chronic disease burden in china jiang he 011911 · causes of death in women 268.5 242.3 214.1 45.9...

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


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


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


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


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


UrbanRural

Age-standardized Mortality for the Five Leading Causes of Death by Urbanization


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


Infectious diseases

Stroke

Heart diseases

Cancer


Accidents

Cancer

Stroke

Heart diseases


NorthSouth

Age-standardized Mortality for the Five Leading Causes of Death by Geographic Regions


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


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


<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


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)


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


0 200 400 600 800 1000

Women

Men

Women

Men

Women

Men






763.2

48.1

67.9

469.8

642.9

528.8

Premature deaths attributable to BP in men and women in China, 2005


0 200 400 600 800 1000 1200 1400 1600

Urban

Rural

Urban

Rural

Urban

Rural






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


0 200 400 600 800 1000

Urban

Rural

Urban

Rural

Urban

Rural






446.6

69.4

779.4

333.4

845.4

46.6

Premature deaths attributable to BP in rural and urban in China, 2005


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

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


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)


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)


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, %


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


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


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


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


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


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)


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

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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