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  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

Percent of urban population from 1970-2025 in industrialized and developing countries UN DELSA. World Urbanization Prospects, 1994 revisions, ST/ESA/SERA/150, New York, 1995 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, 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 Omran, Millbank Mem Fund Quart, 1971;49,215 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 (treatment, contraception, abortion) Omran, Millbank Mem Fund Quart, 1971;49,215 IUMSP-GCT

Models of demographic transition Omran, Millbank Mem Fund Quart, 1971;49,215 Mortality and birth rates driven to various extents by socio-economic development, public health & medical interventions IUMSP-GCT

Recent declines in fertility rates in various developing countries United Nations, 1993 IUMSP-GCT

Determinants of fertility rates 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 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 Notestein, 1945; Simons (IUMSP) 1995 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) Vital statistics & UPCCD, Seychelles, 2001 IUMSP-GCT

Aging populations: trends in number of persons (millions) aged 60 Kalache, Principles and Practice of Geriatric Medicine, 1985 IUMSP-GCT

Impact of growing and aging populations in industrialized and developing countries World population structure by region, 1950-1990 UN Demographic Yearbook, 1990, New York, 1992 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 US Department of Agriculture (1994) IUMSP-GCT

Nutritional transition: rapid adoption of a high fat diet, China Reddy & Yusuf. Circulation 1998;97:569 IUMSP-GCT

Higher levels of several risk factors in Seychelles than in Switzerland (age 35-64, 1989-1991) Males Females (>160/95 or tt) Hypertension 35 30 15 14 Smoking (>1 cig/day) 53 13 34 24 Blood total cholesterol (>6.5) 11 20 46 39 Seychelles Blood HDL-cholesterol <0.9 mmol/l 11 8 12 2 Switzerland Blood lipoprotein(a) 33 35 >300 mg/l Bovet et al. Arterioscler Thromb 1991;11:1730-6 Wietlisbach et al. Prev Med 1997;26:523-33 10 13 5 28 Obesity (BMI>30) 11 12 Diabetes 7 7 5 5 (diff. criteria) 20 40 60 20 40 60 IUMSP-GCT Prevalence (%) Prevalence (%)

Increasing levels of several risk factors in a rapidly developing country, Seychelles, 1989-1994 Males Females High cholesterol (>6.5) 21 32 11 20 Hypertension (>160/95) 42 27 31 24 Smoking 41 8 54 12 1994 Diabetes (diff. criteria) 8 5 1989 7 7 Obesity (BMI>30) 10 34 Bovet et al. Seychelles Med Den J 1997;5:8-24 [www.seychelles.net/smdj] Bovet et al. Arterioscler Thromb 1991;11:1730-6 5 29 Heavy exercise at work 14 2 36 18 Leisure exercise weekly 20 13 3 2 20 40 60 20 40 60 IUMSP-GCT Prevalence (%) Prevalence (%)

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 Definition of overweight and countries except Seychelles: Cole, BMJ 2000;320:1240 Data for Seychelles: Stettler et al. Int J Obes 2002;26:214-19. 4 UK UK USA USA Brazil Brazil Singapore Singapore Netherlands Hong Kong Seychelles Netherlands Hong Kong Seychelles IUMSP-GCT

'High normal' 'Hypertension' US Seychelles 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 Prevalence (%) 10 10 9.5 10 8.3 Criteria from 1996 NIH Task Force Report on HBP in children Height percentiles from NCHS/WHO database 5 5 5 Boys Girls Boys Girls 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

Socioeconomic transition in disease patterns: early- vs Socioeconomic transition in disease patterns: early- vs. late-adopter communities Early adopters: higher social and economic development: earlier rise and earlier decline of CVD Late adopters: when mediators of risk (process foods, cig, mechanized transport become mass produced for mass consumption (e.g. CVD & African-Americans) Time IUMSP-GCT

Rural-urban differences in levels of risk factors (Shanghai region, 1985) Zhai S, McGarvey. Human Biology, 1992;64:807 IUMSP-GCT

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

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

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

100% 80% Health expenditure 60% Percent DALYs 40% 20% 0% EME All other 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% EME= established market economies Murray et al. National health expenditures. WHO, 1994 Global Forum for Health Research (www.globalforumhealth.org) 20% 13 0% EME All other IUMSP-GCT

Aid disbursements for health by type of disease burden: current low priority given to NCDs Murray et al, 1994 IUMSP-GCT

Allocation of resources for NCD control concentrates on equipment, not on prevention (Growth in medical equipment imports in one state of India) Jha et al. World Bank, 1996 IUMSP-GCT