Elsevier

The Lancet

Volume 372, Issue 9650, 8–14 November 2008, Pages 1697-1705
The Lancet

Series
Emergence of chronic non-communicable diseases in China

https://doi.org/10.1016/S0140-6736(08)61366-5Get rights and content

Summary

China has experienced an epidemiological transition shifting from the infectious to the chronic diseases in much shorter time than many other countries. The pace and spread of behavioural changes, including changing diets, decreased physical activity, high rates of male smoking, and other high risk behaviours, has accelerated to an unprecedented degree. As a result, the burden of chronic diseases, preventable morbidity and mortality, and associated health-care costs could now increase substantially. China already has 177 million adults with hypertension; furthermore, 303 million adults smoke, which is a third of the world's total number of smokers, and 530 million people in China are passively exposed to second-hand smoke. The prevalence of overweight people and obesity is increasing in Chinese adults and children, because of dietary changes and reduced physical activity. Emergence of chronic diseases presents special challenges for China's ongoing reform of health care, given the large numbers who require curative treatment and the narrow window of opportunity for timely prevention of disease.

Introduction

Many profound changes began with the formation in 1950 of the People's Republic of China, and one of the most striking was a rapid improvement in disease prevention and control leading to marked increases in longevity.1 The epidemiological transition, which occurred earlier and at a slower pace in many western nations was compressed into only a few decades in China, as the predominant cause of mortality shifted from the infectious diseases and perinatal conditions to chronic diseases and injuries. This shift in the contributing causes of mortality was achieved through health interventions such as increased vaccination coverage; better hygiene, sanitation and water quality; improved access to medical care; and advanced social and living standards such as universal education, higher incomes, and better nutrition and housing. Population age structure is also shifting due to fertility and mortality decline, thereby increasing the proportion of elderly people.2

In more recent decades, the momentum of China's epidemiological transition has continued unabated. Many of the known risk factors for chronic diseases have dramatically increased as societal change progresses. These behavioural elements include changing diets, levels of physical activity, tobacco consumption, and automobile use. These same behavioural shifts have been observed in many developed countries over the past 50 years, but they have accelerated at a historically unprecedented pace and scale in China, accompanying the rapid growth of the national economy over the past 30 years.

We will describe the changing patterns of mortality in China, focusing on recent data on prevalence of key behavioural risk factors. The likely effect of these behavioural changes on the health of Chinese people will exacerbate the enormous challenges that chronic diseases will present to efforts to reform the nation's health-care system.

Section snippets

Definitions and data

We used national censuses in 1982,3 1990,4 and 20005 to obtain population and mortality data from all households. The 1982 census (with a reference date of July 1, 1982) collected information on all deaths in the calendar year 1981; the 1990 census (with a reference date of July 1, 1990) collected death information in the calendar year 1989 and between January and June, 1990; the 2000 census (with a reference date of Nov 1, 2000) collected death information in the 12 months before the census,

Mortality pattern changed

Figure 1 shows life expectancy in China from 1945–49 to 1999–2000.6, 30 Life expectancy increased after 1950, and especially quickly before 1975, because of successful control of infectious diseases and maternal and prenatal conditions. Since 1990, life expectancy has plateaued, in association with the emergence of chronic diseases. Life expectancy at birth increased from less than 50 years to nearly 70 years during the 40 years between 1950 and 1990. Between 1990 and 2000, however, life

Behavioural risk factors

Two major forces have been responsible for the emergence of chronic diseases in China. The first has been the very rapid transition of China's population from a youthful to an ageing population as life expectancy has increased. This so-called greying of China's population has increased causes of death associated with elderly populations. Birth rates have plummeted, and China's one-child family policy has been a strong driver of population ageing.31 Whereas 7·6% of the population were aged 60

Dietary changes

Along with the substantial rise in people's income during the rapid economic development of China over the past 20 years, the food supply and variety of food products has increased, with accompanying changes in dietary patterns. The intake of cereal decreased substantially over this period, whereas intakes of meat and edible oil increased. Fat intake increased from 68·3 g per day in 1982 to 85·6 g per day for urban Chinese, and from 39·6 g to 72·6 g for rural Chinese.20 In both urban and rural

Hypertension

The prevalence of hypertension in China has been rising rapidly during the last 30 years. In 2002, nearly 18% of Chinese adults aged 15 years and older had hypertension, corresponding to 177 million people.34 No other country has a larger group of people with hypertension. One presumed causative factor is high salt intake in both urban and rural Chinese diets. In 2002, the average daily salt intake for a reference man (aged 18 years with light level of physical activity) was 12 g per day,20

Overweight people and obesity

By the WHO definitions, 18·9% of Chinese adults aged 18 years and older were overweight in 2002, and 2·9% were obese. However, by definitions used elsewhere in Asia, prevalences were higher, with 31% overweight people and 12·1% obese people in 2002.22, 23 The Chinese Ministry of Health has recommended that people with a body-mass index of 24 kg/m2 or more should be considered overweight, and that those with an index of 28 kg/m2 or more should be considered obese. Based on these thresholds,

Tobacco use

China is the largest tobacco grower and consumer in the world.28 One in every three smokers in the world is a Chinese man.38, 39 Domestic tobacco production has steadily increased from 80 billion cigarettes in 1949, to 256 billion in 1968, 651 billion in 1979, 1630 billion in 1990,40 and 1723 billion in 2002. Consumption of cigarettes increased to 2022 billion in 2006,41, 42 17·4% higher than in 2002. 99·2% of domestically produced cigarettes are consumed in China and only 0·8% are exported.42

Responding to chronic disease

These data show that China has completed the epidemiological transition from a predominance of infectious diseases and maternal and perinatal conditions to chronic diseases and injury. Whereas non-communicable diseases constituted 58·2% of all deaths in 1973–75, the proportion had increased to 73·8% in 1991. By 2000, 82·9% of all deaths were due to non-communicable diseases, corresponding to the loss of about 70% of all disability-adjusted life-years.44

Unfortunately, the prevalence and burden

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