• Definition of the ‘health transition’• Trends of disease patterns in populations• The 4 stages of the epidemiological transition• The cardiovascular disease transition

• Engines of the health transition– Urbanization, demographic, epidemiologic, socioeconomic and health care

• Other determinants of NCDs

• Predicted trends in disease patterns, ‘Global Burden of Disease’

• The double burden of disease • Impact of NCDs on public health

• Evidence for the preventability of CVD• Strategies for the primary prevention of CVD• Public health response to emerging CVD

IUMSP-GCT

Health transition: demographic transition and epidemiologic transition

Economic, social & environ mental

changes

public sanitation, housing,

health care

nutrition

technology for health

care

mortality( infant mortality) life expectancy fertility

Increasing and aging population

persons at at risk of

developing NCDs

levels of RF:fat, calories, tobacco,

sedentary habits

Industrialization & urbanization

NCD infectious diseases

per cap. income, wealth

IUMSP-GCT

Percent of urban population from 1970-2025 in industrialized and developing countries

IUMSP-GCT

0

20

40

60

80

100

Developedcountries

Former socialisteconomies

Developingcountries

Perc

ent o

f urb

an p

opul

atio

n

1970 1994 2025

• Definition of the ‘health transition’• Trends of disease patterns in populations• The 4 stages of the epidemiological transition• The cardiovascular disease transition• Engines of the health transition

– Urbanization, demographic, epidemiologic, socioeconomic and health care

• Other determinants of NCDs• Predicted trends in disease patterns, ‘Global Burden of Disease’• The double burden of disease• Impact of NCDs on public health• Evidence for the preventability of CVD• Strategies for the primary prevention of CVD• Public health response to emerging CVD

IUMSP-GCT

Demographic transition: indicators over time(UK as an example of the ‘Western’ model)

• Mortality rate

• Fertility rate

( birth rate)

• Size population

• Age population

IUMSP-GCT

0

10

20

30

40

50

1800 1840 1880 1920 1960

Birt

h &

de

ath

rate

s (p

er

10

00

)

0

10

20

30

40

50

Po

pul

atio

n (m

illio

ns)

Models of demographic transition Heterogeneity of social and economic development among countries

and over different periods of time leads to distinguish:

• Classical (or Western) model – mostly economical and social factors, started in 18th-19th century

• Accelerated model (Japan, Eastern Europe)– started later but evolved quicker

• Delayed (or contemporary) model (most developing countries)– rapid decrease in overall mortality (mainly child deaths) but less (delayed) decrease in

birth rates, hence explosive population growth– important role of public health and medical interventions (treatment, contraception,

abortion)

IUMSP-GCT

Models of demographic transition

Mortality and birth rates driven to various extents by socio-economic development, public health & medical interventions IUMSP-GCT

0

10

20

30

40

50

1800 1840 1880 1920 1960

Birth &

death rates (per 1000)

0

10

20

30

40

50

Recent declines in fertility rates in various developing countries

1965-70 1985-90 Prop. diff.(%).

Thailand 6.1 2.3 62China 6.0 2.3 62Bangladesh 6.9 3.6 48Turkey 5.6 3.0 46Mexico 6.7 3.8 43Indonesia 5.6 3.3 41Brazil 5.3 3.5 34Egypt 6.6 4.4 33India 5.7 4.2 26Philippines 6.0 4.7 21Pakistan 7.0 7.0 0Nigeria 6.9 6.9 0IUMSP-GCT

Determinants of fertility rates

High fertility

• Economic needs of self-sufficient agrarian communities

• Little striving for advancement

• High child mortality

• Religious doctrines and community sanctions

• 'Individual' not important

• Childbearing is major source of prestige and economic support for women

Low fertility• Cost of children, earning power down• Reduced child mortality• Family and community less important

for mobile city dwellers• Factory employment makes

individual responsible for his/her own accomplishment

• Education and rational point of view become important

• Later marriage, migration, abortion, contraception

IUMSP-GCT

Demographic transition in Seychelles: 3-fold increase of the number of people 50-70 by 2020-

30 (hence expected large increase in NCDs)

IUMSP-GCT

0

2,000

4,000

6,000

8,000

10,000

0-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75+

Age category

Pop

ulat

ion

per

5-ye

ar c

ateg

ory

1976 1990 2000 2020 2030

Aging populations: trends in number of persons (millions) aged 60

1950 1975 2000 2025 Increase(fold)

1950-2025Brazil 2 6 14 32 15Mexico 1 3 7 18 13Nigeria 1 3 6 16 12Indonesia 4 7 15 31 8China 42 74 135 284 7Bangladesh 3 3 7 17 6Japan 6 13 26 33 6India 32 30 66 146 5USSR 16 34 54 71 4USA 19 32 40 67 4Italy 6 10 14 16 3Germany 7 12 13 15 2IUMSP-GCT

Impact of growing and aging populations in industrialized and developing countries

World population structure by region, 1950-1990

IUMSP-GCT

0

1000

2000

3000

4000

5000

6000

1950 1960 1970 1980 1990

Mill

ions

West Asia (3.1)

South Asia (2.5)

SE Asia (2.5)

East Asia (2.0)

Africa (3.0)

S. America (2.7)

N. America (1.7)

Ex-USSR (1.6)

Europe (1.2)

• Definition of the ‘health transition’• Trends of disease patterns in populations• The 4 stages of the epidemiological transition• The cardiovascular disease transition• Engines of the health transition

– Urbanization, demographic, lifestyle, socioeconomic and health care

• Other determinants of NCDs• Predicted trends in disease patterns, ‘Global Burden of Disease’• The double burden of disease• Impact of NCDs on public health• Evidence for the preventability of CVD• Strategies for the primary prevention of CVD• Public health response to emerging CVD

IUMSP-GCT

Lifestyle transition

• Behaviors (e.g. smoking, sedentary habits)

• Nutritional transition (e.g. fats, complex carbohydrates) – industrialization– urbanization– globalization of world markets and

mass media

IUMSP-GCT

Changes in cigarettes consumption (sales) in developing and developed countries, 1974-1992

IUMSP-GCT

0

50

100

150

2001

97

4

19

76

19

78

19

80

19

82

19

84

19

86

19

88

19

90

Pe

rce

nt c

hang

e (

%)

China

South Korea

India

Thailand

USA

UK

Canada

Nutritional transition: rapid adoption of a high fat diet, China

IUMSP-GCT

0%

20%

40%

60%

80%

100%

Higher incomeearners

Middle incomeearners

Low incomeearners

Pro

po

rtio

n o

f pe

rso

ns

w

ith >

30

% fa

t die

t (%

)

1989 1993

Higher levels of several risk factors in Seychelles than in Switzerland (age 35-64, 1989-1991)

IUMSP-GCT

Hypertension

(>160/95 or tt)

Smoking (>1 cig/day)

Blood total cholesterol

(>6.5)

Blood HDL-cholesterol

<0.9 mmol/l

Blood lipoprotein(a)

>300 mg/l

Obesity (BMI>30)

Diabetes (diff. criteria)

5

11

10

12

46

34

15

7

5

33

11

11

53

35

0 20 40 60

Prevalence (%)

Males

5

12

13

2

39

24

14

7

28

35

8

20

13

30

0 20 40 60

Prevalence (%)

Seychelles

Switzerland

Females

Increasing levels of several risk factors in a rapidly developing country, Seychelles, 1989-1994

IUMSP-GCT

High cholesterol (>6.5)

Hypertension (>160/95)

Smoking

Diabetes (diff. criteria)

Obesity (BMI>30)

Heavy exercise at work

Leisure exercise weekly

3

36

5

7

54

31

11

20

14

10

8

41

42

21

0 20 40 60Prevalence (%)

Males

2

18

29

7

12

24

20

13

2

34

5

8

27

32

0 20 40 60Prevalence (%)

1994

1989

Females

Prevalence of overweight and obesity in children, age 5-17, in developed and developing countries

(using same criteria)

IUMSP-GCT

0

4

8

12

16

20

US

A

UK

Ne

the

rlan

ds

Sin

ga

pore

Ho

ng

Ko

ng

Bra

zil

Se

ych

elle

s

US

A

UK

Ne

the

rlan

ds

Sin

ga

pore

Ho

ng

Ko

ng

Bra

zil

Se

ych

elle

s

Pro

port

ion

(%)

Overweight Obesity

BoysGirls

Prevalence of high systolic blood pressure in children, age 5-17, Seychelles and USA (using same criteria)

IUMSP-GCT

10 10

5 5

14.015.3

8.39.5

0

5

10

15

20

Boys Girls Boys Girls

Pre

vale

nce

(%

)

US

Seychelles

'High normal' 'Hypertension'

• Definition of the ‘health transition’

• Trends of disease patterns in populations

• The 4 stages of the epidemiological transition

• The cardiovascular disease transition

• Engines of the health transition– Urbanization, demographic, lifestyle, socioeconomic and health care

• Other determinants of NCDs

• Predicted trends in disease patterns, ‘Global Burden of Disease’

• The double burden of disease

• Impact of NCDs on public health

• Evidence for the preventability of CVD

• Strategies for the primary prevention of CVD

• Public health response to emerging CVD

IUMSP-GCT

Socioeconomic transition in disease patterns: early- vs. late-adopter communities

Time IUMSP-GCT

Time

CVD

mor

talit

y

Early adoptercommunity Late adopter

community

Age of onset of degenerative and manmade diseases

Age of onset of delayed degenerativediseases

Rural-urban differences in levels of risk factors (Shanghai region, 1985)

Urban Hongku(n=1591)

Rural, Baoshan(n=1200)

Height (m) 1.62 1.58

Weight (kg) 59.2 54.5

Body mass index (kg/m2) 22.4 21.5

SBP (mm Hg) 125 119

DBP (mmHg) 80 76

Cholesterol (mg/dl) 164.3 158.4

IUMSP-GCT

Socio-economic differential in risk factor levels (random sample of 9254 adults of Dar es Salaam, 1999)

•

SESindicators

Prevalence in index

category (%)

Body mass index (kg/m2)

(adusted for age & sex)

Systolic BP (mmHg)

(adjusted for age, sex & BMI)

OR for smoking(adjusted for sex & age)

EducationSecondary or morevs non manual unskilled 22 +1.48 -5.3 0.72OccupationNon manual skilled vs. manual unskileed 7 +0.66 -2.7 0.40WealthRefrigerator at homevs. not 18 +1.44 -1.5 0.52Flush toilet at homevs. latrine 15 +1.21 -2.1 0.63

Some issues related to socioeconomic transitionEquity

• access to information & health care related to RF and NCDs• costs related to adopting healthy behaviors/lifestyles• costs of treatment for chronic NCDs

Socioeconomic differences within populations• pockets of underdevelopment within western countries• large variations in development within developing countries

Forward and backward dynamic of development• underdevelopment can follow phases of development (e.g.

FSE)

IUMSP-GCT

• Definition of the ‘health transition’

• Trends of disease patterns in populations

• The 4 stages of the epidemiological transition

• The cardiovascular disease transition

• Engines of the health transition– Urbanization, demographic, lifestyle, socioeconomic and health care

• Other determinants of NCDs

• Predicted trends in disease patterns, ‘Global Burden of Disease’

• The double burden of disease

• Impact of NCDs on public health

• Evidence for the preventability of CVD

• Strategies for the primary prevention of CVD

• Public health response to emerging CVD

IUMSP-GCT

Health care transition

• Availability of preventive and curative services– immunization, contraception, maternal/child care, antibiotics

• Large influence on the dynamics of demographic transition– e.g. ‘delayed transition model’ in many developing countries

(decrease in infant mortality not followed by proportionate decrease in birth/fertility rates: population increase ++)

• Large heterogeneity between populations due to costs and efficiency in allocation of health services

IUMSP-GCT

Burden of disease and health expenditures in industrialized and developing countries: the '90/10 desequilibrium'

IUMSP-GCT

13

87

93

7

0%

20%

40%

60%

80%

100%

EME All other

Per

cent Health

expenditure

DALYs

Aid disbursements for health by type of disease burden: current low priority given to NCDs

Disease % ofDALYs

Funds in $(million)

$ perDALY

Communicable,maternal and perinatal

50 807 1.32

Non-communicable 38 74 0.16

Injuries 12 9 0.06

IUMSP-GCT

Allocation of resources for NCD control concentrates on equipment, not on prevention

(Growth in medical equipment imports in one state of India)

Item 1981 1992

Electromedical equipment 1.4 61.0

X-ray apparatus 8.6 17.3

Other medical/surgical 25.6 24.2

In millions $

IUMSP-GCT