【精品】富贵病——中国流行学趋势

1、主题：富贵病中国流行病学趋势由陈君实院士等在90年代的研究成果，今天已经成为事实！慢性病己经成为富 贵病！富贵病的特征：吃富贵食物：吃肉，吃加工型食品，喝酒等等富贵的生活习惯：运动少，开车，看电视得富贵的疾病：癌症，高血压，糖尿病，心血管疾病等china： from diseases ofpoverty todiseases of affluence. policyimplications of theepidemiologicaltransitiont. colin campbell, chen junshi, thierry brun, banoo parpia, qu yinsheng,

2、 chen chumming, and catherine geisslercontent：intro i methods i results and discussion i policy implications references i exclusive interview with colin campbell 'division of nutritional sciences, cornell university, ithaca , institute of nutrition & food hygiene, chinese academy of preventi

3、ve medicine, beijing, institute of mediterranean agriculture, montpellier, 'department of food and nutritional science, kings college, university of london.(received 5th february, 1991; in final form november 5th, 1991)introductionone hundred and forty years ago john hughes bennett, senior profe

4、ssor of clinical medicine at the university of edinburgh, when writing about the causes of cancer, said that nutritional conditions that favored the risk of tuberculosis were opposite to those favoring the risk of cancer (bennett, 1849). just three years before, walshe had published cancer mortality

5、 data and proposed that cancer was a hdisease of civilizationh (walshe, 1846) because death rates were higher amongst the upper income citizenry. on many occasions since then, it has been observed that disease prevalence changes radically after economic development (pellett, 1989). the diseases that

6、 were responsible for a vast majority of deaths in europe and north america in the nineteenth century are not the primary causes of death today.although the specific reasons for these changes in mortality rates are not well understood, a few of the more general characteristics of these trends are as

7、 follows. the decline in infectious and communicable diseases follows an increase in, and more equitable distribution of, economic resources. an extensive investigation of mortality rate trends in england and wales in the eighteenth, nineteenth and twentieth centuries (mckeown and record, 1955; mcke

8、own and record, 1962; mckeown et al, 1975) indicates that the nineteenth century decline in mortality rates for the most prevalent infectious diseases was wholly attributable to enviromental control, not to intervention with curative medicines and vaccines.mckeown et al. (1975) suggest that a better

9、 diet, improved hygiene, and a more favorable relationship between microorganisms and humans were major contributors to these trends, with better nutrition accounting for about three-fourths of the effect. deliberate improvements in sanitation, however, may have been somewhat more important than he

10、supposed as suggested by cairns (1985) who added that the wider use of cotton, which did not shrink like wool, allowed clothes to be washed and, in so doing, people also washed themselves- in many developing nations there has been a rapid increase in the incidence of cardiovascular disease, obesity,

11、 diabetes, lung cancer and a host of other health disorders concomitant with a rise in economic affluence (pellett, 1989). in contrast with the communicable and infectious diseases affecting the rural poor, the more economically privileged urban sectors in these countries suffer from a rising preval

12、- ence of chronic degenerative diseases appropriately referred to as 'diseases of misdevelopment1 by dumont (1989). not only do these chronic diseases have a debilitating effect on a productive segment of the active elite but also the costs of treating these diseases tend to absorb a disproporti

13、onate share of the public health resources in favor of an already privileged social group. it is therefore of utmost importance to developing nations to avoid creating a new and costly pathology soon after emerging from the scourge of infectious and nutritionaldeficiency diseases (pellett, 1989).chi

14、na, a vast and densely populated country in the process of rapid modernization offers a unique setting to study the relationship between dietary, environ- mental and economic changes and health indicators. two recent surveys (national cancer control office, 1979; chen et al, 1990) in the people'

15、s republic of china have confirmed the emergence of a similar trend in certain areas of this country: that is, an increase in chronic diseases and a decrease in communicable diseases. this paper reports on an analysis of primary data collected in an ecologic survey of dietary and lifestyle factors (

16、chen et al 1990) together with secondary data on disease-specific mortality rates for the survey sites (national cancer control office, 1979). two broad research questions are addressed:1) are there any discernible patterns or clusters of disease distribution across china?and2) what effect, if any,

17、do nutritional factors or dietary patterns have on this distribution?an analysis of these chinese data, which is the focus of this communication, provides evidence to suggest that diseases such as cancers and coronary heart disease may share a common nutritional etiology based on the enrichment of d

18、iets with animal products. policy implications of these findings for china and other countries also are briefly discussed.methodsdata from a 1976 retrospective mortality survey ft)r 197375 causes of death and a ecologic survey in 1983 84 were combined to study the relationship between various mortal

19、ity rates and several dietary, lifestyle and environmental charac- teristics in 65 mostly rural counties in china (et al, 1990). sampling procedures and analytical methodology have been described in detail by chen et al ( 1990) and are only briefly noted below.the mortality data were obtained from t

20、he same survey of causes of death for 1973-75 that resulted in the publication of the atlas of cancer mortality in china (national cancer control office, 1979). cause of death was determined using medical records from clinics and hospitals and by questioning relatives and close friends of the deceas

21、ed person in addition to area officials. diagnosis and classi- fication of the cause of death were standardized by the chinese ministry of public health. the accuracy and reliability of these mortality rates is more fully discussed in the foreward to the atlas (national cancer control office, 1979)

22、and further underscored by similar values obtained in neighboring counties juxtaposed on opposite sides of provincial borders and surveyed by different health survey teams (le et al, 1981). in addition the wide range of values across survey counties for most causes of death and the generally high co

23、rrelation between values by sex, indicates a minimal impact of diagnostic errors. deliberate precautions were taken to distinguish causes of death easily confused with one another such as liver cancer and hepatocirrhosis, stomach cancer and gastric ulcer, lung cancer and pulmonary tb, amongst others

24、.disease-specific mortality rates for each county were calculated as cumulative mortality rates per 1,000 persons by sex for all ages up to age 64, and for all ages up to age 15. the cumulative mortality rate up to a particular age is nnn times the sum of the annual crude death rates in all age grou

25、ps up to that age, where nnh is the number of single years in an age group (who, 1976). thus, the cumulative mortality rate for a particular disease may be interpreted as approximately equivalent to the cumulative risk of death by age 64 (or age 15, as the case might be), in the absence of death fro

26、m other causes. the question of competing risks is unlikely to be of relevance in the context of this analysis primarily because mortality data have been expressed as age-standardized rates. furthermore, there is no reason to believe that risk of chronic degenerative disease during middle age is goi

27、ng to be different for individuals who otherwise would have died from non-degenerative diseases earlier in life.the ecologic survey was conducted in 65 rural counties dispersed throughout the populated regions of china, selected to represent the full range of mortality rates for seven of the most pr

28、evalent cancers. a three-stage random cluster sampling procedure was used to select the smaller survey units of communes (2 per county), production brigades (2 per commune) and production teams (2 per production brigade). within each of the 260 production teams, 25 households were randomly selected

29、from an official registry of residences yielding 100 households per county. a total of approximately 6500 adults aged 35-64 were included in the survey, with 100 individuals per county, half of each sex. the study design and remaining experimental details are provided by chen et al. (1990).the infor

30、mation obtained from this survey included nutritional metabolic, hormonal, environmental, reproductive, demographic and socioeconomic characteristics. the combined data from the two surveys of 65 counties (130 communes) consisted of 367 items of information including cumulative disease-specific coun

31、ty mortality rates (from the 1973-1975 retrospective study) and a comprehensive set of dietary, lifestyle and environmental characteristics. the analysis assumes the stability of biochemical indicators and dietary patterns in the population over time. the negligible migration in this population (an

32、average of 94% of the survey subjects were born in their county of residence), food production and consumption patterns based on stable locally available crops, and the remarkably constant trend in the national food intake data (piazza, 1986) underscore the validity of such an assumption.pearson pro

33、duct-moment correlation coefficients were used to relate every variable with all other variables in the compiled data set. these correlation co-efficients are cross-sectional measures of association between characteristics and were used as such with the recognition that they do not establish a causa

34、l link between the variables examined. geographic clustering of disease mortality rates was investigated by visual inspection of a table of correlation coefficients for each disease with every other disease. disease mortality rates that were directly correlated (p 0.05) with each other were placed i

35、n one group; inversely correlated (p 0.05) rates comprised the second group (table 2). any disease mortality rate that did not show a consistent correlation (when significant) with all diseases included in each of the two groups was omitted from the set.results and discussionthree features of these

36、data make this epidemiologic investigation of mortality in china particularly appropriate and informative. first, the ranges of mortality rates across china as illustrated for a few diseases in table 1, were far greater than those typically observed for countries that are more industrialized (and le

37、ss economically diverse). such broad ranges may facilitate the detection of otherwise unobserved relationships. second, mortality rates were distributed around china in clusters that formed unique geographic patterns for each disease (national cancer control office, 1979; chen et al, 1990). the uniq

38、ueness of these patterns indicates the presence of specific causes for each disease, perhaps related to routine consumption of locally grown foods. and third, among these several dozen disease categoriestable iaverage age-.standardized county mortality rates per 100/)00 and ranges for selected disea

39、ses in the people's republic of china, 1973 - 75*disease males femalescancers1 nasopharynx 8 (0-75)ss 4 (0-26) esophagus 120(1-435) 72(0 286) stomach 9(6-386) 41 (2-141) liver 78(7-248) 26(3-67)colorectal 14(1-67) 10(2-61)lung 23(3-59) 10(0-26) leukemia 4 (0-9) 3 (0-7)non-cancerspulmonary tuberc

40、ulosis 113(31-270) 70(26 230)infectious diseases 31 (6 64) 23 (4-50)diabetes 4(0-9) 3(0-14)myocardial infarcation / coronary heart disease 12(0-52) 10(0-50) hypertensive heart disease 16(1-43) 15 (2-65) rheumatic heart disease 16(0-55) 27 (3-99)stroke 77 (20 197) 64 (21-251) pneumonia 14 (2-54) 11(0

41、-56) cirrhosis of the liver 51(6-155) 26(2-58) digestive disease other than ulcer 23(3-61) 18 (4 55)age truncated, 35-64 years; standardised to world population (who, 1976). 7tht)se cancer ites were used in the selection of the 1983 survey counties- they represent the full range of mortality rates f

42、or all 2392 counties in china. the average annual age-standardized county mortality rates are based t)n age-sex-specific deaths in each of the 65 counties (49 counties for noncancers) for the population aged 35-64 years.range of county mortality rate in the 65 (49 counties for non-cancers) counties,

43、 35-64 years-some were significantly correlated with each other, thus suggesting that they might share a common underlying nutritional etiology. in addition to providing important information on the chief correlates and possible causes of geographic differences between these mortality rates, the dat

44、a could also be useful in the investigation of mortality rate trends over time. at the turn of the century, for example, reclus (1905) noted the similarities between chronological and geographic trends of economic development and concluded thatgeography is nothing but history into space and similarl

45、y history is geography on a time scale.n if so, the present health profile of some economically developed counties in china might be used to predict changes in more traditional counties. such projections could be useful in planning nutrition, health and agricultural strategies.diseases in group a (t

46、able 11) are those generally associated with impoverished conditions while most of those in group b tend to be characteristic of more affluent societies. to investigate common causes underlying each disease group, cumulative mortality rates for each disease group were calculated for each survey coun

47、ty. the relationship between these group mortality rates and the various characteristics measured in the 1983-1984 ecologic survey were then analyzed (chen et al, 1990) and the correlations that were statistically significant at p<o.ol are listed in table 111.as expected, diseases of poverty are

48、associated more with agricultural than with industrial activity. areas where these diseases are common are located further inland where mean elevation is higher and overall economic activity, literacy and population density are lower. in contrast, diseases of affluence are found in the more densely

49、populated rural areas1 nearer the seacoast where industrial activitytable 11self-clustered disease groupsgroup a - disease of poverty group b diseases of affluencepneumonia (16) stomach cancer (5)intestinal obstructions (i 2) liver cancer (10)peptic ulcer (13) col,in cancer (9)other digestive disord

50、ers ( 17) lung cancer (16)nephritis ( 12) breast cancer (ipulmonary tuberculosis ( 10) leukemia (15)infectious diseases (other than tuberculosis) (17) diabete (2)parasi(ic diseases (other than schisit)st)miasis) (i 0) coronary heart disease( 1)eclampsia ( 1 3) brain cancer (ages 0- 14) (13)rheumatic

51、 heart disease ( 13)metabolic and endocrine disease (other than diabetes) (io) diseases of pregnancy and birth (other than eclampsia ( 15)*each disease category, when significantly correlated (p<0.05) with any other disease category is positive for disease categories in its own group and negative

52、 for disease categories in the second group.'numbers in parenthesis indicate the number of correlations which are statistically significant at p<0.05 (from a total of 20 comparisons).the major municipalities of shanghai, beijing and tianjin were not included in this survey.and literacy rates

53、are higher and more fish, eggs, soy sauce, beer and processed starch and sugar products are consumed. however, such univariate geographic correlations do not provide strong evidence of causal relationships between dietary factors and these diseases, particularly because relatively small amounts of s

54、everal of these specific foods are consumed. for example, mean egg consumption in china nationwide is very low bywestern practices, with mean daily intake being only about 5-10% that for the united states; egg consumption averages less than once per week in 78% of the 65 survey counties fish consump

55、tion averages only about 15% of the median intake in the united states, except for three counties in the southeastern coastal provinces of fujian, guangdong and zhejiang. beer and processed starch and sugar products are also consumed in much lower quantities.therefore, consumption of these foods is

56、probably more indicative of general economic conditions and other local circumstances than of biological relationships to disease. the correlation of diseases of poverty with higher levels of arsenic contamination of food remains unexplained.table iiicorrelations of disease groups with various chara

57、cteristics characteristics / diseases of poverty / diseases of affluence plasmatotal cholesterol 0.48*urea nitrogen -0.47 0.40albumin 0.44antibody to core hbv 0.44 -0.32cotinine 0.37 0.50urineribonavin excess -o.41 0.45chloride 0.48red blood cellshemoglobin -0.39total n3 fatty acids (rbc) 0.44questi

58、onnaireheight -0.59 0.51 weight -0.45 0.41beer (per day) -0.32 0.59fgg (per year) -0.54* 0.31total pregnancies 0.53' -0.38stillborn 0.51 -0.34infant mortality 0.69 -0.47dietary surveyfish (g/day) 0.56processed starch and sugar 0.5 1soysauce -0.41arsenic 0.41beer 0.59gocraphic characteristicsmean

59、 elevation 0.43 0.39mean longitude 0.48 0.40ciross value of industrial and agricultural output, 0.44population density* 0.45 0.41literacy ratel 0.51 0.39agricultural employment1 0.64* -0,58industrial employment1 0.631 0.58further characteristics of the areas where diseases of poverty are more common include greater infant mortality and a greater number of pregnancies per woman. the average age of the women surveyed in 1983