Definition of the ‘health transition’ Trends of disease patterns in populations

1. 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

2. Health transition: demographic transition and epidemiologic transition Economic, social & environ mental changes  mortality ( infant mortality)  life expectancy   fertility  nutrition  technology for health care Industrialization & urbanization  public sanitation, housing, health care  per cap. income,  wealth  NCD  infectious diseases persons at at risk of developing NCDs Increasing and aging population  levels of RF: fat, calories, tobacco, sedentary habits IUMSP-GCT

3. Percent of urban population from 1970-2025 in industrialized and developing countries IUMSP-GCT

4. 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

5. 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

6. 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

7. Models of demographic transition Mortality and birth rates driven to various extents by socio-economic development, public health & medical interventions IUMSP-GCT

8. Recent declines in fertility rates in various developing countries IUMSP-GCT

9. 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 Determinants of fertility rates IUMSP-GCT

10. 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

11. Aging populations: trends in number of persons (millions) aged 60 IUMSP-GCT

12. Impact of growing and aging populations in industrialized and developing countriesWorld population structure by region, 1950-1990 IUMSP-GCT

13. 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

14. 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

15. Changes in cigarettes consumption (sales) in developing and developed countries, 1974-1992 IUMSP-GCT

16. Nutritional transition: rapid adoption of a high fat diet, China IUMSP-GCT

17. Higher levels of several risk factors in Seychelles than in Switzerland (age 35-64, 1989-1991) Females Males (>160/95 or tt) 35 30 Hypertension 15 14 53 13 Smoking (>1 cig/day) 34 24 Blood total cholesterol 11 20 (>6.5) 39 46 Seychelles Blood HDL-cholesterol 11 8 <0.9 mmol/l 12 2 Switzerland Blood lipoprotein(a) 33 35 >300 mg/l 10 13 5 28 (BMI>30) Obesity 11 12 7 7 Diabetes 5 5 (diff. criteria) 0 20 40 60 0 20 40 60 IUMSP-GCT Prevalence (%) Prevalence (%)

18. Increasing levels of several risk factors in a rapidly developing country, Seychelles, 1989-1994 Males Females 21 32 High cholesterol (>6.5) 11 20 42 27 Hypertension (>160/95) 31 24 41 8 Smoking 54 12 1994 8 5 Diabetes (diff. criteria) 1989 7 7 Obesity (BMI>30) 10 34 5 29 Heavy exercise at work 14 2 36 18 Leisure exercise weekly 20 13 3 2 0 20 40 60 0 20 40 60 IUMSP-GCT Prevalence (%) Prevalence (%)

19. Prevalence of overweight and obesity in children, age 5-17, in developed and developing countries (using same criteria) Overweight Obesity 20 Girls Boys 16 12 Proportion (%) 8 4 0 UK UK USA USA Brazil Brazil Singapore Singapore Hong Kong Seychelles Hong Kong Seychelles Netherlands Netherlands IUMSP-GCT

20. Prevalence of high systolic blood pressure in children, age 5-17, Seychelles and USA (using same criteria) 20 'High normal' 'Hypertension' 15.3 14.0 15 US Seychelles 10 10 Prevalence (%) 9.5 10 8.3 5 5 5 0 IUMSP-GCT Boys Girls Boys Girls

21. 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

22. Socioeconomic transition in disease patterns: early- vs. late-adopter communities Time IUMSP-GCT

23. Rural-urban differences in levels of risk factors (Shanghai region, 1985) IUMSP-GCT

24. Socio-economic differential in risk factor levels (random sample of 9254 adults of Dar es Salaam, 1999) Prevalence Body mass Systolic BP OR for in index SES index (kg/m2) (mmHg) smoking category indicators (adusted for age (adjusted for (adjusted for (%) & sex) age, sex & BMI) sex & age) Education Secondary or more +1.48 -5.3 0.72 22 vs non manual unskilled Occupation Non manual skilled +0.66 -2.7 0.40 7 vs. manual unskileed Wealth Refrigerator at home +1.44 -1.5 0.52 18 vs. not Flush toilet at home +1.21 -2.1 0.63 15 vs. latrine

25. 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 development (e.g. FSE) IUMSP-GCT

26. 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

27. 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

28. Burden of disease and health expenditures in industrialized and developing countries: the '90/10 desequilibrium' 100% 7 80% Health expenditure 60% 93 Percent 87 DALYs 40% 20% 13 0% All other EME IUMSP-GCT

29. Aid disbursements for health by type of disease burden: current low priority given to NCDs IUMSP-GCT

30. Allocation of resources for NCD control concentrates on equipment, not on prevention(Growth in medical equipment imports in one state of India) IUMSP-GCT