVENTION);7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health categories: CANCER AND NEOPLASMS;CARDIOVASCULAR;METABOLIC AND ENDOCRINE;ORAL AND GASTROINTESTINAL;STROKE