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