•
•
•
•
•
•
•
•
•
•
•
•
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
IUMSP-GCT
Public health response to emerging CVD
Health transition: demographic transition
and epidemiologic transition
Industrialization
& urbanization
 per cap. income,
 wealth
Economic,
social &
environ
mental
changes
 levels of RF:
fat, calories, tobacco,
sedentary habits
 public
sanitation,
housing,
health care
 NCD
 infectious
diseases
 nutrition

technology
for health
care
 mortality
( infant mortality)
 life expectancy
  fertility
 persons at
at risk of
developing
NCDs
Increasing
and aging
population
IUMSP-GCT
Percent of urban population
Percent of urban population from 1970-2025
in industrialized and developing countries
100
1970
1994
2025
80
60
40
20
0
D e ve lo p e d
F o rm e r so cia list
co u n trie s
e co n o m ie s
D e velo p in g
co un trieIUMSP-GCT
s
•
•
•
•
•
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)
40
Population
Birth rate
50
40
•
30
Death rate
20
30
20
Population (m illions)
Birth & death rates (per 1000)
50
 Mortality rate
•  Fertility rate
( birth rate)
•  Size population
•  Age population
10
0
1800 1840 1880 1920 1960
10
0
IUMSP-GCT
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
IUMSP-GCT
(treatment, contraception, abortion)
Models of demographic transition
Western
50
Accelerated (Japan, FSE)
50
50
Delayed (Most LDC)
100
50
80
40
12
40
40
40
9
Birth rate
30
30
30
60
30
6
Death rate
20
20
20
40
20
3
10
10
10
20
UK
Japan
0
0
1800
1840 1880
10
1920 1960
Sri-Lanka
0
1800
0
1840
1880
1920
1960
0
1800
0
1840
1880
1920
1960
Mortality and birth rates driven to various
extents by socio-economic development, public
IUMSP-GCT
health & medical interventions
P opulation (millions)
B irth & death rates (per 1000)
Population
Recent declines in fertility rates in various
developing countries
Thailand
China
Bangladesh
Turkey
Mexico
Indonesia
Brazil
Egypt
India
Philippines
Pakistan
Nigeria
1965-70
1985-90
6.1
6.0
6.9
5.6
6.7
5.6
5.3
6.6
5.7
6.0
7.0
6.9
2.3
2.3
3.6
3.0
3.8
3.3
3.5
4.4
4.2
4.7
7.0
6.9
Prop. diff.
(%).
62
62
48
46
43
41
34
33
26
21
0
0IUMSP-GCT
Determinants of fertility rates
High fertility
• Economic needs of selfsufficient 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
8 ,0 0 0
6 ,0 0 0
1976
4 ,0 0 0
1990
2030
2020
2000
2 ,0 0 0
75+
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0
0-4
Population per 5-year category
Demographic transition in Seychelles: 3-fold
increase of the number of people 50-70 by 20201 0 30
,0 0 0 (hence expected large increase in NCDs)
IUMSP-GCT
Ag e c a te g o ry
Aging populations: trends in number of persons
(millions) aged 60
1950
Brazil
Mexico
Nigeria
Indonesia
China
Bangladesh
Japan
India
USSR
USA
Italy
Germany
2
1
1
4
42
3
6
32
16
19
6
7
1975
6
3
3
7
74
3
13
30
34
32
10
12
2000
14
7
6
15
135
7
26
66
54
40
14
13
2025
32
18
16
31
284
17
33
146
71
67
16
15
Increase
(fold)
1950-2025
15
13
12
8
7
6
6
5
4
4
3
IUMSP-GCT 2
Impact of growing and aging populations in
industrialized and developing countries
World population structure by region, 1950-1990
Increase (fold)
1950-1990
6000
W es t As ia (3.1)
5000
S outh As ia (2.5)
Millions
4000
S E As ia
(2.5)
E as t As ia
(2.0)
Afric a
(3.0)
3000
2000
S . Am eric a (2.7)
N. Am eric a (1.7)
1000
0
1950
1960
1970
1980
1990
E x-US S R
(1.6)
E urope
(1.2)
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
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
China: 390%
200
C hina
S o uth K o re a
150
India
100
India
Tha ila nd
US A
UK
50
UK
C a na da
1990
1988
1986
1984
1982
1980
1978
1976
0
1974
Percent change (% )
Thailand
IUMSP-GCT
Nutritional transition: rapid adoption of a
high fat diet, China
100%
Proportion of pers ons
with >30% fat diet (%)
1989
1993
80%
60%
40%
20%
0%
H ig h e r in c o m e
M id d le in c o m e
e a rn e rs
e a rn e rs
L o w in c o m e
e a IUMSP-GCT
rn e rs
Higher levels of several risk factors in Seychelles
than in Switzerland (age 35-64, 1989-1991)
Females
Males
Hypertension (>160/95
or tt)
Smoking (>1 cig/day)
15
35
34
Blood total (>6.5)
cholesterol
Blood HDL- <0.9 mmol/l
cholesterol
Blood
>300 mg/l
lipoprotein(a)
11
14
53
13
5
Obesity (BMI>30)
46
2
39
Seychelles
Switzerland
8
33
13
11
12
35
28
7
5
7
5
Diabetes
24
20
11
12
10
30
(diff. criteria)
0
20
40
60
Prevalence (%)
0
20
40
60
IUMSP-GCT
Prevalence (%)
Increasing levels of several risk factors in a rapidly
developing country, Seychelles, 1989-1994
Males
High cholesterol (>6.5)
11
Females
21
20
42
Hypertension (>160/95)
27
24
31
41
Smoking
32
8
54
12
1994
8
7
Diabetes (diff. criteria)
Obesity (BMI>30)
5
5
7
10
34
29
14
Heavy exercise at work
2
36
Leisure exercise
weekly
3
0
1989
20
18
13
2
20
40
Prevalence (%)
60
0
20
40
IUMSP-GCT
Prevalence (%)
60
Prevalence of overweight and obesity in children,
age 5-17, in developed and developing countries
(using same criteria)
Overweight
Obesity
20
Girls
Boys
Proportion (%)
16
12
8
4
Seychelles
Brazil
Hong Kong
Singapore
Netherlands
UK
USA
Seychelles
Brazil
Hong Kong
Singapore
Netherlands
UK
USA
0
IUMSP-GCT
Prevalence of high systolic blood pressure in children,
age 5-17, Seychelles and USA (using same criteria)
20
'High normal'
'Hypertension'
Prevalence (%)
15.3
14.0
15
10
US
10
Seychelles
10
9.5
8.3
5
5
Boys
GirlsIUMSP-GCT
5
0
Boys
Girls
•
•
•
•
•
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
E a rly a d o p te r
c o m m u n ity
L a te a d o p te r
C VD mo rta lity
c o m m u n ity
A g e o f o ns e t o f
A g e o f o ns e t of
d e g e ne ra tive a nd
d e la ye d d e g e ne ra tive
m a nm a d e d is e a s e s
d is e a s e s
Time
IUMSP-GCT
Rural-urban differences in levels of risk factors
(Shanghai region, 1985)
Height (m)
Urban Hongku
(n=1591)
1.62
Rural, Baoshan
(n=1200)
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
164.3
158.4
Cholesterol (mg/dl)
IUMSP-GCT
Socio-economic differential in risk factor levels (random
sample of 9254 adults of Dar es Salaam, 1999)
SES
indicators
Prevalence Body mass Systolic BP OR for
in index index (kg/m2) (mmHg)
smoking
category (adusted for age (adjusted for (adjusted for
& sex)
age, sex & BMI) sex & age)
(%)
Education
Secondary or more
vs non manual unskilled
22
+1.48
-5.3
0.72
Occupation
Non manual skilled
vs. manual unskileed
7
+0.66
-2.7
0.40
Refrigerator at home
vs. not
18
+1.44
-1.5
0.52
•
Flush toilet
at home
vs. latrine
15
+1.21
-2.1
0.63
Wealth
Some issues related to socioeconomic
transition
Equity
• 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
IUMSP-GCT
development (e.g. FSE)
•
•
•
•
•
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'
100%
7
Percent
80%
60%
Health
expenditur
93
87
40%
DALYs
20%
13
0%
EME
All other
IUMSP-GCT
Aid disbursements for health by type of disease
burden: current low priority given to NCDs
Disease
% of
DALYs
Funds in $
(million)
$ per
DALY
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)
1981
1992
Electromedical equipment
1.4
61.0
X-ray apparatus
8.6
17.3
Other medical/surgical
25.6
24.2
Item
In millions $
IUMSP-GCT