Sarah Cuschieri: Transforming small-state initiatives into the strength of Europe
Dr. Sarah Cuschieri, a leading voice in chronic disease epidemiology and small-state health systems, shares her insights on how JACARDI can accelerate Europe’s fight against cardiovascular disease and diabetes. “When every country speaks the same practical language of prevention, collaboration becomes scalable”, she explains. She also reflects on the importance of data, inclusion, and mentoring the next generation, reminding us that effective prevention is both a scientific and a human endeavour.
Drawing on your work in chronic disease epidemiology and the realities of small states, where do you see JACARDI’s greatest leverage in slowing the rise of cardiovascular disease and diabetes across Europe?
Drawing on my experience in chronic disease epidemiology and the realities of small states, JACARDI’s greatest leverage lies in transforming small-state initiatives into the strength of Europe.
First, small states can act as test beds for integrated prevention and care pathways, where whole-population coverage, centralized health systems, and close primary–secondary linkages allow rapid piloting and evaluation of cardiovascular and diabetes interventions. Evidence generated in these compact settings can be rapidly refined and transferred to larger Member States.
Second, small states excel at policy agility. With short governance chains, multidisciplinary teams, and accessible data infrastructures, they can translate guidelines into everyday practice faster than larger systems. Embedding JACARDI’s harmonized tools and care pathway templates in these contexts demonstrates how evidence can move from paper to patient in real time.
Third, small states provide a unique lens on equity and resilience. Their populations often mirror Europe’s diversity within a manageable scale, making them ideal for testing community-level engagement, health-literacy interventions, and cross-sector collaboration for risk-factor reduction.
By harnessing these advantages—rapid implementation, whole-system evaluation, and equitable design—JACARDI can convert its evidence base into practical, scalable prevention and care models that slow the rise of cardiovascular disease and diabetes across Europe.
How does participating in JACARDI advance your organisation’s goals on cardiovascular disease (CVD) and diabetes – whether through data, capacity-building, or policy impact?
From our vantage point at the University of Malta and through our broader collaboration within the Small States Health Platform, participation in JACARDI directly advances our institutional goals in CVD and diabetes prevention by strengthening the bridge between evidence, policy, and practice.
As a small island state with a centralized health system and accessible national datasets, Malta offers a unique setting to pilot integrated chronic disease pathways, risk factor surveillance tools, and community-based prevention models. Through JACARDI, we can both contribute real-world evidence from a small-population context and adapt proven interventions to local realities such as limited specialist capacity and high multimorbidity.
Moreover, JACARDI aligns with the University’s commitment to capacity building and implementation science, empowering clinicians, public health professionals, and researchers to translate data into sustainable prevention and care strategies. By embedding our work within this pan-European network, we ensure that Malta’s experience informs regional learning, while also benefitting from shared innovation to accelerate progress on CVD and diabetes management across small states and beyond.
You’ve often bridged research, policy, and practice. How do you think JACARDI can set a new standard for collaboration – across countries, disciplines, and data systems – so prevention becomes easier to implement and harder to ignore?
JACARDI has the potential to redefine how Europe collaborates on chronic disease prevention by turning fragmentation into function. Its strength lies in uniting researchers, policymakers, and practitioners around a shared implementation framework rather than isolated projects.
From a small-state perspective, success depends on breaking silos through simplicity and shared value. JACARDI can set a new standard by creating common, adaptable prevention “building blocks”, standardized care pathways, minimal data dashboards, and training modules that can be easily embedded into national systems, regardless of size or resources. When every country speaks the same practical language of prevention, collaboration becomes scalable.
Equally important is data solidarity, linking health information systems through harmonized indicators rather than complex infrastructures. This enables meaningful cross-country learning while respecting local capacities and governance.
Finally, JACARDI’s cross-disciplinary model, bringing together clinicians, epidemiologists, behavioural scientists, and community actors makes prevention not only evidence-based but implementable. By focusing on what works in real settings, it can make prevention easier to deliver and harder to ignore, setting a benchmark for how Europe acts collectively against cardiovascular disease and diabetes.
As a female leader in epidemiology who mentors the next generation, what were your key take-aways from the JACARDI General Assembly in Madrid, from a scientific and cultural point of view?
As a female leader in epidemiology, and someone deeply committed to mentoring the next generation, I left the JACARDI General Assembly in Madrid with a renewed sense of both scientific purpose and shared humanity. Scientifically, I want us to consolidate how JACARDI’s pilots are not just generating data, but truly changing practice, showing that prevention of cardiovascular disease and diabetes can be embedded into everyday care, across every health system, large or small.
Culturally, the moment JACARDI turned pink carries special meaning for me. It symbolises equity, voice, and visibility, giving women in science, medicine, and policy the space to lead and shape health agendas. It reminds us that public health is not only about outcomes but about inclusion and compassion.
I left Madrid knowing that we are building a network where collaboration transcends borders and disciplines, and where every young researcher – especially women – can see themselves reflected in leadership, discovery, and change. That, to me, would be the true legacy of JACARDI.
You made it to the top 2% of the most cited scientists in the world for five consecutive years, and you’ve written the book “To Do or Not to Do a PhD?” offering guidance to early-career researchers. What message would you send to young researchers, especially women just starting their careers in public health, particularly when facing various challenges?
I would tell young researchers – especially women – that they belong in this space, even when they have doubts. Every scientist, at every stage, faces moments of uncertainty; what matters is not the absence of doubt, but the courage to keep contributing despite it.
From my own journey, and through mentoring many early-career researchers, I’ve learned that success in public health is rarely a straight line. Structural barriers exist, but so do strong networks, mentors, and communities like JACARDI that value inclusion and collaboration. Seek those spaces that lift you up, and don’t be afraid to take your place at the table.
When I wrote To Do or Not to Do a PhD?, it was to remind researchers that impact isn’t defined by titles or citations—it’s defined by curiosity, persistence, and integrity. Imposter syndrome fades when you realize that public health needs diverse voices, perspectives, and lived experiences.
So my message is simple: be bold, be kind, and keep going. Science is richer, and societies are healthier, when you do.
Dr. Sarah Cuschieri is a Senior Lecturer at the University of Malta, Adjunct Professor at Western University, Canada, and a member of JACARDI’s Scientific Advisory Board. A medical doctor turned epidemiologist, she leads pioneering research into obesity, diabetes and chronic disease across small‑state contexts, heads the Chronic Disease Epidemiology Research Network and serves as Vice‑President of the Chronic Diseases Section of European Public Health Association (EUPHA). Internationally recognized for her scholarship, she ranks among the top 2% of most‑cited scientists.
Learn more about Dr. Cuschieri and her work, or connect on LinkedIn.
Bridging Borders: promoting public health across cultures
Katarzyna Brukało is an Assistant Professor at the Faculty of Public Health, Medical University of Silesia (SUM) in Katowice, Poland. She is a public health and dietetics specialist with over 15 years of academic and research experience. Her current work focuses on innovative approaches to NCD prevention, health promotion, and evidence-based policy. She is actively involved in EU and WHO projects such as JAHEE, Best Re-MaP, Health4EUkids, JACARDI, and JA PreventNCD.
You lead 15 very diverse pilot projects in JA PreventNCD, all centered around the concept of healthy living environments. Why is working at the local level so important, and what impact do you hope these pilots will have?
Our work package is very broad, because we have 15 pilot projects that are all very different. For example, we are adapting breastfeeding best practices from our Norwegian partners and implementing them in Greece. These are two very different contexts, with different conditions, and we also have pilots that promote drinking tap water, among many other activities.
What’s important is that all of these are implemented at the local level. This means we are close to the communities, close to the citizens, and that’s where we can make the biggest impact. Local governments and local structures have real power, and when we use this effectively, we can build on this work to make an impact on national policies as well. It’s like a puzzle: each pilot is one piece, and together they create the bigger picture.
Looking at the bigger picture, what is your dream result at the end of this project journey?
Our vision is not that Norway should become like Greece, or Greece like Norway. Instead, the real goal is that we learn from one another, build a good professional relationship with the facilitators, understand each other’s barriers, and use this knowledge to build responsible, community-based public health initiatives based on peer learning.
SUM University is also active in JACARDI. How do JACARDI and Prevent NCDs complement each other, and what added value do they bring when combined?
It’s very valuable that we are part of both Joint Actions, which we often call sister actions. JACARDI focuses mainly on cardiovascular diseases and type 2 diabetes, while Prevent NCDs addresses non-communicable diseases more broadly, including cancer.
Together, they allow us to tackle the full spectrum of non-communicable diseases. Only by acting together can we make a real impact, not just at the national level but also internationally.
You are known as an engaging communicator. How would you inspire others to make public health messages resonate?
For me, the key in communicating about public health is to be clear and responsible. We need to stand behind every word we say, because mistakes can lead to misinformation or even fuel fake news.
It’s also important to stay open to discussion, even engage in difficult debates and tough questions. Hard questions mean people are listening, reflecting, and engaging with what we say. That is, after all, why it is called public health, because it is for the public, and it must involve the public. Communication is central to this: raising awareness, building health literacy, and empowering people to understand their options.
About the JACARDI & JA PreventNCD collaboration:
The two projects are part of a broader network of European Union initiatives aimed at tackling non-communicable diseases (NCDs) and promoting public health. They work together to share knowledge, strategies, and resources, thereby amplifying their impact across the EU. By harnessing the synergies of these collaborative efforts, we can enhance the effectiveness of our initiatives, ensuring a more comprehensive approach to NCD prevention-and management, as well as health promotion.Explore more about the work of PreventNCDs here.
“There is a positive story to be told here” — what we learned at the DigiCare4You Workshop
In line with HaDEA’s commitment to foster synergies and share knowledge across EU health initiatives, JACARDI actively engages with a wide portfolio of projects – from Joint Actions and EU4Health grants to Horizon-funded interventions. JACARDI team members recently attended the DigiCare4You Capacity Building and Recommendations Development Workshop with International Stakeholders, held in Lisbon during the annual ICIC conference.
The event underscored how ongoing stakeholder engagement is vital to disseminate results, explore upscaling opportunities, develop evidence-based national policies and lay the groundwork for future cross-country collaborations. We invite readers to learn more about this ambitious intervention – running in parallel to our own pilot implementations – which is already demonstrating early results, implementation insights, and an inspiring commitment to meaningful change in health self-management.
A people-centric, digital health solution for preventing and managing diabetes and hypertension
The Horizon2020-funded DigiCare4You project offers a new model for the early prevention and management of type 2 diabetes (T2D) and hypertension (HTN) by engaging schools, communities, and healthcare systems in an intersectoral approach. At its core, the project empowers families and connects health and education sectors, equipping individuals with digital tools to better manage their health.Building on the evidence-based Feel4Diabetes study, DigiCare4You is being implemented in two high-income (Greece, Spain) and two middle-income countries (Albania, Bulgaria), targeting over 10,000 families across socio-economic groups.
Screen, support, empower – the DigiCare4You approach
DigiCare4You applies a two-step screening model leveraging existing child growth monitoring activities in schools and health centers through which parents and caregivers are approached to complete the FINDRISC questionnaire as the first screening step. Adults identified as at risk are then referred for a second screening, which includes anthropometric and clinical assessments to detect conditions such as prediabetes, type 2 diabetes, or hypertension.
Those confirmed at risk are subsequently invited to join the DigiCare4You two-year, mHealth-supported intervention programme, focused on lifestyle change, self-management, and family support. A multilingual mobile app offers access to health data, tracking tools, and educational resources and even recipies. Importantly, the intervention supports healthier behaviors in both adults and children through school and community-based activities.
DigiCare4You combines digital innovation, equity-driven outreach, and participatory research, while integrating into existing systems and investing in health professional training – ensuring sustainable, real-world impact.
Early results revealed: first findings inspire confidence
The Capacity Building and Recommendations Development (CBRD) Workshop gathered international experts at the midpoint of project implementation to review progress and shape the upcoming Roadmap for Scale-Up.Prof. Brian Oldenburg elevated the spirit of the event stating that: “Early findings are promising enough to say that there is a positive story to be told here.” Indeed, early results are compelling:
- Fewer adults with intermediate hyperglycaemia progressed to T2D; many returned to normal glucose levels.
- Participants with T2D improved their HbA1c.
- Adults with obesity experienced weight loss, BMI reduction, and lower cholesterol—without increased medication reliance.
From research to real-world impact
The workshop emphasized the transition from effectiveness to implementation research – examining how interventions work in real-life conditions. Dr Rajesh Vedanthan facilitated a compelling discussion in which implementers candidly shared successes and challenges.
Key takeaways from country implementers:
- Strong consensus: “Yes, we would start and do it again.”
- Motivation stems from seeing behavior change within families—especially when children and caregivers reinforce each other’s progress.
- Burnout among healthcare staff is a concern—but aligning DigiCare4You with existing systems proved an effective strategy.
- Local ownership and trust, especially through primary care systems and schools, were pivotal.
- Participants emphasized the importance of engaging families holistically, with one Bulgarian team member noting how “changing the behavior at home” can be one of the most lasting outcomes.
Additionally, one noted barrier to engagement was previous unsuccessful attempts at weight control, highlighting the need for tailored motivational support.
Cost-effectiveness, scalability, and the road ahead
Preliminary analyses suggest strong cost-effectiveness, especially when targeting adults with intermediate hyperglycaemia in MICs. A Scalability Decision Support Tool was developed to assess implementation readiness across five domains: NCD care context, digital literacy, support systems, screening capacity, and digital integration. These insights inform the forthcoming Roadmap for Scale-Up.
JACARDI Relevance
The presence of experts involved in both JACARDI and DigiCare4You highlights the existence of a vibrant, cross-country network of professionals dedicated to cardiovascular and diabetes care. The workshop featured members of the JACARDI Stakeholder Advisory Board, including a policy advisor from the European Diabetes Federation, epidemiologist and researcher from EUPHA, healthcare professionals involved in the pilot implementation in Portugal, representatives from the industry developing digital tools, and communication experts. Together, these individuals demonstrate the strength of this interconnected community.
Such events provide valuable opportunities to learn, grow and exchange knowledge, and have the potential to shape and enhance the quality of ongoing interventions. Given the different timelines of these projects, the initial findings of the DigiCare4You project can provide valuable insights for the JACARDI teams, given that the implementation of the pilots has only just begun.
Looking ahead
In its final year, DigiCare4You will focus on completing the intervention, finalizing cost-effectiveness studies, and refining its scalability tools. A second CBRD workshop will present final results and a full Roadmap for Scale-Up, providing a concrete guide for policy and replication.
As the burden of type 2 diabetes (T2D) in Europe is expected to reach 72 million people by 2050, DigiCare4You is emerging as a promising prevention model. “We design a programme, and when we start to implement it, we are confronted with the reality on the ground. Reality is revealed, and we act according to people’s needs,” said Prof. Yannis Manios, Project Coordinator. Meeting people where they are – with empathy, innovation and commitment – may be the most powerful intervention of all.
Discover more about the DigiCare4You project here.
Knut Inge Klepp and Linda Granlund: It’s important to find ways to build a community
With more than 1,600 health care professionals, scientists and public health experts involved, both JACARDI and JA PreventNCD recognize the necessity of fostering and building a strong sense of community and collaboration. According to the coordinators of JA PreventNCD, Knut Inge Klepp and Linda Granlund, building that sense of unity is no small feat, but is essential to make the most of the extraordinary investment and collective effort to tackle non-communicable diseases across Europe. In this conversation, the two coordinators explore the opportunities presented by this unprecedented joint commitment to prevention and the challenges of coordinating such large-scale projects.
What does JACARDI mean to you personally and to JA PreventNCD?
Knut Inge Klepp: There are so many synergies and so many opportunities for collaboration. It’s really useful to be able to work closely with the coordination team at JACARDI. Having colleagues you can share your victories and challenges with strengthens us as a team.
Linda Granlund: I agree with Knut Inge. Working closely with JACARDI is incredibly valuable for us, both as coordinators and as collaborators. It allows us to discuss details, but also to make sure that we avoid any overlap. On a personal note, I have lived with type 1 diabetes for 42 years, so staying informed about the developments in this field is not only professionally important but also deeply relevant to me.
Thank you for sharing! As Dr. Gauden Galea of WHO Europe explained at the Synergy meeting in Brussels this autumn (Strengthening NCD Monitoring Systems in the EU: A Collaborative Approach), after the COVID pandemic, the momentum for prevention and treatment of noncommunicable diseases was lost and the focus shifted to other areas of public health. How do you see the situation now?
Knut Inge Klepp: Well, we have these two joint actions, where the European Commission and the Member States have combined their efforts together, along with the smaller action grants. In total, almost 200 million euros are on the table. I think that reflects a significant turning point. Moving forward, our focus will be on making the best use of the substantial financial support, human capital and political commitment behind these projects.
Linda Granlund: When the Commissioner emphasized this focus, it signaled a significant shift, underscored by strong engagement and active involvement from Member States. With 21 countries participating in JACARDI and 25 in JA Prevent, it’s clear that these nations are committing substantial effort and resources to support our work.
How do you maintain focus while providing flexibility for task leaders and experts?
Linda Granlund: It’s important, to refer back to the background documents, Europe’s Beating Cancer Plan and the Healthier Together initiative. These provide essential guidance amid the many details of the project, work packages, tasks and subtasks. Without anchoring our efforts to these overarching goals, it’s easy to lose focus.
Knut Inge Klepp: First and foremost, it’s important to recognize that this is a significant challenge and we are fully committed to addressing it. Building on what Linda mentioned, our main objective is to ensure that our work aligns with the background documents. We regularly review these objectives and ask work package leaders, task leaders, subtask leaders and even pilot leaders to reflect on how their efforts contribute to the overall objectives. This ongoing process ensures that we are constantly reminded of what we are working towards and what we want to achieve.
Coordinating a project of this scale requires resilience, flexibility, bulletproof management and scientific rigor. What has been the most unexpected challenge you have faced so far in your first year, requiring you to think outside of the box?
Knut Inge Klepp: There are many challenges. One thing we’ve focused on recently is realizing that while we have frequent contact with a smaller group of work package leaders and maybe the task leaders and so on, there are probably between 500 and 1,000 people involved in this project – many of whom we haven’t met personally. We’ve interacted with a lot of them on screen, but it’s also important to find ways to build community, ownership of the project and a common culture. And that is also something that you are very consciously working on within JACARDI.
Linda Granlund: We have talked a lot about the different cultures involved when you have 25 countries working together. Finding a common tone is very important. How do we talk about the project? What do we emphasize? This process takes time, especially as the people involved come from different backgrounds, even if some share similar expertise.
Your dedication to creating a more health-promoting environment in Europe is well reflected in your work with a Youth Advisory Group. In your vision, what’s the NCD issue you envision for them to have to solve when you hand over the future?
Knut Inge Klepp: I started working on my first international non-communicable disease (NCD) prevention project in 1979. That was 45 years ago. Looking back, 30 years seems like a pretty short time. The scale and the context are different, but it’s striking that some of the issues we’re dealing with are quite similar. I think one of the values of this youth panel is their ability to bring a perspective that is grounded in their reality. In terms of health issues, we are seeing the convergence of NCDs with mental health and infectious diseases. The pandemic highlighted the vulnerability of people with underlying NCDs to infectious diseases. Addressing these interconnected challenges is something that today’s young people will have to deal with, even as we continue to work towards solutions in the present.
Linda Granlund: I think when we hand over the results in four or five years, we’ll have an understanding of that. Collaboration across sectors is essential, as we now focus on addressing the underlying factors that contribute to preventing NCDs. These are primarily related to the health care system, but we need to involve the other sectors more, such as the school sector, the transport sector, and create a mutual understanding of why they need to be involved and in what capacity. With the support of the EU Commission, this approach will benefit all the countries involved.
Learn more and connect:
JA Prevent NCD
Linda Granlund is the Division Director for Public Health at the Norwegian Directorate of Health, a role she has held since 2015. With over 20 years of experience, she has led initiatives to improve public health and nutrition. Previously, Linda worked in roles including Director of Health and Nutrition at a Norwegian food company that produces and markets some of the country’s most well-known and beloved food products, where she advanced projects to promote healthier eating. Linda also served as Vice Chair of Diabetesforbundet, the Norwegian Diabetes Association, advocating for better diabetes care. Her expertise spans health policy, nutrition, and public health advocacy.
Knut Inge Klepp is the Executive Director of the Division of Mental and Physical Health at the Norwegian Institute of Public Health. He has had an extensive career in public health, previously serving as the Director General of Public Health at the Norwegian Directorate of Health. Klepp is also an adjunct professor at the University of Oslo. His academic focus includes adolescent nutrition, obesity prevention, and nutrition policy. He has led numerous EU research projects, has published over 250 papers in peer reviewed journals and contributed significantly to international health initiatives, including WHO’s efforts to reduce non-communicable diseases.
Learn more about Knut Inge Klepp and his work here and connect on LinkedIn here.
Elisabeth Dupont: A joint approach on CVD and diabetes is more than just the sum of the two!
JACARDI has the potential to be truly transformative according to Elisabeth Dupont, Regional Manager at the International Diabetes Federation Europe (IDF Europe) and member of JACARDI’s Stakeholder Advisory Board. In an enlightening discussion, we explore the powerful synergy of tackling diabetes and cardiovascular diseases through an integrated approach. With years of experience in patient advocacy, Elisabeth shares valuable insights on policy engagement, stressing the importance of early collaboration with policymakers, while harnessing the collective voice of national diabetes associations and people with lived experience. Her expertise particularly shines through when discussing patient involvement in healthcare initiatives.
How do you see JACARDI’s role in tackling the increasing prevalence of diabetes in Europe?
Over 32 million people in the EU live with diabetes, and this figure is expected to rise to 38 million by 2030. Adding to this challenge is the fact that more than one-third of people with diabetes remain undiagnosed, underscoring the urgent need to improve diabetes prevention, management, and care. Diabetes is a highly complex and evolving condition, with various expressions and causes, requiring a life-course approach. Its scientific and policy links to cardiovascular diseases (CVDs) further highlight the importance of initiatives like JACARDI.
The Joint Action on Cardiovascular Diseases and Diabetes, which addresses the entire patient pathway, has the potential to be truly transformative. By bringing together 76 partners across 21 countries, JACARDI will enhance understanding of the diabetes landscape at regional, national, and European levels. Successful pilot projects will serve as proof of concept, demonstrating what truly impacts health outcomes and quality of life for people with diabetes, and how healthcare systems must adapt or transform to improve detection, early diagnosis, access to education, and high-quality treatment and care. A joint approach on CVD and diabetes is more than just the sum of the two!
What advice do you have for JACARDI’s pilots to translate their results into policy?
My first piece of advice would be to engage with policymakers as early as possible, leveraging the support and influence of national diabetes associations and people with lived experience. Translating project results into policy changes requires collaboration with the community and a clear understanding of how the project aligns with regional and national diabetes priorities, such as addressing healthcare workforce shortages, improving access to care in rural areas, or enhancing early diagnosis, integrating care and ensuring equitable access to innovation. It’s also essential to demonstrate the added value for healthcare systems and highlight the pilot’s positive impact on patient outcomes and quality of life.
IDF Europe is one of the key stakeholders of JACARDI. How can we strengthen this cooperation to address the growing challenge of diabetes and bring real and tangible added value to populations and patients?
IDF Europe is an umbrella organization of 72 diabetes associations, active in 45 countries, representing both people living with diabetes and healthcare professionals. IDF Europe strongly believes that the voice of people living with diabetes must remain central at all levels to ensure that interventions, innovations, and policy changes truly address their needs and deliver tangible impact. We welcome the opportunity to advise work package leaders and pilot leaders to ensure patient input and feedback are consistently integrated.
To ensure the long-term sustainability of the Joint Action, it is crucial to establish ongoing communication with the wider diabetes community, keeping them regularly informed of progress and involving diabetes associations in pilot activities where their contributions can enhance the project. Additionally, we suggest leveraging the IDF Europe network to communicate about the Joint Action and co-develop advocacy campaigns that promote policy changes based on successful pilot outcomes.
Elisabeth Dupont has been working for more than 15 years as senior project manager for the International Network for Cancer Treatment and Research, the African Cancer Registry Network and the US National Cancer Institute Center of Global Health. In 2019 she joined IDF Europe as Regional Manager. She is passionate about promoting collaboration and partnerships and putting the voice of people living with chronic conditions, including diabetes, center stage.
Learn more about IDF Europe here and connect on LinkedIn here.