NCD in Pacific Island States:

evolution, control and surveillance

Richard Taylor

Professor of Public and International Health

SPHCM, Faculty of Medicine, University of NSW, Sydney, Australia

School of Public Health and Community Medicine

What this presentation is NOT about

• The crucial research and successful prevention and control of non-communicable disease as major causes of premature mortality in most affected countries (not Russia etc) during the 20th century (see Appendix). This is presumed knowledge

• Re-iteration of international agency material concerning NCD prevention and control in the 21st century

What this presentation IS about

• NCD evolution and difficulties in control and surveillance in the context of Pacific Island populations particularly affected based on empirical data, with commentary on findings

Non communicable disease evolution, control and surveillance in Pacific States

NCD is a difficult acronym for a group of related diseases.

Used by international agencies since the late 20th Century

Covers major diseases which linked by common and inter-

related risk factors requiring integrated preventive responses

According to WHO, NCD consists of:

• Cardiovascular disease (CHD, Stroke), diabetes mellitus (adult

onset), cancer, chronic obstructive pulmonary disease

• Risk factors related to diet, tobacco and alcohol consumption

and physical activity

Diet: energy (calories), saturated and trans fatty acids, salt

Definition and scope of NCDs

Purpose of Surveillance

• Determine magnitude and distribution of morbidity and premature mortality from particular diseases to set control priorities and target sub-groups affected

• Determine trends to assess effectiveness of responses and interventions for NCD control in populations

Surveillance of long term trends in NCDs in populations

• NCD risk factors from population surveys

• Adult premature mortality by cause and life expectancy

• Process and implementation indicators

Non-Communicable Disease (NCD) in Pacific Island States, Surveillance and Control

NCD Pacific Isd: evolution, control and surveillance

Melanesia

Micronesia

Polynesia

Polynesia

Sydney

Easter

Island

Pacific Island States

mid 2013 population estimates

← Including Papua New Guinea

(7.4 million)

Excluding Papua New Guinea →

Fiji 860,000

Solomon Islands 611,000

Vanuatu 265,000

Polynésie Française 261,000

Nouvelle Calédonie 259,000

Samoa 187,000

Guam 175,000

Tonga 103,000

Kiribati 109,000

Life expectancy

at birth, both

sexes (years)

Significant proportional CVD

mortality (>20%) and low

infection mortality (<10%)

Significant proportional CVD

mortality (>20%) and

significant infection mortality

(>20%)

Significant proportional

infection mortality

(>20%) and low CVD

mortality (<10%)

>75

Australia

New Zealand

France

United States

United Kingdom

72-75

Guam

American Samoa

French Polynesia

New Caledonia

Australia 1971-84

70-71

Cook Islands

Northern Marianas

Australia 1950-70

65-69

Fiji, Tonga

Fed. States Micronesia

Palau

Tuvalu

Wallis and Futuna

Indigenous Australians 2003

Samoa

Vanuatu

Australia 1930-49

60-64

Kiribati

Marshall Islands

Australia 1920-29

Solomon Islands

<60

Nauru

Australia 1910-19

Papua New Guinea

Some limitation of

life expectancy

from NCD (adults)

Double burden of disease:

limitation of life expectancy

from both NCD (adults) and

infection/malnutrition

(child/adult)

Significant limitation of

life expectancy from

infection/malnutrition

(child/adult)

Significant limitation

of life expectancy

from NCD (adults)

Little limitation of

life expectancy

from NCD (adults)

Traditional pattern

with infection/

malnutrition limiting

life expectancy

(child/adult)

Double Burden of

Disease in Pacific Island

States

Based on Life

Expectancy and

Proportional Mortality

from Infections and

Cardiovascular Disease

(CVD) as Indicators,

Circa 2000

(except where otherwise

indicated)

Niue and Tokelau not included

because populations < 1,500

Adapted from: Taylor R. The

Double Disease Burden in

Pacific Island States (except

Papua New Guinea); Chapter 15,

pp 279-301. In: Health

Transitions and the Double

Disease Burden in Asia and the

Pacific. Histories of Responses

to non-communicable and

communicable disease. Editors:

Lewis MJ, MacPherson KL.

Routledge Advances in Asia-

Pacific Studies. Routledge.

Oxford and New York. 2013

Meta-analyses of cross-sectional surveys of NCD risk factors

in Pacific Island states circa 1980- present

• Search for cross-sectional studies or studies which could be rendered

cross-sectional (e.g. cohort studies)

• Designed to be nationally representative or could be rendered

approximately representative by statistical adjustment to closest previous

census for age group, urban/rural and ethnicity (if needed), for each sex

• Contained data with sufficient numbers on age, sex, ethnicity, urban/rural,

self-reported NCD status (on medication), anthropometric measurements,

blood pressure, blood glucose, etc

• Search involved: PubMed, Medline, Google Scholar, web searching, and

consultations with key informants from universities, international/regional

agencies, government agencies; and secondary searching of bibliographies.

• Studies not included were generally of one or few selected sites, small

numbers and incomplete data tabulation.

• Imputation of some risk factors required for some surveys because of only

partial data available

Mortality data analyses by level and cause from routine

mortality recording supplemented by demographic estimates

• Mortality recording by health departments (passive) and /or civil

registerers (active) and/or other sources. Multiple sources requires de-

duplication but offers the opportunity for capture-recapture analyses

• Issues with coverage (geographic) and completeness within covered

areas. Issues with quality of death certification, cause of death coding and

derivation of underlying cause of death

• Use of tabulated data problematic because of incomplete and changing

tabulations by period, age group, sex, cause, and ethnicity and

geographic area (if required). Often only ‘Top Ten’ causes for all ages and

both sexes combined provided.

• Tabulations of underlying cause of death incorporate misclassification

bias from errors in certification and coding

• All cause mortality also be derived from direct/indirect demographic

methods based on censuses/surveys: retrospective deaths, CEBCS,

orphanhood and widowhood techniques all with measurement and

selection bias; further complicated by imputation from model life tables

Fiji

Population 860,000 (2013)

Carter K, Cornelius M,

Taylor R, Ali S, Rao C,

Lopez A, Lewai V,

Goundar R, Mowry C.

Mortality trends in Fiji.

Australian and New

Zealand Journal of

Public Health.

35(5):412-420, 2011.

Fiji: published life expectancy

estimates from 1950

Black squares: Indirect demographic estimates

Open triangles: Reported deaths MoH

Males

Females

Carter K, Cornelius M, Taylor R, Ali S, Rao C, Lopez A, Lewai

V, Goundar R, Mowry C.

Mortality trends in Fiji.

Australian and New Zealand Journal of Public Health.

35(5):412-420, 2011.

Fiji life expectancy from 1950

and cardiovascular mortality

Plateau from

1985: (20+ yrs)

LE 64 yrs

Males

Plateau from

1985: (20+ yrs)

LE 69 yrs

Females

Males

Females

Both sexes

Black squares: Indirect demographic estimates

Open triangles and square: Reported deaths MoH

Adult

15-59 yrs

mortality by

ethnicity in

Fiji, and

Australian

and New

Zealand,

1975-2008

Life expectancy

at birth by

ethnicity in Fiji,

and Australia

and New

Zealand,

1975-2008

Taylor R, Carter K, Naidu S,

Linhart C, Azim S, Rao C,

Lopez A. Divergent mortality

trends by ethnicity in Fiji.

Aust NZ J Public Health.

37(6):509-15. Dec 2013

Meta-analyses of cross-sectional surveys of

NCD risk factors in Fiji Islands

Surveys

1980 National Cardiovascular and Diabetes Survey (NCVDS) n=3,068

1993 National Nutrition Survey (NNS) n=4,606

2002 STEPS survey (n=6,788)

2004 NNS (n=4,276)

2009 Eye Health Survey (EHS) n=1,381

2011 STEPS survey (n=2,668)

Unit record data obtained on all Fiji studies

Statistical analysis

Meta-analysis and meta-regression used to determine trends over time

based on parameters from unit record or aggregate (count) data

Trends in obesity prevalence by sex/ethnicity, Fiji, 1980-2011

Standard cut-point for obesity BMI≥30kg/m2. Survey prevalences age-adjusted to previous census. Trend from

meta-regression of age adjusted rates. Unfilled markers: 1993 and 2004 NNS and 2009 EHS.

Lin S, Tukana I, Linhart C, Morrell S, Taylor R, Vatucawaqa P, Magliano D, Zimmet P. Trends in diabetes and

obesity in Fiji over 30 years, 1980-2011, based on empirical data. Journal of Diabetes. Published 15 Sept 2015.

Trend in mean systolic/diastolic blood pressure (mmHg), and

hypertension prevalence (%), by sex/ethnicity, Fiji, 1980-2011

Meta-regression for linear trend

HT: hypertension = systolic BP ≥140 and/or diastolic BP ≥90 mmHg and/or taking medication for HT

Data age and rural/urban adjusted to the most recent previous census to increase national representativeness

Linhart C, Tukana I, Lin S, Taylor R, Morrell S, Vatucawaqa P, Magliano D, Zimmet P. Continued increases in

hypertension over three decades in Fiji, and the influence of obesity. Journal of Hypertension. Pub 17 Dec 2015

Trends in diabetes prevalence by sex/ethnicity, Fiji, 1980-2011

T2DM: fasting plasma glucose, FPG ≥7.0mmol/L and/or on medication for T2DM

Survey prevalences age-adjusted to previous census. Unfilled markers: 1993 and 2004 NNS and 2009 EHS.

Trend from meta-regression of age adjusted rates. Sensitivity analysis: Solid line (all 6 surveys); broken line (5

surveys, excludes 2009 EHS); dotted line (3 surveys, excludes 2009 EHS and 1993 and 2004 NNS)

Lin S, Tukana I, Linhart C, Morrell S, Taylor R, Vatucawaqa P, Magliano D, Zimmet P. Diabetes and obesity

trends in Fiji over 30 years based on empirical data. Journal of Diabetes. Published 15 Sept 2015.

Tonga

Population 103,000 (2013)

Diabetes and obesity prevalence trends in Tonga

Adults 25-64 years, 1978-2011

1973 cross sectional Cardiovascular and Metabolic (CVM) study (n=791)

A series of decennial surveys examining body physiques (n=222), 1983

(n=227), 1990 (n=192) and 2001 (n=137)

1998-2000 Tonga Diabetes and Cardiovascular Disease Prevalence (DCDP)

survey (n=1,024)

2004 (n=1,016) WHO 2004 Tonga STEPS

2011 (n=2,551) WHO 2011 Tonga STEPS survey

De-identified unit records acquired for 2004 and 2011 Tonga STEPS survey,

and unit records for 1998-2000 Tonga DCDP available in part

Diabetes and obesity prevalence trends in Tonga

Adults 25-64 years, 1973-2011

Lin S, Hufanga S, Linhart C, Morrell S, Taylor R, Magliano DJ, Zimmet P. Diabetes and obesity trends in Tonga

over 40 years. Asia Pacific Journal of Public Health. Accepted 27 March 2016. In Press 2016.

Tongan adults, population surveys, 1973-2011. T2DM: fasting plasma glucose, FPG ≥7.0mmol/L and/or on

medication for T2DM. Cut-point for obesity = BMI≥30kg/m2. Survey prevalences age-adjusted to previous

census. Linear trend from meta-regression of prevalences

Males

Fiji

Males Tonga

Females Tonga

Hufanga S, Carter KL, Rao C, Lopez AD,

Taylor R. Mortality trends in Tonga: an

assessment based on a synthesis of local data.

Population Health Metrics. 2012 Aug. 10(1):14-

Tonga life expectancy

estimates from 1940

Based on reconciliation of deaths

from multiple sources (4-5)

and capture recapture models

Females 2010. Solid lines

Plausible LE range 65-69 yrs

Males 2010. Solid lines

Plausible LE range 60-64 yrs

Tonga

age-standardised

mortality for selected

causes 2001-2009

Plausible ranges based

on upper and lower

mortality scenarios

Males

Females

Carter KL, Hufanga S, Rao C,

Akauola S, Lopez AD, Rampitage

R, Taylor R.

Causes of death in Tonga: quality

of certification and implications

for statistics.

Population Health Metrics

10(1):14. 2012.

Samoa

Population 187,000

Trends in diabetes and obesity prevalence in Samoa

Adults 25-64 years, 1978-2013

1978 Non-Communicable Disease Risk Factor (NCDRF) survey (n=1,489)

1991 13-year follow-up of (NCDRF) (n=1,776)

1991 Samoan Adiposity and Cardiovascular Disease Risk Factor (SACRF)

longitudinal study (n=748)

1995 SACRF follow-up (n=726)

2002 Samoa STEPS (n=2,804)

Samoan Family Study of Overweight and Diabetes (SFSOD) in 2003 (n=958)

2010 Genome-Wide Association Study (GWAS), n=3,475

Samoa 2013 STEPS (n=1,766)

Unit record data obtained for all surveys

Trends in diabetes and obesity prevalence in Samoa

Adults 25-64 years, 1978-2013

Adjusted to previous census for division of residence and age. T2DM: fasting plasma glucose, FPG

≥7.0mmol/L and/or on medication for T2DM. Standard cut-point for obesity BMI≥30kg/m2

Lin S, Naseri T, Linhart C, Morrell S, Taylor R, McGarvey S, Magliano D, Zimmet P. Trends in diabetes and

obesity in Samoa from population surveys over 35 years, 1978-201. Under review 2016.

Wallis et Futuna

Territoire d'outre-mer

de la France

Population 12,100 (2013)

Wallis Island Polynesians: changes in NCD risk factors

over 30 years 1980 - 2009. Adults 25-64 years

BP: Blood pressure: Hypertension (HT): SBP ≥140 and/or DBP ≥140 mmHg and/or on

HT medication, as %.

Type 2 Diabetes mellitus (T2DM): fasting plasma glucose (FPG) ≥7.0 mmol/L and/or

on medication for T2DM, as %

Age standardised to the 2008 census of Wallis Island by 10 year age groups

NCD Risk factors Men Women

1980 n=212

2009 n=116

1980 n=228

2009 n=153

Mean systolic BP (mmHg) 117.8 136.2 117.4 129.0

Mean diastolic BP (mmHg) 73.5 79.6 74.5 75.9

Hypertension ≥140/90 or meds (%) 11.7 43.0 15.1 29.6

Diabetes mellitus T2DM (%) 2.3 12.2 4.0 15.8

Mean body mass index (Kg/m2) 27.4 32.5 29.9 34.7

Obesity (%) BMI ≥30 25.0 61.7 48.6 77.2

Obesity (%) BMI ≥32 14.1 45.4 36.1 67.3

Serum cholesterol 3.9 4.4 4.3 3.9

Serum cholesterol ≥5.2mmol/L 6.8 20.7 17.2 7.5

Linhart C, Tivollier J-M,

R Taylor, Barguil Y,

Magliano DJ,

Bourguignon C,

Zimmet P.

Changes in

cardiovascular disease

risk factors over 30

years in Polynesians in

the French Pacific

Territory of Wallis

Island.

European Journal of

Preventive Cardiology.

Published 7 Sept 2015All differences between 1980 and 2009 significant at p<0.01 for each sex

Wallis Island

Polynesians:

changes in

NCD risk

factors 1980-

2009

Linhart C, Tivollier J-M,

R Taylor, Barguil Y,

Magliano DJ,

Bourguignon C,

Zimmet P.

Changes in

cardiovascular disease

risk factors over 30

years in Polynesians in

the French Pacific

Territory of Wallis

Island.

European Journal of

Preventive Cardiology.

Published 7 Sept 2015

Kiribati life expectancy at birth by sex 1970-2007

Linhart C, Carter K, Taylor R, Rao C, Lopez A. Mortality Trends in Pacific Island States. SPHCM, UNSW,

Sydney Australia; Secretariat for the Pacific Community (SPC), Noumea, New Caledonia; SPH, UQ)

Brisbane, Australia. June 2014. From indirect demographic methods and modelled (GBD) black

a. Carter K, Baiteke T, Teea T, Tabunga T, Itienang M, Rao C, Lopez A, Taylor R. Mortality and life

expectancy in Kiribati based on analysis of reported deaths. Population Health Metrics. 14:3, 2016.

Based on reconciled reported deaths a

Curves exclude GBD estimates

Population 109,000 (2013)

Population 109,000 (2013)

French Polynesia: Life expectancy at birth by sex

1975-2008 Population: 261,000 (2013)

Linhart C, Carter K, Taylor R, Rao C, Lopez A. Mortality Trends in Pacific Island States. SPHCM,

UNSW, Sydney Australia; Secretariat for the Pacific Community (SPC), Noumea, New

Caledonia; SPH, UQ) Brisbane, Australia. June 2014.

Nauru life expectancy at birth by sex 1960-2007

Carter K, Soakai S, Taylor R, Gadabu I, Rao C, Thoma K, Lopez A. Mortality trends and the

epidemiological transition in Nauru. Asia Pacific Journal of Public Health 23(1):10-23, 2011.

Population

10,500

(2013)

Challenges with NCD surveillance in Pacific states

Cross-sectional NCD and risk factor surveys

1. Infrequency: often 10 yearly

2. Technical issues with surveys: response rates,

selection bias, measurement bias

3. Delay in analysis and reporting results (years)

4. Insufficient analysis of period trends

5. Inadequate response to findings by intensifying or

changing prevention and control

6. Insufficient assessment of specific interventions

Challenges with NCD surveillance in Pacific states

Mortality by age group, sex, cause of death

1. Level of mortality and life expectancy

• Incomplete registration of deaths in several states -

coverage (e.g. U/R) and completeness (%)

• Use of demographic techniques by censuses and

surveys to estimate mortality and impute model life

tables which often under-estimate adult mortality

• Disguise the effects of NCD on premature mortality

Challenges with NCD surveillance in Pacific states

Mortality by age group, sex, cause of death

2. Cause of death (CoD)

•Extensive issues in many states with quality of

• CoD certification, including indefinite causes,

implausible sequences on death certificates (DC) etc

• Differences between DC and electronic record (XLS)

• Coding and selection of underlying CoD

• Infrequent use of Part II (contributory causes) leads to

Diabetes (and Hypertension), without specific lethal

complications, coded as the underlying CoD according to

ICD 10 when placed in Part I

• This produces over-estimation of Diabetes (and HT) as

underlying CoD according to ICD 10 logic and

underestimation of CVD as underlying CoD

Prevention and control of cardiovascular disease, diabetes

and tobacco-related cancer and lung disease in populations

THE POPULATION APPROACH

• Health promotion involving behavioural interventions (media, settings, etc)

and structural modifications to change diet (reduce saturated animal fats, salt

and energy intake), reduce tobacco and alcohol consumption and increase

physical activity. Directed to proximate and ultimate causes

• Does not involve medical intervention and very cost effective (if successful)

• Reduces mean levels of risk factors, including in those at moderate risk, from

which a substantial proportion of disease and premature mortality emanate c.f.

G Rose 1985

Prevention and control of cardiovascular disease, diabetes

and tobacco-related cancer and lung disease in populations

THE INDIVIDUAL HIGH RISK APPROACH

• Detection of individuals at high risk of NCD disease and premature mortality with

individual management and advice and/or medications as primary or secondary

prevention. Opportunistic or population screening

• May reduce numbers at high risk, but does not affect those at moderate risk, nor

the underlying behavioural and structural issues responsible for NCD risk factors

• Requires extensive medical testing (‘screening’) of individuals, availability of

diagnostics and medications, and considerable adherence and compliance, and

thus expensive and beyond many LMIC budgets

• Population screening requires conformity to well known criteria for screening, and

evidence of effectiveness (reduction in CVD episodes and death in populations)

from trials. Present evidence is from RCT of efficacy.

Prevention and control of cardiovascular disease,

diabetes, cancer and lung disease in populations

• Atherosclerotic cardiovascular disease , especially coronary heart disease

and stroke, has been controlled as a major cause of premature mortality in many

populations though decline in population risk factors, and contributions from

individual high risk approach and secondary prevention.

But many populations have not yet benefited

• Lung cancer (LC), other tobacco related cancers and COPD have declined

significantly in populations with declines in smoking prevalences (LC: lag 20 yrs)

• Cancer is complex has many causes: prevention and control involves reduction in

exposure to carcinogens (or vaccination), screening (few cancers), early diagnosis

and availability of treatment (surgery, X-ray, chemo) – often very limited in LMIC

• Diabetes mellitus (Type 2, adult onset) prevalence has not been reduced in any

population, although evidence of: (1) causation by obesity/lack of exercise;

(2) improved outcomes with treatment; (3) some success (30-60% RR reduction) in

RCT of intensive intervention in volunteers with impaired glucose tolerance

Further investigation needed, especially in populations with relatively low obesity %

Observations on implementation of prevention and

control of NCD in some Pacific Isd states

Behavioural Health Promotion

• SNAP (smoking, nutrition, alcohol, physical activity) framework for

individual/community interventions directed at behavioural NCD RFs

• Mass media campaigns (often unevaluated)

• ‘Wellness cascade’ for health education/promotion (life course approach)

• volunteer Community Health Workers (CHW) for PHC NCD prevention/

control

High risk approach

• WHO PEN protocols for RF detection and management. PEN: Package of

Essential Non-communicable disease interventions for PHC in low-

resource settings

• Personal NCD and diabetes record books

Population mortality and morbidity

• Probability of dying 30-70 years from

NCD: Cardiovascular disease, Cancer,

Diabetes or Chronic respiratory disease

(Broad Dx ?35-64 for Pacific?)

• Cancer incidence by site (?is cancer

mortality by site sufficient?)

Population NCD risk factors

• Alcohol harmful use

• Fruit/Vegetable low intake (?)

• Physical inactivity

• Salt intake (?measure?)

• Saturated fat intake (?what is it?

?measure?)

• Tobacco use

• Diabetes/raised blood glucose

• Blood pressure raised

• Obesity/Overweight

• Serum cholesterol raised

WHO Global Surveillance of NCDs

Lower Middle Income Country applicability

Process indicators

• Screening (?effectiveness?)

• Medication/vaccine availability (indeed)

• Policies to limit saturated (and trans)

fat intake (?Energy and salt intake?)

• Marketing to children (!!)

Multiple Absolute CVD

risk prediction charts

• A major improvement in considering

total absolute CVD risk from multiple

risk factors – reduces over treatment

• Calculated from Framingham data !

modified by regional CVD mortality

• A 20% absolute risk of CVD

episodes or sudden death over 10

years is considered ‘high’: 2% p.a.

• Drug treatment would reduce

absolute CVD risk by 30% (from

efficacy trials) or by 6 percentage

points in absolute risk: from 20% to

14% (over 10 years) or from 2% to

1.4% p.a. Based on 100% treated.

WHO PEN protocols for CVD RF detection and treatment

• PEN: Package of Essential Non-communicable disease interventions

for Primary Health Care in low-resource settings. Now being

implemented in many Pacific countries

• Claims to incorporate both the population-based and high risk strategy

• But most of the implementation focuses on the high risk strategy

involving mass screening and pharmaceutical treatment

• Predicted treatment efficacy based on results of RCT in developed

countries generally show RR of CVD around 0.8 for treated subjects over

10 years for CVD episodes or sudden death

• Combined drug treatment reduces combined cardiovascular disease

mortality and morbidity by about 30%, whatever the pre-treatment

absolute risk

• Effectiveness trials of CVD outcomes from mass screening and

treatment in developing countries needed that include the ability of the

health system to deliver screening and treatment, population

participation, and patient adherence and compliance (c.f. MRFIT trial)

Conclusions

• Many Pacific Island states are undergoing a version of the

epidemiological transition (not described by Omran) where there is a real

increase in age-specific mortality from NCD and stagnation or decline in

life expectancy - not dissimilar to Northern European and North

American countries (and ANZ) 50 years ago, but at a lower level of life

expectancy plateaux (around 5 years)

• International evidence from populations indicates that epidemics of

NCD are neither inevitable nor irreversible. They are a consequence of

risk factors in populations which result from way of life and consumption

patterns, and their structural causes

• Current NCD prevention and control efforts in LMIC seem to focus

more on the individual high risk screening with ‘advice’ and/or

pharmaceutical treatment (based on efficacy trials) and relative neglect

of the changes required to lower population risk factors

Conclusions

• Surveillance of NCD risk factors and cause-specific mortality in

populations of LMIC countries is difficult because of significant bias,

(measurement / selection), problems in analysis and reporting, and

under-use of results to constantly strengthen and change prevention

and control strategies: we must learn from effectiveness of tobacco

control measures

• Strengthening of the political economy approach is required in public

health prevention and control of NCD in populations to:

• reduce consumption of products causing elevation of risk factors

and increase physical activity

• mitigate unhelpful influences of producers who pursue their own

legitimate objectives, through the political process

Appendix

• Major events in NCD control

• International declines in coronary heart disease (CHD) mortality

• Comparison of trends in CHD and life expectancy in selected countries

Acute myocardial infarction clinico-path correlation in Hertz then JAMA in the 1st decade 20th century (although Heberden describes angina in 1770)

1920-30s: UK/USA Epidemiological studies of rises in CHD and lung cancer mortality. CHD mortality higher in upper social classes

1953: CHD and physical activity in London busmen (Jerry Morris)

1954: British Doctors cohort study published (Richard Doll) shows association of tobacco smoking with chronic bronchitis, lung cancer, CHD

1960: Framingham (Mass. USA) cohort study published: proximate modifiable CHD risk factors: blood pressure, serum cholesterol, tobacco smk

Pronouncements against tobacco smoking by: Royal College of Physicians (1962); US Surgeon General (1964) and commencement of tobacco control

1970: Seven 7 countries study (Ancel Keys) shows differences in CHD risk factors and mortality between populations, related to diet, with no CVD epidemic in Southern Europe (or Japan)

Timeline of some significant events in NCD control

1971: Epidemiological Transition (Omran). Rise in NCD proportional mortality deaths due to decline in infection - with decline in total mortality

1978 NIH (US) meeting on decline in CHD mortality. Sustained declines in CHD mortality in many high CHD mortality countries from 1970s-1980s

1982 First WHO Expert Committee on control of cardiovascular disease

1986 article Geoffrey Rose: “Sick individuals and sick populations” shows that substantial proportion of CHD deaths are at moderate risk (not high risk) – the paper of the century for population epidemiology

From the late 1980s sustained decreases in male mortality from lung cancer after 20 years of declines in tobacco smoking prevalences

MRFIT study (US) shows declines in mortality (at 5 yrs) with risk factor treatment slightly (not stat sig) greater than controls (stat sig at 10 yrs)

Community intervention trials in the US also show little benefit because of declines in risk factors in control groups

Timeline of significant events in NCD control

MONICA studies 1980s-90s indicating that CHD mortality reduction

predominantly due to reduction in incidence and severity of cases

1990: Statistical analyses using multiple measures of BP (McMahon, Peto et

al.) and ser Chol [Wall] show effects (RR) of risk factors on CHD mortality

underestimated by at least 50% vs one measure

Reduction in CHD/CVD mortality in several central and eastern European

countries after 1990 – but CVD in Russia and central worsens

Rediscovery of NCD by international agencies from 2000 with many LMIC

entering the epidemiological transition

Advances in individual secondary prevention from the 1990s with advent

of better medications for control of BP and ser Chol based on RCT evidence

of efficacy (RR ≈ 0.8 over 10 yrs)

Timeline of some significant events in NCD control

Coronary heart disease mortality

from 1950Males (age std)

35-74 years

Mirzaei M, Truswell AS,

Taylor R, Leeder S.

Coronary heart disease

(CHD) epidemics: Not all

the same.

Heart. 95:740-746. 2009

Cardiovascular disease mortality for Australia, aged 35-79 years (age standardised) 1935-2005

(a) Males

0

200

400

600

800

1000

1200

1400

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Rat

e per

100,0

00

All circulatory disease

Circulatory disease excluding rheumatic heart disease

Stroke

Ischaemic heart disease

Circulatory disease excluding rheumatic heart disease and stroke

(b) Females

0

200

400

600

800

1000

1200

1400

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Rat

e per

100,0

00

All circulatory disease

Circulatory disease excluding rheumatic heart disease

Stroke

Ischaemic heart disease

Circulatory disease excluding rheumatic heart disease and stroke

Taylor R,

Page A,

Danquah J.

The Australian

epidemic of

cardiovascular

mortality

1935-2005:

effects of

period and

birth cohort.

Journal of

Epidemiology

and

Community

Health. June

2012;

Pages1-7.

50

55

60

65

70

75

80

85

90

0

100

200

300

400

500

600

700

800

Life

exp

ecta

ncy

(ye

ars)

CH

D d

eath

rat

e/1

00

00

0

Year

Male CHD Female CHD Male LE Female LE Australia

Coronary heart disease (CHD) mortality age 35-74 years per 100,000 and life expectancy at birth in Australia

Plateau in life expectancy in both males and females during the late 1950s and 1960s in males and during the 1960s in females at the height of the epidemic of CHD mortalityResumption of increase in life expectancy from 1970 in both sexes with decline in CHD mortality

Note ICD version coding artefacts

50

55

60

65

70

75

80

85

90

0

100

200

300

400

500

600

700

800

Life

exp

ecta

ncy

(ye

ars)

CH

D d

eath

rat

e/1

00

00

0

Year

Male CHD Female CHD Male LE Female LE United States of America

Coronary heart

disease (CHD)

mortality age 35-74

years per 100,000 and

life expectancy at birth

in USA

Plateau in life expectancy in males during the 1950s and 1960s and in females during the late 1950s and 1960s at the height of the epidemic of CHD mortalityResumption of increase in life expectancy from 1970 in both sexes with decline in CHD mortality

50

55

60

65

70

75

80

85

90

0

100

200

300

400

500

600

700

800

Life

exp

ecta

ncy

(ye

ars)

CH

D d

eath

rat

e/1

00

00

0

Year

Male CHD Female CHD Male LE Female LE

Note ICD version coding artefacts

Italy

Coronary heart

disease (CHD)

mortality age 35-74

years per 100,000

and life expectancy

at birth in Italy

Reduction in rate of

increase in LE in males

and to some extent in

females from mid 1950s

No plateaux in LE

Moderate CHD mortality

with declines since the

1970s

50

55

60

65

70

75

80

85

90

0

100

200

300

400

500

600

700

800

Life

exp

ecta

ncy

(ye

ars)

CH

D d

eath

rat

e/1

00

00

0

Year

Male CHD Female CHD Male LE Female LE

Note ICD version coding artefacts

Greece

Coronary heart

disease (CHD)

mortality age 35-74

years per 100,000 and

life expectancy at birth

in Greece

Reduction in rate of

increase in LE in males and

females from mid 1950s

No plateaux in LE

Low CHD mortality with little

change