Health transition and emerging cardiovascular disease in developing countries: situation and strategies for prevention Pascal Bovet, MD, MPH, Senior Lecturer Institute of Social and Preventive Medicine Group for Epidemiologic Transition and Cardiovascular Disease University of Lausanne, Switzerland http://www.hospvd.ch/iumsp http://www.hospvd.ch/iumsp/info/gct/index.htm WHO collaborating center for population-based cardiovascular research and prevention in populations in health transition 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

The health transition Originally described in the 1970s (Omran, later Olshansky, Ault) As socioeconomic development proceeds, mortality and fertility rates shift from high to low rates, populations get larger and older, and disease pattern shifts from one dominated by infectious diseases, perinatal diseases and nutritional disorders to one dominated by NCDs conventional classification of 4 stages relating socioeconomic development and disease patterns Key to understanding current and future health patterns useful tool to anticipate health needs in developing countries experiencing early stages of health transition particularly in countries where data on mortality and risk factors are scarce Omran AR. The epidemiologic transition. Milbank Mem Fund Q 1971;49:509-538 Olshansky & Ault. The fourth stage of epidemiologic transition. Milbank Mem Fund Q 1986;64:355-91 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

Health transition: proportionate mortality over time (US, 1900-1970, Omran) 100% Other causes Violence 80% Diabetes Stroke 60% Heart disease Percent of all deaths Cancer 40% Dis. of early infancy Omran, Millbank Mem Fund Quart, 1971;49,215 Diarrhea enteritis Pneumonia 20% Other infectious d. Tuberculosis 0% 1900 1910 1920 1930 1940 1950 1960 1970 IUMSP-GCT

Health transition: proportionate mortality by broad cause of death (US, 1900-1970) 100% 80% Other Violence 60% Percent of all deaths Cancer 40% CVD Omran, Millbank Mem Fund Quart, 1971;49,215 20% Infectious 0% 1900 1910 1920 1930 1940 1950 1960 1970 IUMSP-GCT

Health transition: mortality rates (US, 1910-1970) (up to >1000 earlier) Omran. Epidemiologic transition in the US. Pop Bull, 1977;32, No 2:1-39 IUMSP-GCT

The health transition favors the young over the old (Age-specific mortality rates, US, 1890-1970) Omran. Epidemiologic transition in the US. Pop Bull, 1977;32, No 2:1-39 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

The 4 stages of the health transition Omran. The epidemiologic transition. Millbank Mem Fund Q 1971 ;49 :509-38 Olshansky & Ault. The 4th stage of the epidemiological transition. Millbank Mem Fund Q 1986 ;64 :355-91 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

Transition in cardiovascular disease patterns along the health transition Late stage of health transition High income economies IHD > stroke Stroke of ischemic origin Older age Lower case fatality Early stage of health transition Low & middle income economies Stroke > IHD Stroke of hemorrhagic origin Younger age (stroke, IHD) Higher case fatality IUMSP-GCT

Differences in proportionate CVD mortality across regions at different stages of development, 1990 100% IHD 80% CVA 60% Cardio myopathies 40% Murray & Lopez. Global comparative assessments in health sector. WHO, 1994 Rheumatic 20% 0% West India China East Europe Middle East Latin America Sub- Saharan IUMSP-GCT

The high burden of stroke in developing countries: stroke mortality rates in selected countries, age 40-69 Seychelles: cohort study; Dar es Salaam: AMMP verbal autopsy (Lancet 2000); others: WHO. IUMSP-GCT

High toll of NCD/CVD in middle age in developing countries: mortality by broad cause, Seychelles, 1993-1995 Bovet P et al. CVD Prevention 1999;2:261-272 High CVD mortality High (preventable) CVD mortality in middle-aged persons (particularly in men)

Stages of the health transition: focus on the type and regional distribution of cardiovascular disease

A model of the health transition accounting for mortality rates of diseases and types of CVD IUMSP-GCT

How to interpret the health transition across populations at different stages of development: emergence and decline of CVD IUMSP-GCT