Definition of the health transition

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 expectan
cy
? ? fertility
? nutrition ? technology for health care
? public sanitation, housing, health care
Industrialization urbanization
? per cap. income, ? wealth
Increasing and aging population
? persons at at risk of developing NCDs
? NCD ? infectious diseases
? levels of RF fat, calories, tobacco, sedenta
ry 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
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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
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Models of demographic transition
Mortality and birth rates driven to various
extents by socio-economic development, public
health medical interventions
IUMSP-GCT
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Recent declines in fertility rates in various
developing countries
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
  

IUMSP-GCT
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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
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Aging populations trends in number of persons
(millions) aged ?60
IUMSP-GCT
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Impact of growing and aging populations in
industrialized and developing countries World
population structure by region, 1950-1990
IUMSP-GCT
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• 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
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Changes in cigarettes consumption (sales) in
developing and developed countries, 1974-1992
IUMSP-GCT
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Nutritional transition rapid adoption of a high
fat diet, China
IUMSP-GCT
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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

12
2
Switzerland
Blood lipoprotein(a)
33
35
300 mg/l
10
13
5
28
(BMI30)
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
(BMI30)
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
Boys
Girls
16
12
Proportion ()
8
4
0
UK
UK
USA
USA
Brazil
Brazil
Singapore
Singapore
Hong Kong
Seychelles
Hong Kong
Seychelles
Netherlands
Netherlands
IUMSP-GCT
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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
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Rural-urban differences in levels of risk factors
(Shanghai region, 1985)
IUMSP-GCT
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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
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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