Definition of the

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, lifestyle,
  socioeconomic and health care
• Other determinants of NCDs Impact of NCDs on
  public health
• 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

• The health transition predicts an unprecedented
  epidemic of NCD/CVD in developing countries
• Is there enough evidence that CVD can be
  prevented at the first place ? Yes!!

IUMSP-GCT
3
Primary prevention of coronary disease through
diet and lifestyle (Nurses Health Study, 89141
women )
4
Low risk factor profile is associated with low
CVD mortality (several US cohorts)

5
Risk status, income and CVD mortality low RF
profile predicts low CVD mortality irrespective
of income

• Men aged 35-57
• MRFIT

IUMSP-GCT
6
CVD risk factors
large potential for prevention
-
Non
modifiable RF
age, sex, history
Behavioral RF
Endpoints
Physiological RF
Smoking
Heart disease

Hypertension
Unhealthy diet
Stroke

Cholesterol
(salt, fat, fruit
veg
)
Vascular disease

Diabetes
Sedentary lifestyles
Some cancers

Obesity
Resp
. disease
Socio
economic
-
cultural determinants
Early life characteristics
modifiable
IUMSP-GCT
7
Cardiovascular disease a multifactorial disease

• Reduce blood pressure
• Reduce serum cholesterol
• Reduce the number of smokers
• Reduce the number of persons with overweight
• Ensure healthy diet (change diet)
• Prevent (and control) diabetes
• Improve social conditions

IUMSP-GCT
8

• 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
9

• The health transition predicts an unprecedented
  epidemic of NCD/CVD in developing countries
• Do we know enough to prevent this CVD epidemic
  in the first place? Yes!!
• Do we know enough to make a difference? Yes!!

IUMSP-GCT
10
The health transition in developing countries
which possible responses ?

• 4 engines for heath transition
• Demographic (populations get older)
• Not modifiable
• Lifestyle-epidemiologic (age-specific risk factor
  rates change)
• Modifiable
• Socio-economic (differential risk factors levels
  across SES)
• Modifiable
• Health services (access/use of preventive
  curative services)
• Modifiable

IUMSP-GCT
11
Linear relation between relative risk of CVD and
risk factor level in populations (the example of
diastolic BP and stroke, Eastern Asia)

IUMSP-GCT
12
Relative risk, RF prevalence and attributable
fraction low impact on strategies limited to
high risk patients (the case of blood pressure
and CHD)
13
Population and high risk preventive strategies
14
Strategies to prevent the emergence of NCD/CVD
Primary prevention (limit the number of new cases)

• Population strategy
• Public health approach
• Targets population

• High risk strategy
• Clinical management
• Targets individuals

IUMSP-GCT
15
Public health approach vs. high risk strategy
High-risk
Population
Advantages



Radical
(
incidence)

Benefit for individual large

Advantages



Potential large benefit

Easy to understand, hence
motivation and rewards for


Cost effective (policy)
individuals


Can target unaware


Needs person's cooperation
population groups
Limitations



Need for mass change is hard

Impact on total burden small
to communicate
Limitations


Often misused


Interventions other than


Costly (screening)
policies hard to implement


Palliative (does not solve


Benefit for individual small,
overall problem, 'rescue')
hence weak motivation of


Distracts from population
individuals and physicians
approaches


Interventions can challenge
vested interests/societal norms
16
Estimated stroke/CHD deaths that could be averted
in 2020 by applying population and high-risk
preventive strategies
Combined population and high risk approaches
additive
17
Yield of a screening and treatment (high risk)
strategy at population level long-term
compliance to a 1-tablet/day antihypertensive
medication
18

• 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
19
Areas for public health interventions policies
to prevent and control NCD/CVD in developing
countries

• Reduction of sodium consumption
• developed countries 75 in processed food
  developing countries often most from
  discretionary use (opportunity)
• Food policies promoting healthy foods
• Interventions/policies to promote physical
  exercise
• Tobacco control
• legislation, Framework Convention of Tobacco
  Control
• Health education integrated in school curriculum
• In all instances, need for multisectoral approach

20
Constraints for NCD/CVD prevention in developing
countries

• Limited recognition/available data of major NCDs
• Double burden of disease
• Lack of commitment at international level
• Prevention not taken seriously (market pressure
  favoring therapy)
• Failure to influence the policy of government
  departments
• Conditions like stroke/CHD considered diseases
  for the specialist
• Health care needs not addressed prospectively
  by existing health systems (lack of perspective
  of health transition)
• Costs are rising and resources are dwindling

21
Preventing NCD/CVD in developing countries a
window of opportunity

• Relatively low levels of some risk factors in
  many developing countries
• Opportunity for prevention in the first place
  (primordial prevention)
• Unlike for western countries (where CVD epidemics
  was understood at its peak and addressed mainly
  through case-management
• Prevention is the best option as an approach
  mainly based on case-management is not affordable
  for most DC
• Monitor trends in CVD risk factors

IUMSP-GCT
22
Global strategy for the prevention and control
of NCD/CVD in
developing countries

• Prevention in the first place
• reduce major risk factors through population
  strategy
• targeted high risk strategies
• Case management
• identify and promote cost-effective and
  affordable interventions
• Surveillance
• assess the patterns and trends of main risk
  factors (mortality the past morbidity the
  present risk factors the future)

23
Health transition and emerging NCD/CVD in
developing countries implications for the public
health response

• The paradigm of the health transition provides an
  evolutionary perspective which transcends the
  limitations of confined cross-sectional views of
  the CVD epidemic and argues towards strategic
  choices of policies and programs which take into
  account the present as well the future burdens of
  CVD.
• The direction of the epidemic in developing
  countries is clear and the dimensions of the
  future burden can be predicted by combined
  demographic and economic models.
• The case for preventive public health action
  becomes stronger when it is recognized that the
  future health care demands of a full-blown
  epidemic will be well beyond the capacity of the
  public health system.

24
Health transition and emerging NCD/CVD in
developing countries the way forward

• Reappraise the coming NCD/CVD epidemic
• Apply the knowledge
• Focus on primary prevention with focus on health
  policies
• Target high risk strategies (hypertension,
  diabetes)
• Identify and apply low cost and affordable
  interventions for case management
• Set surveillance systems (particularly risk
  factors)
• Need to strengthen capacity building, leadership,
  partnership