Transcript Definition of the `health transition`

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
IUMSP-GCT
• Definition of the ‘health transition’
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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
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, 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
Percent of all deaths
Violence
80%
Diabetes
Stroke
60%
Heart disease
Cancer
40%
Dis. of early infancy
Diarrhea enteritis
20%
Pneumonia
Other infectious d.
0%
Tuberculosis
IUMSP-GCT
Health transition: proportionate mortality by
broad cause of death (US, 1900-1970)
Percent of all deaths
100%
80%
60%
40%
Other
Violence
Cancer
CVD
20%
Infectious
0%
IUMSP-GCT
Health transition: mortality rates (US, 1910-1970)
Death rate per 100,000 population
(up to >1000 earlier)
600
Infectious diseases
500
Heart disease
400
Cancer
300
Stroke
Violent/accident
200
Infancy disease
100
Tuberculosis
0
1900
1920
1940
1960
1980
IUMSP-GCT
The health transition favors the young over the old
(Age-specific mortality rates, US, 1890-1970)
250
Deaths per 1000 population
<1
200
150
75-84
100
1-4
50
55-64
20-24
0
1880
1900
1920
1940
1960
IUMSP-GCT
1980
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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, 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
IUMSP-GCT
• Public health response to emerging CVD
The 4 stages of the health transition
Phases
Socioeconomic
development
+
Life
expectancy
~30
++
(developing
countries)
30-50
3*
Age of degenerative +++
and man-made
(countries in
diseases
transition)
50-55
4**
Age of delayed
degenerative
diseases
~70
1*
2*
Age of pestilence
(infection) and
famine
Age of receding
pandemics
++++
(western
countries)
Change in broad disease Change within broad
categories
disease categories
(proportionate mortality)
Infections
CVD: 5-10% related to
Nutritional deficiencies
nutrition/infection (e.g.
RHD, Chagas)
Improved sanitation :
CVD: 10-35%
Hypertensive heart
 infections,  diet
disease, stroke. sequels of
(salt),  aging
RHD and CHF
CVD: 35-65%. Obesity,
 aging,  lifestyles
related to high SES (diet, dyslipidemias, HBP,
activity, addiction)
smoking  CHD, stroke,
often at early age ;
PVD (first in  SES)
 reduced risk behaviors CVD <50% (delayed 
in the population
total CVD due to aging
(prevention and health
population &  prevalence
promotion) and  new
due to better treatment)
treatments
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, 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
Early stage of health
transition
Low & middle income
economies
• Stroke > IHD
• Stroke of hemorrhagic origin
• Younger age (stroke, IHD)
• Higher case fatality
Late stage of health
transition
High income
economies
IHD > stroke
• Stroke of ischemic
origin
• Older age
• Lower case fatality
IUMSP-GCT
Differences in proportionate CVD mortality across
regions at different stages of development, 1990
100%
80%
IHD
60%
CVA
40%
Cardio
myopathies
20%
Rheumatic
SubSaharan
China
India
Middle
East
Latin
America
East
Europe
West
0%
IUMSP-GCT
The high burden of stroke in developing countries:
stroke mortality rates in selected countries, age 40-69
K yrgyz tan
R us s ia
B elarus
S eyc helles
D ar es S alaam
E s tonia
Japan
Aus tria
UK
US A
Men
W om en
S w itz erland
-400
-300
-200
-100
0
100
200
300
400
IUMSP-GCT
Mortality rate (per 100,000)
High toll of NCD/CVD in middle age in developing countries:
mortality by broad cause, Seychelles, 1993-1995
Canc er
O th e r
250
Men
Wom e n
200
150
100
50
A g e c a te g o r y
65+
35-64
0-34
65+
35-64
0
0-34
Num ber of deaths per year
CV D
Stages of the health transition: focus on the type and
regional distribution of cardiovascular disease
Phases/stage of
development
Age of pestilence
and famine
Deaths from
CVD
5-10
Age of receding
pandemics
10-35
Age of degenerative 35-65
and man-made
diseases
Age of delayed
<50
degenerative
diseases
Predominant CVD
RHD, infections,
nutritional
cardiomyopathies
As above +
hypertensive heart
disease and
hemorrhagic stroke
All forms of stroke,
IHD at relatively
young ages
Stroke (isch) and
IHD at older ages
Regional examples
in 2000
Sub-Saharan
Africa, rural India,
rural South America
As above +
China
Urban India, Eastern
Europe
Western Europe,
North America,
Australia
A model of the health transition accounting for
mortality rates of diseases and types of CVD
Stage 1
Stage 2
Stage 3
Stage 4
Infection
Nutr. deficienc.
SE develop.
Increase LE
Increase salt
Industrialis.
Urbanisation
Fats, sedent.
smoking
Healthy lifestyles
Case-management
RHD
HBP
Hem. stroke
CHD
Ischem. stroke
Decline &
delay in CVD
O th e r
In ju rie s
M o rtality
C anc er
C VD , is c h e m ic h e a rt d is e a s e
C VD , is c h e m ic s tro ke
C VD , h e m o rrh a g ic s tro ke
C VD , in fe c t/n u tr. c a rd io m .
In fe c tio u s
T im e
( p r o x y: lif e e x p e c t a n c y, d e v e lo p m e n t )
IUMSP-GCT
How to interpret the health transition across
populations at different stages of development:
emergence and decline of CVD
H ig h in co m e
co u n tries
Low rates
E co n o m ies
Low increase
in tran sitio n
Rapid increase
M id d le in co m e
co u n tries
Reach peak
L o w in co m e
P rogressive
decline
co u n tries
1950
1960
1970
1980
1990
2000
2010
IUMSP-GCT