The five-target ‘25 × 25’ strategy for tackling the emerging global epidemic of non-communicable diseases (NCDs) focuses on four diseases (CVD, diabetes, cancer, and chronic respiratory disease), four risk factors (tobacco, diet and physical activity, dietary salt, and alcohol), and one cardiovascular preventive drug treatment. The goal is to decrease mortality from NCDs by 25 per cent by the year 2025. The ‘standard approach’ to the ‘25 × 25’ strategy has the benefit of simplicity, but also has major weaknesses. These include lack of recognition of: (i) the fundamental drivers of the NCD epidemic; (ii) the ‘missing NCDs’, which are major causes of morbidity; (iii) the ‘missing causes’ and the ‘causes of the causes’; and (iv) the role of health care and the need for integration of interventions.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Kim, S. and Popkin, B.M. (2006) Commentary: Understanding the epidemiology of overweight and obesity – A real global public health concern. International Journal of Epidemiology 35 (1): 60–67.
Beaglehole, R. et al (2011a) UN high-level meeting on non-communicable diseases: Addressing four questions. Lancet 378 (9789): 449–455.
Beaglehole, R. et al (2011b) Priority actions for the non-communicable disease crisis. Lancet 377 (9775): 1438–1447.
WHO. (2010) Global Status Report on Noncommunicable Diseases 2010. Geneva, Switzerland: WHO.
Webb, D.R. et al (2011) Screening for diabetes using an oral glucose tolerance test within a western multi-ethnic population identifies modifiable cardiovascular risk: The ADDITION-Leicester study. Diabetologia 54 (9): 2237–2246.
Danaei, G. et al (2011a) National, regional, and global trends in systolic blood pressure since 1980: Systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet 377 (9765): 568–577.
Danaei, G. et al (2011b) National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: Systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet 378 (9785): 31–40.
Farzadfar, F. et al (2011) National, regional, and global trends in serum total cholesterol since 1980: Systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants. Lancet 377 (9765): 578–586.
Finucane, M.M. et al (2011) National, regional, and global trends in body-mass index since 1980: Systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 377 (9765): 557–567.
(2013) 66th World Health Assembly: Second Report of Committee A. Geneva, Switzerland.
Beaglehole, R. et al (2012) Measuring progress on NCDs: One goal and five targets. Lancet 380 (9850): 1283–1285.
WHO. (2013) WHO Global NCD Action Plan 2013–2020. Geneva, Switzerland: WHO.
Alleyne, G., Binagwaho, A., Jahan, S., Nugent, R., Rojhani, A. and Stuckler, D. (2013) Embedding non-communicable diseases in the post-2015 development agenda. The Lancet 381: 566–574.
WHO. (2013) Follow-Up to the Political Declaration of the High-Level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases. Sixty Sixth World Health Assembly Agenda Item 13.1 Geneva, Switzerland: WHO.
(2013) Vienna Declaration on Nutrition and Noncommunicable Diseases in the Context of Health 2020. WHO Ministerial Conference on Nutrition and Noncommunicable Diseases in the Context of Health. Vienna, Austria.
Lawlor, D.A. and Pearce, N. (2013) The Vienna declaration on nutrition and non-communicable diseases: Time to look upstream. British Medical Journal 347: f4417.
Pearce, N. et al (2014) The road to 25 × 25: How can the five-target strategy reach its goal? Lancet Global Health 2 (3): e126.
Ebrahim, S. (2008) Chronic diseases and calls to action. International Journal of Epidemiology 37 (2): 225–230.
(2013) Apia Communiqué on Healthy Islands, NCDs and the Post-2015 Development Agenda. Tenth Pacific Health Ministers Meeting. Apia, Samoa: WHO.
McKee, M. et al (2014) Towards a comprehensive global approach to prevention and control of NCDs. Globalisation and Health 10: 74.
Chan, M. (2013) Opening Address at the 8th Global Conference on Health Promotion. Helsinki, Finland: WHO.
Stuckler, D., McKee, M., Ebrahim, S. and Basu, S. (2012) Manufacturing epidemics: The role of global producers in increased consumption of unhealthy commodities including processed foods, alcohol, and tobacco. PLoS Medicine 9 (6): e1001235.
Gilmore, A.B. (2012) Understanding the vector in order to plan effective tobacco control policies: An analysis of contemporary tobacco industry materials. Tobacco Control 21 (2): 119–126.
Lee, S., Ling, P.M. and Glantz, S.A. (2012) The vector of the tobacco epidemic: Tobacco industry practices in low and middle-income countries. Cancer Causes & Control 23: 117–129.
Cummins, S. and Macintyre, S. (2006) Food environments and obesity – Neighbourhood or nation? International Journal of Epidemiology 35 (1): 100–104.
(2007) PepsiCo appoints Derek Yach as Director – Global Health Policy, http://www.redorbit.com/news/health/832479/pepsico_appoints_derek_yach_as_director__global_health_policy/, accessed 20 June 2015.
Smith, E. (2012) Corporate image and public health: An Analysis of the Philip Morris, Kraft, and Nestle websites. Journal of Health Communication 17 (5): 582–600.
Kelsey, J. (2012) New-generation free trade agreements threaten progressive tobacco and alcohol policies. Addiction 107: 1719–1721.
Kelsey, J. (2013) The trans-pacific partnership agreement: A gold-plated gift to the global tobacco industry? American Journal of Law & Medicine 39: 237–264.
Geneau, R. et al (2010) Raising the priority of preventing chronic diseases: A political process. Lancet 376 (9753): 1689–1698.
Ebrahim, S. and Smith, G.D. (2001) Exporting failure? Coronary heart disease and stroke in developing countries. International Journal of Epidemiology 30 (2): 201–205.
Joshi, R. et al (2012) The rural Andrapradesh cardiovascular prevention study (RAPCAPS). Journal of the American College of Cardiology 13: 1188–1196.
Chapman, S. and Richardson, J. (1990) Tobacco excise and declining tobacco consumption – The case of Papua New Guinea. American Journal of Public Health 80 (5): 537–540.
Uusitalo, U. et al (1996) Fall in total cholesterol concentration over five years in association with changes in fatty acid composition of cooking oil in Mauritius: Cross sectional survey. British Medical Journal 313 (7064): 1044–1046.
Lundahl, B. et al (2013) Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling 93 (2): 157–168.
Chow, C.K. et al (2013) Prevalence, awareness, treatment, and control of hypertension in rural and urban communities in high-, middle-, and low-income countries. Journal of the American Medical Association 310 (9): 959–968.
Yusuf, S. et al (2014) Cardiovascular risk and events in 17 low-, middle-, and high-income countries. The New England Journal of Medicine 371 (9): 818–827.
Jaime Miranda, J. and Zaman, M.J. (2010) Exporting ‘failure’: Why research from rich countries may not benefit the developing world. Revista De Saude Publica 44 (1): 185–189.
Rose, G. (2001) Sick individuals and sick populations. International Journal of Epidemiology 30 (3): 427–432.
Knai, C., Petticrew, M., Durand, M.A. and Eastmore, E. (forthcoming) Are the public health responsibility deal alcohol pledges likely to improve public health? An evidence synthesis. Addiction, in press.
Murray, C.J.L. et al (2013) Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380 (9859): 2197–2223.
Vos, T. et al (2013) Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: A systematic analysis for the global burden of disease study 2010. Lancet 380 (9859): 2163–2196.
Wang, H. et al (2012) Age-specific and sex-specific mortality in 187 countries, 1970–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 380 (9859): 2071–2094.
Lozano, R. et al (2013) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the global burden of disease study 2010. Lancet 380 (9859): 2095–2128.
Pearce, N. et al (2013) Asthma in the global NCD agenda: A neglected epidemic. Lancet Respiratory Medicine 1: 96–97.
Collins, P.Y. et al (2011) Grand challenges in global mental health. Nature 475 (7354): 27–30.
Ngo, V.K. et al (2013) Grand challenges: Integrating mental health care into the non-communicable disease agenda. Plos Medicine 10 (5).
Prince, M. et al (2007) Global mental health 1 – No health without mental health. Lancet 370 (9590): 859–877.
Lim, S.S. et al (2013) A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the global burden of disease study 2010. Lancet 380 (9859): 2224–2260.
Cullinan, P. and Pearce, N. (2012) The asbestos disease epidemic: Here today, here tomorrow. Thorax 67 (2): 98–99.
Pearce, N. and Matos, E. (1994) Occupational cancer in developing countries: Introduction. In: N. Pearce, E. Matos, H. Vainio, P. Boffetta and M. Kogevinas (eds.) Occupational Cancer in Developing Countries. Lyon, France: IARC, pp. 1–3.
Williams, J.H., Phillips, T.D., Jolly, P.E., Stiles, J.K., Jolly, C.M. and Aggarwal, D. (2004) Human aflatoxicosis in developing countries: A review of toxicology, exposure, potential health consequences, and interventions. American Journal of Clinical Nutrition 80 (5): 1106–1122.
Commission on Social Determinants of Health. (2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva, Switzerland: WHO.
Breman, J.G. and Arita, I. (1980) The confirmation and maintenance of smallpox eradication. New England Journal of Medicine 303 (22): 1263–1273.
(2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva, Switzerland: WHO.
Frumkin, H., Frank, L. and Jackson, R. (2004) Urban Sprawl and Public Health: Designing, Planning and Building for Healthy Communities. London: Island Press.
Bain, C. (2006) Commentary: What’s past is prologue. International Journal of Epidemiology 35 (1): 16–17.
Haines, A. et al (2009) Health and climate change 6 public health benefits of strategies to reduce greenhouse-gas emissions: Overview and implications for policy makers. Lancet 374 (9707): 2104–2114.
Patz, J.A., Frumkin, H., Holloway, T., Vimont, D.J. and Haines, A. (2014) Climate change challenges and opportunities for global health. Jama-Journal of the American Medical Association 312 (15): 1565–1580.
Haines, A., Alleyne, G., Kickbusch, I. and Dora, C. (2012) From the Earth summit to Rio+20: Integration of health and sustainable development. The Lancet 378: 2189–2197.
Haines, A. (2012) Health Benefits of a Low Carbon Economy. Public Health 126: S33–S39.
Milner, J. et al (forthcoming) Health effects of adopting low greenhouse gas emission diets in the UK. British Medical Journal. in press.
WHO. (2014) Sixty-Eighth World Assembly 24 April 2014. Progress Reports A68/36. Geneva, Switzerland: WHO.
WHO. (2015) Health in All Policies: Training Manual. Geneva, Switzerland: WHO.
Hu, F.B. (2008) Obesity Epidemiology. New York: Oxford University Press.
Hallal, P.C., Reis, R.S., Barros, M.V.G., Nahas, M.V. and Pratt, M. (2010) Physical activity promotion in low- and middle-income settings: Lessons from Brazil. Journal of Physical Activity & Health 7: S331–S332.
Millett, C., Agrawal, S., Sullivan, R., Vaz, M. and Kurpad, A. (2013) Associations between active travel to work and overweight, hypertension, and diabetes in India: A cross-sectional study. PLoS Medicine 10 (6): e1001459.
Mohan, D. (2009) Urban transport: Moving from the 19th century to the 21st century concerns, http://www.vref.se/download/18.778e24d112a169fd1c180006144/, accessed 20 June 2015.
Margetts, B. (2004) WHO global strategy on diet, physical activity and health. Public Health Nutrition 7 (3): 361–363.
Ebrahim, S., Taylor, F., Ward, K., Beswick, A., Burke, M. and Smith, G.D. (2011) Multiple risk factor interventions for primary prevention of coronary heart disease. Cochrane Database of Systematic Reviews, doi: 10.1002/14651858.CD001561.pub3.
Heran, B.S. et al (2011) Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database of Systematic Reviews, doi: 10.1002/14651858.CD001800.pub2.
Thomas, D.E., Elliott, E.J. and Naughton, G.A. (2006) Exercise for type 2 diabetes mellitus. The Cochrane Database of Systematic Reviews: CD002968-CD002968.
Yates, T., Khunti, K., Bull, F., Gorely, T. and Davies, M.J. (2007) The role of physical activity in the management of impaired glucose tolerance: A systematic review. Diabetologia 50 (6): 1116–1126.
Lorenc, T., Petticrew, M., Welch, V. and Tugwell, P. (2013) What types of interventions generate inequalities? Evidence from systematic reviews. Journal of Epidemiology and Community Health 67 (2): 190–193.
Rydin, Y. et al (2012) Shaping cities for health: Complexity and the planning of urban environments in the 21st century. Lancet 379 (9831): 2079–2108.
Atun, R. et al (2013) Improving responsiveness of health systems to non-communicable diseases. Lancet 381 (9867): 690–697.
Rasella, D., Harhay, M.O., Pamponet, M.L., Aquyino, R. and Barreto, M.L. (2014) Impact of primary health care on mortality from heart and cerebrovascular diseases in Brazil: A nationwide analysis of longitudinal data. British Medical Journal 349: 94014.
Beaglehole, R. et al (2008) Alma-Ata: Rebirth and revision 3 – Improving the prevention and management of chronic disease in low-income and middle-income countries: A priority for primary health care. Lancet 372 (9642): 940–949.
Chestnov, O., Obermeyer, W., St John, J., Van Hilten, M. and Kulikov, A. (2014) Towards the world we want. Bulletin of the World Health Organisation 92: 263.
Leppo, K., Ollila, E., Peña, S., Wismar, M. and Cook, S. (2013) Health in All Policies: Seizing Opportunities, Implementing Policies. United Nations Research Institute for Social Development.
Angell, S.Y., Cobb, L.K., Curtis, C.J., Konty, K.J. and Silver, L.D. (2012) Change in trans fatty acid content of fast-food purchases associated with New York City’s restaurant regulation: A pre-post study. Annals of Internal Medicine 157: 81–86.
Jarrett, J. et al (2012) Effect of increasing active travel in urban England and Wales on costs to the national health service. Lancet 379 (9832): 2198–2205.
Rosen, L. et al (2010) A framework for developing an evidence-based, comprehensive tobacco control program. Health Research Policy and Systems 8: 17.
Brownell, K.D. et al (2010) Personal responsibility and obesity: A constructive approach to a controversial issue. Health Affairs 29 (3): 379–387.
Siegel, K.R., Ali, M.K., Srinivasiah, A., Nugent, R.A. and Narayan, K.M.V. (2014) Do we produce enough fruits and vegetables to meet global health need? Plos One 9 (8), 10.1371/journal.pone.0104059.
Tesh, S. (1988) Hidden Arguments: Political Ideiology and Disease Prevention Policy. New Brunswick, NJ: Rutgers.
Frances, R. (2013) The Mid Staffordshire NHS Foundation Trust Public Inquiry. Report of the Mid Staffordshire NHS Foundation Trust, The Stationery Office, London.
Matheson, D. (2013) From Great to Good; How a Leading New Zealand DHB Lost its Ability to Focus on Equity During a Period of Economic Constraint. Wellington: Massey University.
(2002) Report of the Commission on Macroeconomics and Health. Geneva, Switzerland: WHO.
Haines, A. (2012) Health benefits of a low carbon economy. Public Health 126: S33–S39.
Bloom, D.E. et al (2011) The Global Economic Burden of Noncommunicable Diseases. Geneva, Switzerland: World Economic Forum.
Howell, L. (2013) Global Risks 2013, 8th edn. Geneva, Switzerland: World Economic Forum.
Edwards, R., Russell, M., Thomson, G., Wilson, N. and Gifford, H. (2011) Daring to dream: Reactions to tobacco endgame ideas among policy-makers, media and public health practitioners. BMC Public Health 11: 580.
This work was supported by the Wellcome Trust Institutional Strategic Support Fund, 097834/Z/11/B; the Health Research Council of New Zealand; and the Heart, Lung and Blood Institute of the US National Institutes of Health, Department of Health and Human Services, under Contract No. HHSN268200900033C.
The standard approach to prevention and control of non-communicable disease, called ‘25x25’ has the benefit of simplicity, but also has major weaknesses described herein.
About this article
Cite this article
Pearce, N., Ebrahim, S., McKee, M. et al. Global prevention and control of NCDs: Limitations of the standard approach. J Public Health Pol 36, 408–425 (2015). https://doi.org/10.1057/jphp.2015.29
- non-communicable diseases (NCDs)
- risk factors for NCDS