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
UN DELSA. World Urbanization Prospects, 1994 revisions, ST/ESA/SERA/150, New York, 1995
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
Omran, Millbank Mem Fund Quart, 1971;49,215
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)
Omran, Millbank Mem Fund Quart, 1971;49,215
IUMSP-GCT

7. 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

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

9. 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

10. Demographic transition in Seychelles: 3-fold increase of the number of people by (hence expected large increase in NCDs)
Vital statistics & UPCCD, Seychelles, 2001
IUMSP-GCT

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

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

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

17. 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 (%)

18. 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 [
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 (%)

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

20. '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

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
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

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

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. 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 (
20% 13 0%
EME
All other
IUMSP-GCT

29. Aid disbursements for health by type of disease burden: current low priority given to NCDs
Murray et al, 1994
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)
Jha et al. World Bank, 1996
IUMSP-GCT

34. Murray, Lopez, 1997

35. *(adjusted for changes in demography, income, education, smoking and time [~technology]) WHO, Evidence Information and Policy, 2000

36. Source: Bonita, WHO, based on rates from 7 Cities Stroke Study in China (Xue-Ming Cheng et al)

38. Murray & Lopez, GBD Priority remains to the unfinished agenda of communicable, maternal, and perinatal diseases in many developing countries
Need to additionally address the new agenda of NCDs and injuries to prevent, delay or curb the ongoing epidemic of NCDs

41. Go to Part III of this lecture