Chronic Disease Burden
in China
Jiang He, MD, PhD, FAHA, FACE
Joseph S. Copes, M.D. Chair and Professor
Department of Epidemiology
Tulane University School of Public Health
and Tropical Medicine
Ten Leading Causes of Death 1900 and 1990, USA
Pneumonia & Influenza
Tuberculosis
Gastroenteritis
Heart Disease
Stroke
Nephpritis
Cancer
Accidents
Diphtheria
Chronic Lung Disease
Suicide
Chronic Liver Disease
Diabetes Mellitus
Other
1990
1900
0
AHA, 2005
5
10
15
20
25
Percent of Total Mortality
30
35
40
Death Rates for Major CVD in the US from 1900 to 1997
CVD
Heart Disease
CHD
Stroke
*Rates are age-adjusted to 2000 standard. Circulation. 2000;102:3137-3147.
Projected Global Distribution of All Deaths
(58 million) by Major Cause, 2005
Other chronic
diseases
9%
Chronic respiratory
diseases
7%
Cardiovascular
diseases
30%
Injuries
9%
Communicable,
maternal, and
perinatal conditions,
and nutritional
deficiencies
30%
Diabetes mellitus
2%
Cancer
13%
Strong K, et al. Lancet 2005;366:1578-82
Mortality due to leading global risk factors
Lopez A, et al. Lancet 2006;367:1747–57.
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
• Economic
•Industrialization and
development
urbanization
• 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
Proportionate Mortality for the Ten Leading
Causes of Death in China, 1957
Respiratory diseases
16.9
Acute infectious disease
36.4
Tuberculosis
7.9
7.5
7.3
2.7
4.1
5.2 5.5
6.6
Digestive diseases
Heart diseases
Stroke
Cancer
Neuropsychiatric
Disorders
Proportionate Mortality for the Ten Leading
Causes of Death in China, 1991-2001
20.1
22.5
1.5
1.5
1.8
2.8
3.1
3.2
22.3
21.3
Heart diseases
Cancer
Stroke
Pneumonia & influenza
Infectious diseases
Accidents
COPD
Chronic liver disease
Diabetes mellitus
Others
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
Mortality per 100,000 PYs
Age-standardized Mortality for the Five Leading
Causes of Death in Men
400
350
300
250
200
150
100
50
0
374.1
319.1
Cancer
Heart
disease
310.5
Stroke
54.0
50.5
Accidents
Infectious
disease
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
Mortality per 100,000 PYs
300
268.5
250
242.3
214.1
200
150
100
45.9
50
35.3
0
Heart
disease
Stroke
Cancer
Pneumonia Infectious
& influenza disease
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 Vascular Death
Mortality per 100,000 PYs
350
Men
Women
310.5
300
250
242.3
200
152.6
120.6
150
100
93.3
76.4
50
13.1 15.7
6.1 13.2
HF
RHD
0
Stroke
CPHD
CHD
CPHD-chronic pulmonary heart disease; CHD-coronary heart disease;
HF-heart failure; RHD-rheumatic heart disease
Mortality per 100,000 PYs
Age-standardized Mortality for the Five Leading Causes
of Cancer Death
150
Men
125
Women
100
96.9
81.2
75
50
65.4
46.7
29.0
25
32.0
43.7
19.1
19.4 15.4
0
Lung
Liver
Stomach Esophagus Colon and
rectum
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
Age-specific Mortality for the Five Leading Causes of
Death by Age Groups, China
1286.9
Heart diseases
1121.4
Stroke
784.1
Cancer
227.4
Pneumonia & influenza
125.0
Infectious diseases
Cancer
265.9
Stroke
171.5
Age ≥65 years
Heart diseases
159.1
Age <65 years
Accidents
32.9
Infectious diseases
32.6
0
200
400
600
800
1000 1200 1400
Mortality per 100,000 Person-years
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 by Urbanization
279.5
271.0
256.1
Cancer
Heart diseases
Stroke
Urban
Rural
42.4
25.6
Pneumonia & influenza
Diabetes mellitus
Heart diseases
330.7
311.1
304.1
Cancer
Stroke
Infectious diseases
73.3
65.7
Accidents
0
50
100
150
200
250
300
350
Mortality per 10,000 Person-years
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
400
Age-standardized Mortality for the Five Leading Causes
of Death by Geographic Regions
359.8
Heart diseases
321.5
Stroke
295.6
Cancer
Accidents
40.5
Pneumonia & influenza
39.9
Cancer
292.3
Heart diseases
220.3
Stroke
215.3
Infectious diseases
North
South
78.4
Pneumonia & influenza
50.0
0
50
100
150
200
250
300
350
Mortality per 100,000 Person-years
He J, Gu D, Duan X, et al. N Engl J Med 2005; 353:1124-34.
400
Prevalence of hypertension among Chinese Men, ages
35 to 74 years, in the 1991 Chinese National
Hypertension Survey and 2000–2001 InterASIA
Prevalence, %
50
40
40.7
28.2
30
17.4
20
10
47.3
1991
2000-2001
40.1
29.3
28.6
20.2
17.9
10.0
0
35-44
45-54
55-64
65-74
Age, y
Gu D, Reynolds K, Wu X, et al. Hypertension. 2002;40:920-927.
Total
Prevalence of hypertension among Chinese Women,
ages 35 to 74 years, in the 1991 Chinese National
Hypertension Survey and 2000–2001 InterASIA
Prevalence, %
60
50
1991
2000-2001
38.9
40
26.8 29.6
30
19.1
20
10
43.5
50.2
6.6
25.8
10.7
0
35-44
45-54
55-64
Age, y
65-74
Gu D, Reynolds K, Wu X, et al. Hypertension. 2002;40:920-927.
Total
Percentage of Persons with Hypertension Who Were
Aware, Treated, and Controlled in China, 2000-2001
60
50.8
Percentage, %
50
40
Men
Women
39.5
30
33.8
26.1
23.5
20
6.1
10
31.0
10.5
0
Aware
†Among
Treated
treated hypertensives
Controlled
Treated &
Controlled†
Multivariate-adjusted RRs of CVD according to deciles of
SBP and DBP among 169,871 Chinese adults
4.0
Systolic blood pressure
Diastolic blood pressure
Relative Risk
3.0
2.0
1.0
0.0
Deciles of BP
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
Multivariate-adjusted RRs of CHD according to deciles of
SBP and DBP among 169,871 Chinese adults
4.0
Systolic Blood Pressure
Diastolic Blood Pressure
Relative Risk
3.0
2.0
1.0
0.0
Deciles of BP
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
Multivariate-adjusted RRs of stroke according to deciles
of SBP and DBP among 169,871 Chinese adults
8.0
Systolic Blood Pressure
Relative Risk
Diastolic Blood Pressure
6.0
4.0
2.0
0.0
Deciles of BP
Gu D, Kelly TN, Wu X, et al. Am J Hypertens 2008; 21:265-272.
Multivariate-adjusted RRs of CVD according to combination of
SBP and DBP levels among 169,871 Chinese adults
4.23
3.14
2.69
Relative Risk
3.11
2.40
2.56
1.84
2.07
2.46
1.39
1.85
1.29
1.47
≥100
90-99
80-89
1.02
1.00
<80
≥160
140-159 120-139
Systolic BP, mm Hg
<120
Multivariate-adjusted RRs of CHD according to combination of
SBP and DBP levels among 169,871 Chinese adults
2.80
2.62
Relative Risk
3.12
1.84
2.38
2.11
1.87
1.88
1.76
1.89
1.38
1.65
1.21
0.92
≥100
90-99
80-89
1.00
<80
≥160
140-159 120-139
Systolic BP, mm Hg
<120
Multivariate-adjusted RRs of stroke according to combination of
SBP and DBP levels among 169,871 Chinese adults
6.96
4.79
Relative Risk
5.07
3.54
3.57
3.97
2.53
3.05
3.63
1.14
1.80
2.47
1.62
1.07
90-99
1.00
80-89
<80
≥160
140-159 120-139
Systolic BP, mm Hg
<120
≥100
Multivariate-adjusted RRs (95% CI) of CVD, CHD, and stroke according to BPs
by 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
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)
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)
Men
Women
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
RRs and PAR of Premature CVD Deaths Attributable to
BP in China, 2005
Normal
PreHypertension
Hypertension
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)
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)
Men
Women
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
Total deaths attributable to BP in men and women in China, 2005
Cardiovascular disease
Men
1,395.4
935.3
Women
Cerebrovascular diseases
1,076.4
Men
Women
786.1
Coronary heart disease
Men
Hypertension
Prehypertension
184.7
Women
100.6
0
200
400
600
800
1000
1200
Absolute Number of Deaths (thousands)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
1400
1600
Premature deaths attributable to BP in men and women in China, 2005
Cardiovascular disease
763.2
Men
528.8
Women
Cerebrovascular diseases
Men
642.9
Women
469.8
Coronary heart disease
Hypertension
Prehypertension
67.9
Men
Women
48.1
0
200
400
600
Absolute Number of Deaths (thousands)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
800
1000
Total deaths attributable to BP in rural and urban in China, 2005
Cardiovascular disease
1,485.6
Rural
Urban
845.1
Cerebrovascular diseases
1,240.4
Rural
Urban
622.0
Coronary heart disease
156.8
Rural
Hypertension
Prehypertension
128.5
Urban
0
200
400
600
800
1000
1200
Absolute Number of Deaths (thousands)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
1400
1600
Premature deaths attributable to BP in rural and urban in China, 2005
Cardiovascular disease
845.4
Rural
446.6
Urban
Cerebrovascular diseases
779.4
Rural
333.4
Urban
Coronary heart disease
46.6
Rural
Urban
Hypertension
Prehypertension
69.4
0
200
400
600
800
Absolute Number of Deaths (thousands)
Jiang He, Dongfeng Gu, Jing Chen, et al. Lancet. 2009
1000
Prevalence of current cigarette smoking in adult
population aged 35-74 years in China, 2000-2001
Percent
(SE)
Estimated Number*
(SE)
34.3 (0.5)
163,253 (2568)
Men
60.2 (0.8)
147,358 (2522)
Women
6.9 (0.4)
15,895 (963)
Total
* In thousands.
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
Prevalence, %
Prevalence of current cigarette smoking by
age in China, 2000-2001
70
60
50
40
30
20
10
0
63.3
Men
62.3
57.8
Women
48.9
4.7
35-44
8.8
6.6
45-54
55-64
Age, years
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
11.2
65-74
Prevalence, %
Prevalence of current cigarette smoking by
age in China, 2000-2001
70
60
50
40
30
20
10
0
63.3
Men
62.3
57.8
Women
48.9
4.7
35-44
8.8
6.6
45-54
55-64
Age, years
Gu D, et al. Am J Public Health. 2004; 94: 1972–1976
11.2
65-74
Relative risk of all-cause mortality in ever-smokers compared
to never-smokers according to pack years smoked in men
Pack years smoked
P-value
for trend
0
<16.1
16.1–30.3
≥30.3
3841
1297
1785
3108
Person-years of
198936
follow-up
96420
113587
115382
Agestandardized
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
No. of events
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Relative risk of all-cause mortality in ever-smokers compared
to never-smokers according to pack years smoked in women
Pack years smoked
P-value
for trend
0
<16.1
16.1–30.3
≥30.3
6195
644
457
418
Person-years of
follow-up
493303
39221
21206
15661
Agestandardized
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
No. of events
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
Prevalence Population
of smoking, attributable
%
risk, %
Absolute number
of deaths
attributable to
smoking in
thousands
Age,
years
Multivariableadjusted RR
(95% CI)
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
Prevalence Population
of smoking, attributable
%
risk, %
Absolute number
of deaths
attributable to
smoking in
thousands
Age,
years
Multivariableadjusted RR
(95% CI)
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 Causespecific 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, %
Population attributable risk of total and
cause-specific mortality associated with cigarette
smoking in China
30
Men
28.0
Women
25
20
15
12.9
8.8
10
5
10.7
5.7
3.1
4.1
2.1
0
All-cause
Cancer
Respiratory
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Vascular
Absolute Number of Deaths in Thousand
Absolute number of total and cause-specific deaths
attributable to cigarette smoking in China
600
Men
538.2
Women
500
400
300
200
240.4
134.8
100
126.6
27.8
48.6
18.2
19.6
0
All-cause
Cancer
Respiratory
Gu D, Kelly TN, Wu X, et al. N Engl J Med 2009;360:150-9.
Vascular
Prevalence, %
Age-Standardized Prevalence of Individual Components
of the Metabolic Syndrome in the Adult Population in
China, 2000-2001
50
45
40
35
30
25
20
15
10
5
0
46.5
Men
Women
24.9 24.6
44.2
38.0
21.9
13.9
12.8 12.6
1.7
Abdominal
Obesity
HypertriLow HDL
glyceridemia Cholesterol
Gu D, et al. Lancet 2005;365:1398-405.
High BP
or Meds
High Glucose
or Meds
Prevalence of the Metabolic Syndrome by Age
in China, 2000-2001
Prevalence, %
•
35
30
25
20
15
10
5
0
In 2000-2001, 64 million (13.7%) Chinese
adults aged 35-74 years had the metabolic
syndrome as defined by ATP III.
Men
Women
28.6
28.0
17.8
17.7
8.4 9.4
35-44
10.5
11.3
45-54
55-64
Age, years
Gu D, et al. Lancet 2005;365:1398-405.
10.4
65-74
9.8
Total
Age-Standardized Prevalence of Body Mass Index
Cut-points Among Men and Women Aged 35-74
Years in China, 2000-2001
60
Prevalence, %
50
46.9
51.7
36.4
40
Men
Women
40.2
26.9
30
31.0
20
8.2
10
11.6
2.8 5.0
0
 23.0
 24.0
 25.0
 28.0
Body Mass Index, kg/m2
Reynolds K et al. Obesity. 2007;15:10–18.
 30.0
Estimated Number in Millions
Estimated Number of Overweight and Obese Adults
Aged 35-74 Years in China, 2000-2001
234
114
120
182
89
93
≥ 24 kg/m2
137
66
72
20
27
≥ 23 kg/m2
≥ 25 kg/m2
47
Total
≥ 28 kg/m2
18
7
11
0
≥ 30 kg/m2
50
100
150
Reynolds K et al. Obesity. 2007;15:10–18.
200
250
Age-Standardized Prevalences of Diabetes among
Chinese Adults 20 Years of Age or Older
Male
Prevalence (%)
12
10
Female
10.6
Overall
10.6
8.7
9.7
8.8
9.7
8
6
4
2
0
Crude
Standardized
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
30
Prevalence (%)
25
20
21.822.0
Male
Female
20.3
18.1
15
11.1
10
5
15.5
13.1
7.3
5.2
2.6
1.2
3.0
0
20-
30-
40-
50-
Age, years
Yang W, et al. N Engl J Med 2010;362:1090-101.
60-
70-
Age-Standardized Prevalences of Pre-diabetes among
Chinese Adults 20 Years of Age or Older
Male
Prevalence (%)
18
16.1
14.9
Female
15.5
Overall
16.1
15.0
15.5
15
12
9
6
3
0
Crude
Standardized
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
Male
40
Female
Prevalence (%)
35
26.4
30
24.1
25
17.7
20
15
10
16.0
18.1
21.1
26.2
22.2
12.2
7.6
9.2
5.7
5
0
20-
30-
40-
50-
Age, years
Yang W, et al. N Engl J Med 2010;362:1090-101.
60-
70-
Prevalences of Diabetes and Pre-diabetes among
Chinese Adults 20 Years of Age or Older, According
to Urban or Rural Residence
Diabetes
Prevalence (%)
16
12
Female
12.8
10.1
8.9
7.7
8
20
Prevalence (%)
Male
20
Pre-diabetes
16
16.6
14.3
15.6
12
8
4
4
0
0
Urban
15.5
Rural
Yang W, et al. N Engl J Med 2010;362:1090-101.
Urban
Rural
Absolute Numbers of Diabetes and Pre-diabetes among
Chinese Adults 20 Years of Age or Older, According to
Urban or Rural Residence
Diabetes
Pre-diabetes
Absolute No. (millions)
50
50
Male
Female
40
40
30
27.3
42.7
33.4
40.8
31.3
30
22.0
20
22.9
20.3
20
10
10
0
0
Urban
Rural
Yang W, et al. N Engl J Med 2010;362:1090-101.
Urban
Rural
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
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•
•
Tulane University, New
Orleans, LA
Bazzano 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, China
Chen 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, China
Xiao J, Yang W, Zhang B
•
•
•
•
Soochow University, Suzhou,
China
Tong W, Xu T, Zhang YH
Johns Hopkins University
Appel LJ, Beaty T, Brancati
FL, Charleston JB, Coresh J,
Klag MJ, Meoni L
Loyola University Chicago
Whelton PK
National Institutes of Health
Jaquish C, Kusek J, Loria C,
Obarzanek E