chronic disease burden in china jiang he 011911 · causes of death in women 268.5 242.3 214.1 45.9...
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Chronic Disease Burden in China
Jiang He, MD, PhD, FAHA, FACEJoseph S. Copes, M.D. Chair and Professor
Department of EpidemiologyTulane University School of Public Health
and Tropical Medicine
Ten Leading Causes of Death 1900 and 1990, USA
0 5 10 15 20 25 30 35 40
OtherDiabetes Mellitus
Chronic Liver DiseaseSuicide
Chronic Lung DiseaseDiphtheriaAccidents
CancerNephpritis
StrokeHeart DiseaseGastroenteritis
TuberculosisPneumonia & Influenza
Percent of Total Mortality
19901900
AHA, 2005
Death Rates for Major CVD in the US from 1900 to 1997
*Rates are age-adjusted to 2000 standard. Circulation. 2000;102:3137-3147.
CVD
Heart Disease
CHD
Stroke
Projected Global Distribution of All Deaths (58 million) by Major Cause, 2005
Cardiovascular diseases
30%
Diabetes mellitus2%
Cancer13%
Communicable, maternal, and
perinatal conditions, and nutritional deficiencies
30%
Injuries9%
Other chronicdiseases
9%
Chronic respiratorydiseases
7%
Strong K, et al. Lancet 2005;366:1578-82
Lopez A, et al. Lancet 2006;367:1747–57.
Mortality due to leading global risk factors
Epidemiological Transition• Epidemiological transition refers to the shift in the
pattern of disease in a population away from infectious and deficiency diseases to chronic noncommunicable diseases.
• There are several factors involved in the epidemiological transition.– Demographic changes – Changes in risk factors, including biological
factors (microorganisms), environmental factors, social, cultural and behavioral factors and clinical medicine.
• Demographic transition • Nutrition transition
•Economic development•Industrialization and urbanization
• Economic development
• Industrialization and urbanization
• Decline in infant mortality and mortality from infectious diseases
• Increase in life expectancy
• Unhealthy diet– high calorie– high fat– high salt
• Physical inactivity• Cigarette smoking• Stress
16.9
7.9
7.5
7.3
6.65.55.2
4.12.7
36.4
Respiratory diseases
Acute infectious disease
Tuberculosis
Digestive diseases
Heart diseases
Stroke
Cancer
NeuropsychiatricDisorders
Proportionate Mortality for the Ten Leading Causes of Death in China, 1957
22.5
22.3
21.3
3.23.1
2.81.81.5
1.5
20.1 Heart diseasesCancerStrokePneumonia & influenzaInfectious diseasesAccidentsCOPDChronic liver diseaseDiabetes mellitusOthers
Proportionate Mortality for the Ten Leading Causes of Death in China, 1991-2001
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
Age-standardized Mortality for the Five Leading Causes of Death in Men
374.1319.1 310.5
54.0 50.5
050
100150200250300350400
Cancer Heartdisease
Stroke Accidents Infectiousdisease
Mor
talit
y pe
r 100
,000
PY
s
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
Age-standardized Mortality for the Five Leading Causes of Death in Women
268.5242.3
214.1
45.9 35.3
0
50
100
150
200
250
300
Heartdisease
Stroke Cancer Pneumonia& influenza
Infectiousdisease
Mor
talit
y pe
r 100
,000
PY
s
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
310.5
152.6
93.3
13.1 6.1
242.3
120.676.4
15.7 13.20
50
100
150
200
250
300
350
Stroke CPHD CHD HF RHD
Mor
talit
y pe
r 100
,000
PY
s
MenWomen
CPHD-chronic pulmonary heart disease; CHD-coronary heart disease; HF-heart failure; RHD-rheumatic heart disease
Age-standardized Mortality for the Five Leading Causes of Vascular Death
96.981.2
65.4
43.7
19.4
46.729.0 32.0
19.1 15.4
0
25
50
75
100
125
150
Lung Liver Stomach Esophagus Colon andrectum
Mor
talit
y pe
r 100
,000
PY
s
MenWomen
Age-standardized Mortality for the Five Leading Causes of Cancer Death
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
32.632.9
159.1171.5
265.9
125.0227.4
784.11121.4
1286.9
0 200 400 600 800 1000 1200 1400
Infectious diseases
Accidents
Heart diseases
Stroke
Cancer
Infectious diseases
Pneumonia & influenza
Cancer
Stroke
Heart diseases
Mortality per 100,000 Person-years
Age ≥65 yearsAge <65 years
Age-specific Mortality for the Five Leading Causes of Death by Age Groups, China
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
65.773.3
304.1311.1
330.7
25.642.4
256.1271.0279.5
0 50 100 150 200 250 300 350 400
AccidentsInfectious diseases
StrokeCancer
Heart diseasesDiabetes mellitus
Pneumonia & influenzaStroke
Heart diseasesCancer
Mortality per 10,000 Person-years
UrbanRural
Age-standardized Mortality for the Five Leading Causes of Death by Urbanization
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
50.0
78.4
215.3
220.3
292.3
39.9
40.5
295.6
321.5
359.8
0 50 100 150 200 250 300 350 400
Pneumonia & influenza
Infectious diseases
Stroke
Heart diseases
Cancer
Pneumonia & influenza
Accidents
Cancer
Stroke
Heart diseases
Mortality per 100,000 Person-years
NorthSouth
Age-standardized Mortality for the Five Leading Causes of Death by Geographic Regions
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
Prevalence of hypertension among Chinese Men, ages 35 to 74 years, in the 1991 Chinese National
Hypertension Survey and 2000–2001 InterASIA
10.0
17.9
29.3
40.1
20.217.4
28.2
40.747.3
28.6
0
10
20
30
40
50
35-44 45-54 55-64 65-74 Total
Pre
vale
nce,
%
Age, y
19912000-2001
Gu D, Reynolds K, Wu X, et al. Hypertension. 2002;40:920-927.
6.6
29.6
43.5
19.110.7
26.8
38.9
50.2
25.8
0102030405060
35-44 45-54 55-64 65-74 Total
Pre
vale
nce,
%
Age, y
19912000-2001
Prevalence of hypertension among Chinese Women, ages 35 to 74 years, in the 1991 Chinese National Hypertension Survey and 2000–2001 InterASIA
Gu D, Reynolds K, Wu X, et al. Hypertension. 2002;40:920-927.
39.5
23.5
6.1
26.1
50.8
33.8
10.5
31.0
0
10
20
30
40
50
60
Aware Treated Controlled
Per
cent
age,
%
MenWomen
Percentage of Persons with Hypertension Who Were Aware, Treated, and Controlled in China, 2000-2001
Treated & Controlled†
†Among treated hypertensives
0.0
1.0
2.0
3.0
4.0
Rel
ativ
e R
isk
Deciles of BP
Systolic blood pressureDiastolic blood pressure
Multivariate-adjusted RRs of CVD according to deciles of SBP and DBP among 169,871 Chinese adults
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
0.0
1.0
2.0
3.0
4.0
Rel
ativ
e R
isk
Deciles of BP
Systolic Blood PressureDiastolic Blood Pressure
Multivariate-adjusted RRs of CHD according to deciles of SBP and DBP among 169,871 Chinese adults
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
0.0
2.0
4.0
6.0
8.0
Rel
ativ
e R
isk
Deciles of BP
Systolic Blood PressureDiastolic Blood Pressure
Multivariate-adjusted RRs of stroke according to deciles of SBP and DBP among 169,871 Chinese adults
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
<8080-89
90-99≥100
≥160 140-159 120-139 <120
2.461.85
1.29 1.00
2.562.07
1.391.02
3.11
2.401.84
1.47
4.23
3.142.69
Systolic BP, mm Hg
Rel
ativ
e R
isk
Multivariate-adjusted RRs of CVD according to combination of SBP and DBP levels among 169,871 Chinese adults
<8080-89
90-99≥100
≥160 140-159 120-139 <120
3.12
1.651.21 1.00
1.84 1.881.38
0.92
2.62
1.87 1.76 1.89
2.80
2.112.38
Systolic BP, mm Hg
Multivariate-adjusted RRs of CHD according to combination of SBP and DBP levels among 169,871 Chinese adults
Rel
ativ
e R
isk
<8080-89
90-99≥100
≥160 140-159 120-139 <120
3.63
2.471.62
1.00
3.973.05
1.801.07
5.07
3.572.53
1.14
6.96
4.79
3.54
Systolic BP, mm Hg
Multivariate-adjusted RRs of stroke according to combination of SBP and DBP levels among 169,871 Chinese adults
Rel
ativ
e R
isk
Multivariate-adjusted RRs (95% CI) of CVD, CHD, and stroke according to BPsby age, BMI, and cigarette smoking among 169 871 Chinese adults
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
RRs and PAR of CVD Deaths Attributable to BP in China, 2005
He J, Gu D, Chen J, et al. Lancet. 2009
RRs and PAR of Stroke Deaths Attributable to BP in China, 2005
Normal Pre-Hypertension Hypertension
Men
RR (95% CI) 1.00 1.45(1.25–1.67)
5.68(4.99–6.47)
PAR (95% CI), % 0.0 14.6(11.9–17.2)
60.0(57.4–62.6)
Women
RR (95% CI) 1.00 1.53(1.28–1.82)
5.73(4.90–6.72)
PAR 95% CI), % 0.0 15.3(12.6–18.0)
59.4(56.4–62.3)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
RRs and PAR of Premature CVD Deaths Attributable to BP in China, 2005
Normal Pre-Hypertension Hypertension
Men
RR (95% CI) 1.00 1.50(1.29–1.74)
4.91(4.28–5.65)
PAR (95% CI), % 0.0 16.0(13.0–19.1)
55.6(52.8–58.5)
Women
RR (95% CI) 1.00 1.42(1.21–1.68)
4.43(3.82–5.15)
PAR (95% CI), % 0.0 12.7(9.7–15.6)
51.4(48.3–54.6)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
0 200 400 600 800 1000 1200 1400 1600
Women
Men
Women
Men
Women
Men
Absolute Number of Deaths (thousands)
HypertensionPrehypertension
Cardiovascular disease
Cerebrovascular diseases
Coronary heart disease
Total deaths attributable to BP in men and women in China, 2005
1,395.4
100.6
184.7
786.1
1,076.4
935.3
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
0 200 400 600 800 1000
Women
Men
Women
Men
Women
Men
Absolute Number of Deaths (thousands)
HypertensionPrehypertension
Cardiovascular disease
Cerebrovascular diseases
Coronary heart disease
763.2
48.1
67.9
469.8
642.9
528.8
Premature deaths attributable to BP in men and women in China, 2005
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
0 200 400 600 800 1000 1200 1400 1600
Urban
Rural
Urban
Rural
Urban
Rural
Absolute Number of Deaths (thousands)
HypertensionPrehypertension
Cardiovascular disease
Cerebrovascular diseases
Coronary heart disease
845.1
128.5
1,240.4
622.0
1,485.6
156.8
Total deaths attributable to BP in rural and urban in China, 2005
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
0 200 400 600 800 1000
Urban
Rural
Urban
Rural
Urban
Rural
Absolute Number of Deaths (thousands)
HypertensionPrehypertension
Cardiovascular disease
Cerebrovascular diseases
Coronary heart disease
446.6
69.4
779.4
333.4
845.4
46.6
Premature deaths attributable to BP in rural and urban in China, 2005
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
Prevalence of current cigarette smoking in adult population aged 35-74 years in China, 2000-2001
Percent
(SE) Estimated Number*
(SE)
Total 34.3 (0.5) 163,253 (2568)
Men 60.2 (0.8) 147,358 (2522)
Women 6.9 (0.4) 15,895 (963)
* In thousands.
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
Prevalence of current cigarette smoking by age in China, 2000-2001
63.3 62.3 57.848.9
4.7 6.6 8.8 11.2
010203040506070
35-44 45-54 55-64 65-74
Pre
vale
nce,
%
Age, years
MenWomen
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
Prevalence of current cigarette smoking by age in China, 2000-2001
63.3 62.3 57.848.9
4.7 6.6 8.8 11.2
010203040506070
35-44 45-54 55-64 65-74
Pre
vale
nce,
%
Age, years
MenWomen
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
Pack years smoked
0 <16.1 16.1–30.3 ≥30.3 P-value for trend
No. of events 3841 1297 1785 3108Person-years of follow-up 198936 96420 113587 115382
Age-standardized rate, /100,000
1278.8 1487.8 1607.2 1740.0 <0.001
Age adjusted RR 1.00 1.10 1.20 1.29 <0.001
Multivariable adjusted RR 1.00 1.10 1.18 1.26 <0.001
Relative risk of all-cause mortality in ever-smokers compared to never-smokers according to pack years smoked in men
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Pack years smoked
0 <16.1 16.1–30.3 ≥30.3 P-value for trend
No. of events 6195 644 457 418Person-years of follow-up 493303 39221 21206 15661
Age-standardized rate, /100,000
1121.5 1380.5 1553.1 1585.7 <0.001
Age adjusted RR 1.00 1.22 1.33 1.42 <0.001
Multivariable adjusted RR 1.00 1.22 1.29 1.38 <0.001
Relative risk of all-cause mortality in ever-smokers compared to never-smokers according to pack years smoked in women
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
RR, PAR and absolute number of deaths associated with tobacco smoking in Chinese men
Age, years
Multivariable-adjusted RR
(95% CI)
Prevalence of smoking,
%
Population attributable
risk, %
Absolute number of deaths
attributable to smoking in thousands
40–54 1.20 (1.07, 1.34) 72.1 12.7 55.6 (17.3, 93.8)
55–64 1.25 (1.15, 1.36) 70.6 15.0 82.4 (51.3, 113.6)
≥ 65 1.19 (1.12, 1.26) 67.8 11.2 400.2 (315.8, 484.6)
Total 1.21 (1.16, 1.26) 71.1 12.9 538.2 (455.8, 620.6)
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
RR, PAR and absolute number of deaths associated with tobacco smoking in Chinese women
Age, years
Multivariable-adjusted RR
(95% CI)
Prevalence of smoking,
%
Population attributable
risk, %
Absolute number of deaths
attributable to smoking in thousands
40–54 1.36 (1.13, 1.63) 7.8 2.7 7.6 (0, 15.7)
55–64 1.31 (1.17, 1.47) 11.4 3.4 12.7 (3.3, 22.1)
≥ 65 1.27 (1.18, 1.37) 15.3 4.0 114.6 (79.4, 149.8)
Total 1.33 (1.25, 1.41) 9.9 3.1 134.8 (108.9, 160.8)
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Multivariate-adjusted Relative Risk of Total and Cause-specific Mortality Associated with Cigarette Smoking
in China
Men Women
All-cause 1.21 (1.16, 1.26) 1.33 (1.25, 1.41)
Cancer 1.55 (1.41, 1.70) 1.62 (1.42, 1.85)
Respiratory 1.14 (1.02, 1.26) 1.43 (1.25, 1.65)
Vascular 1.17 (1.09, 1.26) 1.21 (1.10, 1.34)
Adjusted for age, education, physical activity, alcohol consumption, hypertension, obesity, diabetes, geographic region (north vs. south) and urbanization (urban vs. rural)
Population attributable risk of total and cause-specific mortality associated with cigarette
smoking in China
12.9
28.0
8.810.7
3.15.7
4.12.1
0
5
10
15
20
25
30
All-cause Cancer Respiratory Vascular
MenWomen
Pop
ulat
ion
Attr
ibut
able
Ris
k, %
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Absolute number of total and cause-specific deaths attributable to cigarette smoking in China
538.2
240.4
48.6
126.6134.8
27.8 18.2 19.60
100
200
300
400
500
600
All-cause Cancer Respiratory Vascular
MenWomen
Abs
olut
e N
umbe
r of D
eath
s in
Tho
usan
d
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Age-Standardized Prevalence of Individual Components of the Metabolic Syndrome in the Adult Population in
China, 2000-2001
1.7
24.921.9
44.2
12.813.9
24.6
46.5
38.0
12.6
05
101520253035404550
Pre
vale
nce,
%
MenWomen
AbdominalObesity
Hypertri-glyceridemia
Low HDLCholesterol
High BPor Meds
High Glucoseor Meds
Gu D, et al. Lancet 2005;365:1398-405.
Prevalence of the Metabolic Syndrome by Age in China, 2000-2001
8.4 10.5 11.3 10.4 9.89.4
17.7
28.0 28.6
17.8
05
101520253035
35-44 45-54 55-64 65-74 Total
Pre
vale
nce,
%
Age, years
MenWomen
Gu D, et al. Lancet 2005;365:1398-405.
• In 2000-2001, 64 million (13.7%) Chinese adults aged 35-74 years had the metabolic syndrome as defined by ATP III.
Age-Standardized Prevalence of Body Mass Index Cut-points Among Men and Women Aged 35-74
Years in China, 2000-2001
46.9
36.4
26.9
8.22.8
51.7
40.2
31.0
11.65.0
0
10
20
30
40
50
60
Pre
vale
nce,
%
MenWomen
23.0
Body Mass Index, kg/m2
24.0 25.0 28.0 30.0
Reynolds K et al. Obesity. 2007;15:10–18.
Estimated Number of Overweight and Obese Adults Aged 35-74 Years in China, 2000-2001
11
27
72
93
120
7
20
66
89
114
18
47
137
182
234
0 50 100 150 200 250
Est
imat
ed N
umbe
r in
Milli
ons
Total
≥ 30 kg/m2
≥ 23 kg/m2
≥ 25 kg/m2
≥ 24 kg/m2
≥ 28 kg/m2
Reynolds K et al. Obesity. 2007;15:10–18.
Age-Standardized Prevalences of Diabetes among Chinese Adults 20 Years of Age or Older
10.6 10.6
8.7 8.89.7 9.7
0
2
4
6
8
10
12
Crude Standardized
Pre
vale
nce
(%)
Male Female Overall
Yang W, et al. N Engl J Med 2010;362:1090-101.
Age-Specific Prevalences of Diabetes among Chinese Adults 20 Years of Age or Older
2.65.2
11.1
15.518.1
21.8
1.23.0
7.3
13.1
20.3
22.0
0
5
10
15
20
25
30
20- 30- 40- 50- 60- 70-
Pre
vale
nce
(%)
MaleFemale
Age, years
Yang W, et al. N Engl J Med 2010;362:1090-101.
Age-Standardized Prevalences of Pre-diabetes among Chinese Adults 20 Years of Age or Older
16.1 16.114.9 15.015.5 15.5
0
3
6
9
12
15
18
Crude Standardized
Pre
vale
nce
(%)
Male Female Overall
Yang W, et al. N Engl J Med 2010;362:1090-101.
Age-Specific Prevalences of Pre-diabetes among Chinese Adults 20 Years of Age or Older
7.612.2
17.7 18.1
24.1
26.4
5.79.2
16.0
21.122.2
26.2
0
5
10
15
20
25
30
35
40
20- 30- 40- 50- 60- 70-
Pre
vale
nce
(%)
Male Female
Age, years
Yang W, et al. N Engl J Med 2010;362:1090-101.
Prevalences of Diabetes and Pre-diabetes among Chinese Adults 20 Years of Age or Older, According
to Urban or Rural Residence
12.8
8.910.1
7.7
0
4
8
12
16
20
Urban Rural
Pre
vale
nce
(%)
Male Female
15.516.6
14.315.6
0
4
8
12
16
20
Urban Rural
Pre
vale
nce
(%)
Diabetes Pre-diabetes
Yang W, et al. N Engl J Med 2010;362:1090-101.
Absolute Numbers of Diabetes and Pre-diabetes among Chinese Adults 20 Years of Age or Older, According to
Urban or Rural Residence
27.322.922.0 20.3
0
10
20
30
40
50
Urban Rural
MaleFemale
33.4
42.7
31.3
40.8
0
10
20
30
40
50
Urban Rural
Diabetes Pre-diabetes
Abs
olut
e N
o. (m
illio
ns)
Yang W, et al. N Engl J Med 2010;362:1090-101.
Conclusion• Chronic diseases, including cardiovascular disease
and cancer, are the leading causes of death in China.
• Cardiovascular risk factors, including high blood pressure, cigarette smoking, obesity, and diabetes pose an important global public health burden.
• Without effective interventions, chronic diseases will continue to increase in China.
• Control of modifiable risk factors for chronic disease in the community should be a national public health priority.
Acknowledgements• Tulane University, New
Orleans, LABazzano LA, Chen C-S, Chen J, Hamm LL, Kearney PM, Kelly TN, Mei H, Muntner P, Myers L, Ogden LG, Qi Z, Reynolds K, Thompson AM, Vupputuri S, Wildman RP, Whelton M, Yang W, Yau CL
• Chinese Academy of Medical Sciences, Beijing, ChinaChen JC, Duan X, Gu D, Hu D, Huang J, Ji X, Li J, Liu DH, Liu DP, Lu F, Ma J, Mu J, Wu X, Yao C
• China-Japan Friendship Hospital, Beijing, ChinaXiao J, Yang W, Zhang B
• Soochow University, Suzhou, ChinaTong W, Xu T, Zhang YH
• Johns Hopkins UniversityAppel LJ, Beaty T, Brancati FL, Charleston JB, Coresh J, Klag MJ, Meoni L
• Loyola University ChicagoWhelton PK
• National Institutes of HealthJaquish C, Kusek J, Loria C, Obarzanek E
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