The Demographic/ Epidemiologic/ Urban and Nutrition Transitions

The Demographic/
[[[
Epidemiologic/
Urban and
Nutrition Transitions
Learning Objectives
• By the end of the course the students will be able to:
 Describe the stages in demographic transition
 Define epidemiologic transition and the
mechanisms involved
 Describe models of epidemiologic transition
 Understand urban transition
 Define nutrition transition and the stages involved.

The Demographic Transition
Definition: the change of a population from
high birth and death rates to low birth and
death rates.
 Prior to the industrialization of the world

in the mid 19th century, world population
growth was slow
 Births replaced deaths.

• Thompson’s early work observing changes in
fertility and mortality rates in populations.
• Landry introduced the term ‘demographic

transition’ in describing secular changes in fertility
and mortality in 1934, later reprinted in English.
• This idea was further developed in association

with socio-economic development.
 With the advent of industrialization and
advances in medicine and public health,
death rates began to decline and more
people survived to have children of their
own.
 Widening gap between birth and death

rates fueled population growth worldwide
to an estimated 7.9 billion today.
 Previously, sub-Saharan Africa lagged
behind the rest of the world in population.
 Currently 97% of the increase in world

population will come from developing
countries and
 Africa’s share of global population will

increase from 13% today to 22% by 2050.
 Africa faces a population growth and a
doubled population in the next 30
years.
 Indeed, even in the face of HIV/AIDS,

Africa's population will triple before it
starts to decline.
The Demographic Transition
Four stages
• First stage: high death and birth rates

(slow and steady population growth).
• Second stage: death rates begin to

decline and birth rates remain high
(faster population growth).
The Demographic…
• Third stage: death rates continue to

decline and birth rates begins to decline.
• Fourth and final stage: death and birth

rates balance and population growth
stabilize : In some cases, (e.g. Italy)
population may cease to grow altogether.
[[
[
Demographic transition…
The Classical demographic transition:
• It occurred through Europe, North America in

the 18th, 19th and early 20th centuries.
• Was characterized by slow and steady change.
The death rate had a long and gradual decline.
• The decline was due to three main factors
(agricultural revolution, trade revolution and industrial
revolution). In addition there was public health
improvement.
• No major medical breakthroughs.
• Japan (an exception) in the classical model.
The Present (Contemporary) demographic
transition
•It has started in many developing countries in

the middle of the 20th century
– Birth and death rates start at higher levels
– Death rates declined much more dramatically

and the causes are new medical and public
health technologies
The Present Contemporary) demographic
transition…
–Birth rates remain very high, therefore,

high levels of population growth reaching
3%;
–In countries where fertility decline has

started is mostly due to contraceptive
technology and very little or substantial
economic development.
Health and development implications of
demographic transition.
1. Demographic momentum: implies continued births by

more parents, even though fertility may decline. There
are simply more people having babies.
2. Population age structures will begin to change, and

more Africans will be in older segments of the
population.
16
3. Health care needs will likewise change and a greater
need for chronic disease management will emerge.
4. Coupled with high rates of urban growth
 African planners, politicians and public health experts

have much to consider:
– Sound management of the demographic transition
– an in depth assessment of future costs for a growing and

aging population.
17
Over the next 25 years,
 African governments, donors and non-

governmental partners will have to derive an
effective operational balance between the
infectious disease, burdens of poverty and the
growing proportion of non communicable
diseases
18
 Africa should consider practical policies and
programs to
 stabilize population
 cope with the inevitable upshot of

demographic momentum
 the demographic transition.
19
The Second Demographic Transition ?
(Lesthaeghe R, 2004,2006, 2007)
• Europe of today- sub-replacement fertility

• Addis Ababa- sub-replacement level?
Very important!
• The demographic transition has occurred in

different paces and paths in different
countries and sometimes within countries.
Urban Transition
 Understandably, Africa is no exception to the

trend in urbanization.
 In 2000, Africa was 38% urban (about 297

million).
 By 2030, about 53% of Africa will be urban

with over 700 million urban residents.
23
Urban Transition…
 Worldwide, the highest rates of urban growth

will be in African cities.
 Essential needs for water, house, food,

education, sanitation and other basic public
services will increase rapidly.
24
Urban Transition…
 Urban environments grow at higher rates than rural

areas due to migration plus natural rates of increase.
 On average, urban growth is about 5% worldwide.
 This implies a doubling time of about 14 years.
 Much of the urban growth worldwide will be in slum

populations, which comprise 40%-60% of urban
vicinity.
Epidemiologic transition
Definition:
• Is the general shift from acute infections and
deficiency diseases characteristic of
underdevelopment to chronic non-
communicable diseases characteristic of
modernization and advanced levels of
development.
• The most evident indicators of this transition

are changes in the pattern of mortality,
particularly in cause of death, as well as
changes in morbidity.
What are the mechanisms involved in the
epidemiologic transition?
1. Demographic changes:
• Because of the demographic transition more

people will survive to adulthood; disease
pattern of adults as well as diseases of the
elderly more – non- communicable diseases
epidemiologic transition? …
2. Changes in risk factors:
• Biological factors (alteration in antigenic

identity; emergence of drug-resistant strains
and dual infection)
• Environmental factors (exposure to

environmental pollutants and overcrowding)
epidemiologic transition? …
3. Socio-economic changes
 Welfare policies
 Public health actions
 Cultural and behavioral changes
 Increase use of health technology
 Modernization and rising standards of living
• Increase use of motor vehicles, drug
abuse, etc..
4. Nutritional changes
– Change of eating habits, physical inactivity.
29
Models of Epidemiologic Transition
1. The Classical Epidemiologic Transition
• Gradual and progressive transition as
modernization occurred.
• typical of Western societies (Europe, USA,
NZ, AUS)
2. The Accelerated Epidemiologic Transition

• Faster mortality decline (Japan)
• Faster pace to non-communicable diseases
Models of Epidemiologic Transition…
3. The delayed Epidemiological Transition

• Africa, Latin America and Asia
• Substantial decreases in mortality and
high fertility
• Transition triggered mostly by public

health measures and health technology
and not necessary great economic
development.
Models of Epidemiologic Transition…
• Important!
– Several stages of the epidemiologic

transition can overlap in the same country
(for instance, different socioeconomic
groups may experience the transition
differently)
Epidemiologic Transition
 The complex change in patterns of health and

disease
Interactions between these patterns.
demographic
 economic,
 sociological determinants
 consequences
33
Epidemiologic Transition…
Stages of the Epidemiologic Transition
1.Pestilence ( fatal epidemic disease) and Famine

2.Receding Pandemics
3.Degenerative diseases
All societies experience three “stages" in

the process of modernization
Stages of Epidemiologic Transition
1. The "age of pestilence (Deadly disease)

and famine"
 Mortality is high
 Fluctuating, with an average life

expectancy under 30 years;
35
Stages of Epidemiologic Transition…
 Major shift occurred in most human

populations,
 From a nomadic hunting and gathering lifestyle

to sedentism and primary food production.
36
This shift involved major changes
 In human social organization

 Diet,
 Demographics,
 Behavior that created conditions favorable
for zoonotic infections
 Make the transition to human hosts,

 Preexisting human pathogens to evolve to
more virulent forms. 37
 The subsequent increase in infectious disease

mortality that arose in the context of these changes
describe as the first epidemiologic transition.
 The shift to permanent settlements created larger

aggregates of potential human hosts
 Increasing the frequency of interpersonal contact

within and between communities, likely fostering the
spread and evolution of more acute infections
38
 In addition, accumulation of human waste

would have created optimal conditions for
dispersal of parasites and gastrointestinal
infections.
39
 Agricultural practices increased contact with

parasites.
 With the beginning of food storage, the threat

of contamination and wide-scale outbreaks of
food poisoning increased
40
2. The "age of receding (diminishing)

pandemics",
 life expectancy rises from under 30

to over 50;
41
Coincided with the Industrial Revolution
In mid-nineteenth century
It is distinguished by a marked decline in

infectious disease mortality within
developed countries.
42
 The decline of infectious diseases in the

nineteenth and twentieth centuries has often
been cited as an objective landmark in the
progress of modern civilization
 A product of developments in medical science

and technology in the industrialized world that
would eventually diffuse to less-developed
societies.
43
 Decreased child and maternal mortality resulting from

declining infectious diseases resulted in an overall
increase in population size
 A subsequent increase in life expectancy entailed an

aging population with increasing mortality because of
chronic degenerative diseases associated with the
later years of life.
44
3. The "age of degenerative and man-

made diseases"
Mortality decrease with infectious diseases
Increases the visibility of degenerative

diseases,
Man-made diseases become more and more

frequent
45
Stages of the Epidemiologic Transition
Quality of life, Equity, development and social justice (Stage
V) - futuristic
Age of Delayed Degenerative Diseases (Stage IV)
Improvement in treatment of NCD leading to further increase in
longevity (LE >75 years)
Age of Degenerative, stress and man-made diseases: (Stage III)
Low mortality, less infectious diseases & malnutrition, increasing NCDs
& man-made diseases, tremendous gains in longevity (LE >50 years)
Age of Receding Pandemics: (Stage II)
Epidemics less frequent, infectious diseases less frequent, slow rise in
degenerative diseases begin to appear (LE <50 Years)
Age of Deadly disease and Famine: (Stage I)
Characterized by high and wide swings mortality rates, little population
growth and very low life expectancy (LE <30 years) 46
47
48
The Nutrition Transition
Definition:
• Shift in dietary, physical activity and
inactivity patterns.
• During the nutrition transition:

– Changes in nutritional outcomes, such
average stature and body composition.
The Nutrition Transition…
• Usually societies converge to a pattern of

diet high in saturated fat, sugar and refined
foods and low in fiber- associated foods.
– High levels of degenerative diseases!
• The Nutrition Transition is strictly linked to

the Demographic and Epidemiologic
Transitions.
 There is a consensus that over nutrition is
becoming an increasingly important issue in
many developing countries.
 Experts believe a more rapid shift to over

nutrition is apparent among populations in
moderate- and low-income countries.
 Demographic and epidemiologic transitions

are pre- or at least co-factors in the nutrition
transition.
51
 Obesity rates are escalating everywhere.
 More than 300 million adults worldwide are

overweight
 Most of them are suffering from weight-

related illnesses like diabetes, heart disease
and sleeping disorders
 Developed and developing world will not be

able to cope with treating people with
diseases linked to obesity.
52
 Higher rates of overweight are emerging in
wealthier segments of urban populations
 WHO had predicted that by 2015? 30% of men

and 41% of women in Africa will be
overweight.
 This implies a direct relationship between

socio-economic status, overweight and
obesity.
53
 Processed foods, change in diet, physical

activity ,social attitudes towards nutrition ,
food availability ,consumption patters
promote these trends.
54
 Africa is not immune to over nutrition
 Africa needs to consider the nutrition

transition in the 21st century
 Appropriately balance investments on under

nutrition and over nutrition in the future.
55
From traditional to modern nutrition
From traditional to modern food marketing
From ancient to modern work
From traditional to modern transportation
Village in Ghana, 2005
Source: Die Zeit. Nr. 15, 1. April 2004, S. 44
Figure 1. Stages of Demographic, Epidemiologic and Nutrition
Transitions
Conclusion
• A framework linking demographic and social changes
to disease patterns in populations Transition to NCD
results from success in controlling infectious diseases
• Increase in NCD burden is inevitable when

populations are aging.
• Need to prevent/control NCD (that can be prevented)

to allow resources for the control of unpreventable
conditions
Conclusion
• Transition model provides basis for prospective

planning, also when actual epidemiological data
are not available
• Good news: last transition stage predicts

improved health in populations conditional to
appropriate policy and health care response
Conclusion
• While the age structure of the population

and the distribution of disease change,
socially disadvantaged people and those
who are socially isolated continue to be at
increased risk (this is true for all countries,
developed or under-developed).
Conclusion…
• And when the epidemiologic and

demographic transition collide:
– Increased demand on health and health

care for the elderly
– Middle aged adults in the work force need

flexible jobs because they may be in need
to provide care for their elderly.
Conclusion…
• Older workers will also need more flexible
jobs to contribute fully in the Society
– Societies need to sort out their policies. For
instance benefits and practices related to
retirement, child care, sick leave, part-time work,
health insurance and workers compensation
schemes.
• There is a need to re address the general

socio-economic, cultural and environmental
conditions of the society.
Conclusion…
• The Governments of the developing

countries must design strategies to address
the changes in population structure and
disease pattern with due attention to the
inequalities/inequities in health status within
the country as a whole and across
population groups.

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The Demographic/

 Describe the stages in demographic transition

 Define epidemiologic transition and the

 Describe models of epidemiologic transition

 Understand urban transition

 Define nutrition transition and the stages involved.

 Prior to the industrialization of the world

 Births replaced deaths.

• Landry introduced the term ‘demographic

• This idea was further developed in association

 Widening gap between birth and death

 Currently 97% of the increase in world

 Africa’s share of global population will

 Indeed, even in the face of HIV/AIDS,

• First stage: high death and birth rates

• Second stage: death rates begin to

• Third stage: death rates continue to

• Fourth and final stage: death and birth

• It occurred through Europe, North America in

•It has started in many developing countries in

– Birth and death rates start at higher levels

– Death rates declined much more dramatically

–Birth rates remain very high, therefore,

–In countries where fertility decline has

1. Demographic momentum: implies continued births by

2. Population age structures will begin to change, and

4. Coupled with high rates of urban growth

 African planners, politicians and public health experts

– Sound management of the demographic transition

– an in depth assessment of future costs for a growing and

 African governments, donors and non-

 cope with the inevitable upshot of

 the demographic transition.

• Europe of today- sub-replacement fertility

• The demographic transition has occurred in

 Understandably, Africa is no exception to the

 In 2000, Africa was 38% urban (about 297

 By 2030, about 53% of Africa will be urban

 Worldwide, the highest rates of urban growth

 Essential needs for water, house, food,

 Urban environments grow at higher rates than rural

 On average, urban growth is about 5% worldwide.

 This implies a doubling time of about 14 years.

 Much of the urban growth worldwide will be in slum

• The most evident indicators of this transition

• Because of the demographic transition more

2. Changes in risk factors:

• Biological factors (alteration in antigenic

• Environmental factors (exposure to

2. The Accelerated Epidemiologic Transition

3. The delayed Epidemiological Transition

• Transition triggered mostly by public

– Several stages of the epidemiologic

 The complex change in patterns of health and

Interactions between these patterns.

Stages of the Epidemiologic Transition

1.Pestilence ( fatal epidemic disease) and Famine

All societies experience three “stages" in

1. The "age of pestilence (Deadly disease)

 Fluctuating, with an average life

 Major shift occurred in most human

 From a nomadic hunting and gathering lifestyle