China's Health Shifts With Urbanization, Higher Incomes

Jenni Laidman

June 12, 2013

In 1990, the leading cause of death in China was lower respiratory infection. Twenty years later, according to results from a study published in the June 8 issue of the Lancet, such infections ranked ninth among the causes of death in China, replaced by maladies familiar in any Western country: stroke, ischemic heart disease, chronic obstructive pulmonary disease (COPD), and road injury.

The changes, driven by rapid urbanization and rising incomes in China, are part of a dramatically shifting health picture in the world's most populous nation.

The research showed major improvements in life expectancy, child mortality levels, and infectious disease levels in an analysis of 20 years of data collected in the Global Burden of Disease, Injuries, and Risk Factor Study 2010 for 1990 and 2010. Joint first authors Gonghuan Yang, MD, from the Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and School of Basic Medicine, Peking Union Medical College, Beijing, China, and Yu Wang, MD, director of the Chinese Center for Disease Prevention and Control, Beijing, and colleagues compared several health indicators for China and 18 other G20 countries.

The authors found that China in 2010 ranked tenth among G20 nations for healthy life expectancy at age 67.8 years (95% uncertainty interval [UI], 66.1 - 69.3 years), and twelfth for life expectancy at age 75.7 years (95% UI, 74.9 - 76.5 years). In addition, China ranked eleventh for age-standardized years of life lost (YLLs), which is lower than all other emerging G20 economies and only slightly higher than the YLL of the United States, which ranked eighth. YLLs attributed to infectious disease, childhood injuries, and neonatal maladies in China fell substantially during the 20-year survey period.

However, these improvements were offset by risk factors particular to China, including high rates of tobacco use and high rates of second-hand smoke exposure, ambient air pollution levels, and household air pollution levels.

Chinese men have one of the highest smoking rates in the world, at 52.9%, and Chinese women have one of the lowest rates in the G20 nations, at 2.4%. Tobacco use accounted for 9.5% (95% UI, 7.4% - 11.4%) of disability-adjusted life-years (DALYs) and 16.4% (95% UI, 12.8% - 9.5%) of deaths. Exposure to second-hand smoke was as high as 72.4%, and levels of ambient air pollution in China ranked second highest among G20 nations. Ambient air pollution was the fourth most common (95% UI, third to fifth) risk factor attributable to age-standardized DALYs behind tobacco exposure, high blood pressure, and dietary risk. Household air pollution ranked fifth (95% UI, fourth to sixth) as a risk factor.

A composite of dietary risk factors was the leading risk factor affecting DALYs, accounting for 16.3% (95% UI, 14.5% - 18.0%), and for 30.6% (95% UI, 27.5% - 33.3%) of deaths.

Seven of the 10 leading causes of death in China in 2010 were noncommunicable diseases, including 4 cancers, compared with 4 of the leading causes in 1990, which included no cancers. The top 3 causes of death in China in 2010, in order from highest to lowest, were stroke (1.7 million deaths; 95% UI, 1.5 - 1.8 million deaths), with a median 21% (95% UI, −13 to 37) increase from 1990; ischemic heart disease (948,700 deaths; 95% UI, 774,500 - 1,024,600 deaths), with a median 81% (95% CI, 23% to 103%) change from 1990; and COPD (934,000 deaths; 95% UI, 846,600 - 1,032,300), with a median −45% change (95% UI, −51% to −40%) change. These were followed, in order, by road injury, lung cancer, liver cancer, stomach cancer, self-harm, lower respiratory infection, and esophageal cancer.

In 1990, the leading causes of death, in order from highest to lowest, were lower respiratory infection, stroke, COPD, congenital anomalies, drowning, neonatal encephalopathy, ischemic heart disease, self-harm, preterm birth complications, and road injury.

The authors found demographic changes behind the rise in stroke, heart disease, and other noncommunicable ailments.

"Urbanization and aging are two of the driving forces behind the rise of non-communicable disease. The number of deaths from [noncommunicable diseases] has grown, along with the rates of diabetes, lung cancer, and ischemic heart disease," Dr. Wang said in a press release issued by the Institute for Health Metrics and Evaluation, a global research center at the University of Washington and a partner in the study with the Chinese Center for Disease Control and Prevention and Peking Union Medical College.

The authors have disclosed no relevant financial relationships.

Lancet. 2013;381:1987-2015. Abstract

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