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Health transition and emerging cardiovascular disease in developing
countries: situation and strategies for prevention
IUMSP-GCT
Pascal Bovet, MD, MPH, Senior Lecturer
Institute of Social and Preventive Medicine
Group for Epidemiologic Transition and Cardiovascular Disease
University of Lausanne, Switzerlandhttp://www.hospvd.ch/iumsp
http://www.hospvd.ch/iumsp/info/gct/index.htm
• 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
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)
IUMSP-GCT
0%
20%
40%
60%
80%
100%
1900
1910
1920
1930
1940
1950
1960
1970
Per
cent
of a
ll de
aths
Other causes
Violence
Diabetes
Stroke
Heart disease
Cancer
Dis. of early infancy
Diarrhea enteritis
Pneumonia
Other infectious d.
Tuberculosis
Health transition: proportionate mortality by broad cause of death (US, 1900-1970)
IUMSP-GCT
0%
20%
40%
60%
80%
100%
1900
1910
1920
1930
1940
1950
1960
1970
Pe
rce
nt o
f all
de
ath
s
Other
Violence
Cancer
CVD
Infectious
Health transition: mortality rates (US, 1910-1970)
IUMSP-GCT
0
100
200
300
400
500
600
1900 1920 1940 1960 1980
Dea
th ra
te p
er 1
00,0
00 p
opul
atio
n
Infectious diseases
Heart disease
Cancer
Stroke
Violent/accident
Infancy disease
Tuberculosis
(up to >1000 earlier)
The health transition favors the young over the old(Age-specific mortality rates, US, 1890-1970)
IUMSP-GCT
0
50
100
150
200
250
1880 1900 1920 1940 1960 1980
Death
s p
er
1000 p
opula
tion
<1
75-84
1-4
55-64
20-24
• 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
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Phases Socio-economicdevelopment
Lifeexpec-tancy
Change in broad diseasecategories
Change within broaddisease categories(proportionate mortality)
1* Age of pestilence(infection) andfamine
+ ~30 InfectionsNutritional deficiencies
CVD: 5-10% related tonutrition/infection (e.g.RHD, Chagas)
2* Age of recedingpandemics
++(developingcountries)
30-50 Improved sanitation : infections, diet(salt), aging
CVD: 10-35%Hypertensive heartdisease, stroke. sequels ofRHD and CHF
3* Age of degenerativeand man-madediseases
+++(countries intransition)
50-55 aging, lifestylesrelated to high SES (diet,activity, addiction)
CVD: 35-65%. Obesity,dyslipidemias, HBP,smoking CHD, stroke,often at early age ;PVD (first in SES)
4** Age of delayeddegenerativediseases
++++(westerncountries)
~70 reduced risk behaviorsin the population(prevention and healthpromotion) and newtreatments
CVD <50% (delayed total CVD due to agingpopulation & prevalencedue to better treatment)
• 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
IUMSP-GCT
0%
20%
40%
60%
80%
100%W
est
Ea
stE
uro
pe
Lat
inA
me
rica
Mid
dle
Ea
st
Ind
ia
Ch
ina
Su
b-S
aha
ran
IHD
CVA
Cardio myopathies
Rheumatic
The high burden of stroke in developing countries:stroke mortality rates in selected countries, age 40-69
IUMSP-GCT
-400 -300 -200 -100 0 100 200 300 400
Switzerland
USA
UK
Austria
Japan
Estonia
Dar es Salaam
Seychelles
Belarus
Russia
Kyrgyztan
Mortality rate (per 100,000)
Men Women
High toll of NCD/CVD in middle age in developing countries: mortality by broad cause, Seychelles, 1993-1995
0
50
100
150
200
250
0-3
4
35
-64
65
+
0-3
4
35
-64
65
+
Age category
Nu
mb
er
of d
ea
ths
pe
r ye
ar CVD Cancer Other
Men Women
Stages of the health transition: focus on the type and regional distribution of cardiovascular disease
Phases/stage ofdevelopment
Deaths fromCVD
Predominant CVD Regional examplesin 2000
Age of pestilenceand famine
5-10 RHD, infections,nutritionalcardiomyopathies
Sub-SaharanAfrica, rural India,rural South America
Age of recedingpandemics
10-35 As above +hypertensive heartdisease andhemorrhagic stroke
As above +China
Age of degenerativeand man-madediseases
35-65 All forms of stroke,IHD at relativelyyoung ages
Urban India, EasternEurope
Age of delayeddegenerativediseases
<50 Stroke (isch) andIHD at older ages
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 SE develop. Industrialis. Healthy lifestylesNutr. deficienc. Increase LE Urbanisation Case-management
Increase salt Fats, sedent.smoking
RHD HBP CHD Decline &Hem. stroke Ischem. stroke delay in CVD
IUMSP-GCT
Mo
rta
lity
Other
Injuries
Cancer
CVD, ischemic heart disease
CVD, ischemic stroke
CVD, hemorrhagic stroke
CVD, infect/nutr. cardiom.
Infectious
Time (proxy: life expectancy, development)
How to interpret the health transition across populations at different stages of development:
emergence and decline of CVD
IUMSP-GCT
Low income countries
Middle income countries
Economies in transition
High income countries
Low rates
Low increase
Rapid increase
Reach peak
Progressivedecline
1950 1960 1970 1980 1990 2000 2010
