Herqutanto

Departemen Ilmu Kedokteran Komunitas

FKUI

Relationships among Demographic,

Epidemiologic, and Health
Transition
Health Transition

Epidemiologic Transition

Demographic
Transition
Urbanization
Urbanization
Industrialization
Industrialization

Fertility
Fertility
declines
declines

Infectious
Infectious
Disease
DiseaseMort.
Mort.
declines
declines

Rising
RisingIncomes
Incomes
Expansion
Expansionof
of
Education
Education
Improved
Improved
medical
medical&&PH
PH
technology
technology

Population
Population
ages
ages

Economic
Economic
recession
recession&&
increasing
increasing
inequity
inequity

Chronic
Chronic&&
NCD
NCD
emerges
emerges

Persistence
Persistenceor
or
reemergence
reemergenceof
of
communicable
communicable
diseases
diseases

Protracted polarized epidemiologic

transition
Source: WH Mosley, JB Bobadilla and DT
Jamison, 1993

BODY MASS INDEX

Pop. 18 yrs with overweight and under weight by
age group, NHHS 2004

Proportion of respondents
aged 15 years or above
with Over-Weight and
Obesity,
NHHS
2001, 2004

GLOBAL DEATHS BY CAUSE, ALL AGES

2005
17.528.000

CARDIOVASCULAR
DISEASES

**Resources: WHO and World Bank 2005

7.586.000

2.830.000
1.607.000
HIV/AIDS

TUBERCULOSIS

883.000
MALARIA

CANCER

4.057.000

CHRONIC
RESPIRATORY
DISEASE

1.125.000
DIABETES

WHO Statistics 2007

Age-standardized CVD mortality rate per 100.000

population (2002)
441

Timor Leste

199
Thailand
Vietnam

318
171

COUNTRIES

Singapore
Filipina

336
274

Malaysia
Indonesia

361

China

291

mortality

106

Jepang
Srilanka

314
428

India

Australia

140
182
141
188

United Kingdom

CanadaStates
United
0

WHO Statistics 2007

100

200

300

MORTALITY RATE

400

500

Cause of Death in Indonesia

SKRT 1992, 1995, 2001
35

Persentase
30
25
20
15
10
5
0

Infection Circulation
Respiration Gastro
and
1992 1995 2001
Lung
Laporan SKRT 2001: Studi Morbiditas & Disabilitas, Litbangkes 2002

Cancer

Accident Perinatal

Beberapa contoh penyakit

kronis

HYPERTENSION
Hypertension (HTN) is highly prevalent

and is a significant risk factor for CAD,

LVH, CHF, PVD, stroke, sudden death,
nephropathy, and DM
The incidence of HTN increases as a
function of age
Patients who are normotensive at 55 yr
have 90% risk of developing HTN at some
point in their lives

HYPERTENSION
SKRT 2001
6 % HTN at 25-34 yr
15 % HTN at 35-44 yr
43 % HTN at > 55 yr
2/3 uncontrolled HTN patients at > 60 yr will have

CHD, MCI, or Stroke within 5 year

Risk of HTN is regulated by genetic

background and environmental factors

For every 20/10 mmHg increase BP above
115/75 mmHg, risk of CVD doubles
(Chobanian et al, 2003)

Prevention
and control
of CVD

Social Determinants
(Culture, Economy,
Finance)

Risk Factors
Modifiable
Diet & Nutrition
Physical activity
Tobacco
Alcohol
Non-modifiable
Age
Genetic

Promotion

Promotion and
Prevention

Risk Factors
Modifiable
High lipids
High Blood.
Pressure.
High Blood.
Glucose.
Obesity/Malnouri
shed

Prevention

CARDIO VASCULAR
DISEASE

Surveillance and
Early Treatment

The
Metabolic
Syndrome

Genetic
Diet
predisposition
Physical
Inactivity Socioeconomic Birth size,
Childhood
status
growth

Hyperglycemia

Dyslipidemia
Low HDL, high TG

Abdominal obesity,
Ectopic fat deposition
Insulin
Resistance

Textbook of FM, Rakel, 07

Hyperuricemia
Change in
Adipose
hormones
Endothelial
dysfunction

Hypertension
Diabetes

Systemic
inflammation

CVD

Hypercoagulability
Impaired fibrinolysis

METABOLIC SYNDROME
Risk Factor
Abdominal obesity

Triglycerides
HDL

Blood Pressure
Fasting Glucose

Defining Level
Men : Waist > 90 cm
Women : Waist > 80 cm
>=150 mg/dl
Men : < 40 mg/dl
Women : < 50 mg/dl
>=130 / >=85 mmHg
>=100 mg/dl

Patients who have ANY THREE (3) of five risk factors meet

criteria for the metabolic syndrome

METABOLIC SYNDROME
The incidence of Metabolic Syndrome

increases in men and women as a function

of age (Ford et al 2002, Alexander et al
2003)
Patients with Metabolic Syndrome had
3.77 fold increase in risk of CVD mortality
compared to patients without it (Lakka et
al 2002)

Global Projections for the Diabetes

Epidemic: 20002010
26.5
26.5
32.9
32.9
24%
24%

14.2
14.2
17.5
17.5
23%
23%

15.6
15.6
22.5
22.5
44%
44%

9.4
9.4
14.
14.
11
50
50
%
%

World
2000 = 151 million
2010 = 221 million
Increase of 46%

84.5
84.5
132.
132.
33
57%
57%

1.0
1.0
1.3
1.3
33%
33%

Zimmet P et al. Adapted with permission from Nature 2001; 414: 7827.

The Natural History of Diabetes Mellitus

Primary

Fetal
development

Secondary

Tertiary

Onset of
diabetes

Death

Prevention

Prediabetes Diabetes

IDDM and Genetic

Hyperglycemia
NIDDM susceptibility
I CA +
Insulin dependency
IDDM I AA +
anti-GAD +
Nutrition
Insulin resistance
Obesity
Insulin secretion
NIDDM Physical inactivity
Aging
Increasingly
May be presentfrequent
Complication Absent
ICA- islet-cell cytoplasmic antibodies; IAA- insulin autoantib

The Natural History of Non-insulin-Dependent Diabete

Onset of
Diabetes
Complications
Disability

Death

Environmental
factors
e.g. nutrition
obesity
physical inactivity
Genetic
susceptibility IGT

Insulin resistanceHyperglycemia
Retinopathy Blindness
HyperinsulinemiaHypertensionNephropathy Renal failure
HDL
Atherosclerosis
Cor.Heart Disea
Neuropathy
Amputation
a
HDL- High density lipoprotein; IGT- Impaired Glucose Toler

CIGARETTE SMOKING
Cigarette smoking significantly raises risk of

atherosclerotic disease and potentiates MI

Smoking cessation reduces the risk of MI and
mortality by 36%
Smoking cessation is facilitated by patient
education about the danger of smoking and
pharmacologic intervention with nicotine
replacement and bupropion
Relapse rate are high in the absence of
education and encouragement.

A man, 58 years old, sees his family doctor because of chest

pain. He had been well until 2 weeks ago, when he noticed
tightness in the center of his chest when he was walking uphill.
Questions : Is he sick ? What is the appropriate diagnosis ?
Causal of the illness ? How is the treatment and prognosis ?
Remember Risk Factors (Biopsychosocial)
Died
60 of
CVD

5
8

Died ?
of DM

THERAPY
Pharmacology
Drugs

Non Pharmacology

(health education/ counseling) on :

Diet, Exercise, Smoking Cessation, drugs

compliance

BEHAVIORAL
INTERVENTION
Changes in patients knowledge does not

guarantee changes in patients behavior

Understanding the stages of change

Behavioral changes do not occur rapidly,

may be months or years required

Stage-specific counseling

Prochaskas Model of
Behavior
Change
Precontemplation

Patient is not even thinking about changing the behavior within the

next 6 months
Contemplation
Patient is considering a behavior change within the next 6 months
but not within the next 1 month
Preparation
Patient has stated that he or she will change his or her behavior in
the next 1 month
Action
Patient has actually implemented the behavior change and
contracting has occurred
Maintenance
The behavior change has been in place for at least 6 months and is
being incorporated into patients lifestyle
Relapse
Not a specific stage, but something that can occur at any time
during the process

Associations between behavior, family,

occupation, environment and culture in
individual health
The Mandala of Health
A model of human ecosystem

culture
community
lifestyle
family

Personal
behavior
Sick
care
system

spirit
body

Human
biology

Psycho-socioEconomic
Environment

mind

work

Physical
environment

Human-Made Environment
biosphere

Biosphere
Society-nation
Culture-subculture
Community

Systems hierarchy

Family
Two person
Person
(Experience & behavior)
Nervous-system
Organ/organs systems
Tissues
Cells
Organelles
Molecules
Atoms
Subatomic particles

From: Engel ,GL: The clinical application of the

biopsychosocial model. Am J Psychiatry

Gaya Hidup
Perilaku
Sehat
sehat

Lingkungan
sehat

Akses
yankes
Bermutu &
Merata
Status
kesehatan
optimal
AZRUL AZWAR 29

VARIABEL & INDIKATOR

Gaya hidup sehat

Olahraga
Tdk merokok
Tdk minum alkohol
Dll

Akses yankes
Imunisasi
Ante natal care
KB
Dll

Lingkungan sehat
Air bersih
Rumah sehat
Buang limbah sehat
Dll

Status Kesehatan
AKB
AKBALITA
AKI
Dll
Azrul

30

 Behaviour change
Health promoting environments
Communication and education
Environmental/policy/

behavioural
Training
High risk and identified groups

Age-standardised incidence
and age-specific prevalence
rates of diabetes

Incidence rates for CHD

Prevalence of overweight
and obesity

Rates of non-participation
in regular sustained
moderate aerobic exercise

Prevalence of a high fat

diet

Awareness of the early

symptoms of and risk
factors for diabetes

Access to factors which

maintain health:
Opportunities for
increased physical
activity
availability and
access to healthy
food choices
adoption of health
promoting
organisational
policies

Thank
You