| Background:An understanding of the influence of socioeconomic events on cause-specific mortalities is essential to the development of health policies for prevention and control of immature death.Long-term longitudinal epidemic data are indispensible to characterize the influence of socioeconomic events.The Global Burden of Disease(GBD)study has shown that noncommunicable chronic diseases already surpass communicable,maternal,perinatal,and nutritional disorders in some developing countries like China.The under-5 mortality,a sensitive index of public health service,declined by 79%from 1996 to 2015 in China,although these rates were higher than that in high-income countries.However,the influence of socioeconomic events on cause-specific mortalities have not been systemically evaluated.Shanghai is the largest metropolis founded as a port for international trade just after First Opium War(1840-1842).Since the founding of the People’s Republic of China in 1949,residents in Shanghai have experienced following socioeconomic events:"Development of polluting industries"(1949-the 1980s),"the Chinese famine"(1959-1961),"the great cultural revolution"(1966-1976),"reform and opening up"(since 1979),and "outbreak of hepatitis A"(January 1988)。According to the World Bank standard of per capita income,Shanghai belonged to low-income region before 1994,lower-middle income region during 1996-2005,and upper-middle income region after 2006.8 Vital registration system in Shanghai was established 14 years prior to the national one established in 1987.Due to rapid economic growth,population influx kept increasing in some districts of Shanghai during the past decades.9 To evaluate the influence of socioeconomic events on cause-specific mortalities in naturally growing population in urban Shanghai,we selected Yangpu,an industrial district of urban Shanghai,based on the following reasons.First,Yangpu has a medium level of economy among the urban districts.Second,the residents in Yangpu have experienced all the above public events.Third,the registered residents in Yangpu have been stable,ranging from 0.77×106 to 1.09×106 during 1974-2015.Population influx and efflux were very limited due to the restriction on introduction of big businesses and the household registration system,respectively.Thus,to investigate the influence of socioeconomic events on the mortality of naturally growing population,Yangpu can represent urban Shanghai.Material:The data used in this study were collected from the death registration system of Yangpu District Center for Disease Control in 1974-2014,Shanghai,which contains all the death information of the permanent residents in Yangpu District.The causes of the diseases were coded by ICD-10。Methods:1.We give a descriptive analysis of the change of main causes of death,sex ratio,crude mortality rate and standard mortality rate trend during 41years.2.Decomposing of mortality(1)Calculation:The differences of the mortality of one population in separate time would be considered as the mortality of two population of differendt structure.There is no residual of this method.If we want to quantify the differernces of mortality A and mortality B:then the difference of these two mortality would be:Diff=CDRB-CDRA=∑CXB·MXB-∑CXA·MXA contribution of demographic factor+ contribution of non-demographic factor(2)Data:Divided 40 years length into 4 parts:A=1975-1984 B=1985-1994 C=1995-2004 D=2004-2014 Then we will quantify the Diff of:B-A=(1985-1994)-(1975-1984);C-B=(1995-2004)-(1985-1994);D-C=(2004-2014)-(1995-2004);3.Time trends analysis:We use the software of JoinpointRegressionProgram 4.3.1.0(April,2016)which was developed by American Cancer Statistics to find out where are the jopinpoints during 41 years.This software would help us to find the best model to fit.The joinpoint would be calculated from 0-5 step by step,then the meaningful joinpoints would be found out.4.Population Projection:We use the current age structure to predict the future one with Lesilis Metrix.5.Age-Period-Cohort ModelData preparation The APC analysis in present study enrolled the 20 years and older population,because the mortality rates were low in the young people(20 years old and younger).We divided the enrolled population into subgroups every 5 years during 1976-2014 and also divided the enrolled population into different age groups at an interval of 5 years.After that we formed a Lexis diagram tabulating mortality cases and person-years by age(a),period(p),and cohort(c).We took the cancer-cause of death as an example to show how the Lexis diagram was constructed.The person years in the Lexis diagram were calculated using the following formulas:(1/3La,p+1/6La+1,p+1)×y(A)(1/6La,p+1/3La+1,p+1)×y(B)where the formula A was used to calculate the person years of upper triangle and formula B was used to calculated the person years of lower triangle.L meant the average population sizes during the period p,and y meant the interval years of the periods,ages and cohorts(5 years in this study).The model fitting After the data preparation,the age,period and cohort data were fitted to the model expressed as:log[r(a,p)]=f(a)+g(p)+h(c),where f(a),g(p),and h(c)represented the effects of age,period,and birth cohort,respectively.Each variable was divided into linear and non-linear functions.We smoothed non-linear functions with natural splines.As collinearity existed in APC model(c = p-a),we constrained the slope of period effects to 0 on average.The trend of period and cohort were shown as risk ratio in Figure 3.The risk ratio was the death risk compared with that in the reference years which was set as 1949(the year when the People’s Republic of China was founded)for cohort and 1980(the year immediately after the reform and opening up policy was implemented)for period.Prediction using APC model To predict the mortality during 2016-2030,we constructed an APC model.,which was similar but not the same with the one as previously described.Firstly,to level off the exponential growth in the multiplicative model,we chose power 5 as the link function rather than log link which was commonly used.The advantage of power 5 as the link in the prediction had been demonstrated by Moller in 2002.1 Secondly,we used the recent mortality data rather than whole range data to construct the model,because the recent data was more valuable in predicting the future mortality.The parameters of the prediction process were shown in Table 1 in appendix methods.Population information during 2016-2030,which was necessary for the prediction purpose,was predicted using Leslie matrix model.APC model analysis was conducted using Epi package and Norpred package in R software(Version 3.4.3).ResultsYangpu District of Shanghai has entered the aging society in the year of 1974.Population over the age of 65 accounted for 12.18%in 1974,with the number goes up to 9.21%(1984),10.49%(1994),15.77%(2004),18.22%(2014).The top 5 leading causes of death between 1974-2014 were:circulatory disease,cancer,chronic respiratory disease,injury,endocrine and nutritional metabolic diseases.The higher age-specific mortality was 75-age group(16.83%),85-age group(16.58%),80-age group(16.13%),70-group(14%),65-age group(10.31%).In addition to the age group of 0-years,the proportion of deaths among age-specific groups increased while the older.The majority of highest cause-specific mortality rate are the group of 70-.The ratio of the crude mortality rate between male and female are different,of which the higher ones are:infectious and parasitic diseases(3.71),cancer(2.96),chronic respiratory disease(2.79),perinatal diseases(2.53),nervous system diseases(2.30),genitourinary diseases(2.23).The top leading cause-specific mortality were:circulatory disease,cancer,chronic respiratory disease,while the rank of endocrine and nutritional metabolic diseases go upward from 9th to 4th in male resident and go upward from 7th to 4th in female resident.The rank of urinary diseases get down from 7th to 10th in male resident while get down from 8th to 10th in female resident in every 10-years count.The proportion of infectious,maternal and nutritious diseases decreased from 7.66%n the year of 1974 to 1.86%in 2014,while that of non-communicable chronic diseases increased steadily from 86.03%to 94.42%,that of injuries decreased from 6.31%to 3.72%at the same time.The crude mortality rate of infectious,maternal and nutritious disease decreased from 40.240/100,000(1974)to 16.345/100,000(2014),and the standardized mortality rate decreased from 40.383/100,000(1974)to 10.300/100,000(2014).The crude mortality rate of non-communicable disease increased form 451.983/100,000(1974)to 828.180/100,000(2014)while the standardized mortality rate decreased from 519.936/100,000(1988)to 313.477/100,000(2014).The crude mortality rate of injury changed from 33.139/100,000(1974)to 32.598/100,000(2014),while the peak one was 57.496/100,000(1978)and the lowest one was 28.314/100,000(2013).The standardized mortality rate of injury decreased from 36.536/100,000(1974)to 13.649/100,000(2014),while the lowest one is 34.429/100,000(1982).The results of the decomposition of mortality rate show that:the contribution rate of demographic factors in the increasing of the all-cause mortality was 70%compared with non-demographic factors between the difference of the mortality rate of 1985-94 to 1975-84;the contribution rate of non-demographic factors in the decreasing of the infectious,maternal and nutritious disease mortality was more than 80%compared with demographic factors between the difference of the mortality rate of 1995-84 to 1975-84 and 1995-2004 to 1985-94.The contribution rate of demographic factors in the increasing of the non-communicable disease was 95(male)&88%(female)compared with non-demographic factors between the difference of the mortality rate of 1985-94 to 1975-84.The contribution of the demographic factors and non-demographic factors almost the same in the decreasing of the injury mortality.The results of Joinpoint analyses are:the decreasing turning point of the decreasing of the mortality of infectious,maternal,nutritious disease was the year 1988;the standardized mortality rate of non-communicable disease,circulatory disease,cancer,chronic respiratory disease increased,while they remain stable before 1995 then go upward slightly,then decrease,and slow down after the year of 2005.The mortality rate of endocrine and nutritional metabolic diseases goes upwards slightly before 2001 then largely afterwards.We analyzed all registered permanent residents in Yangpu,with a total of 41,879,864 person-years.A total of 290,332 deaths(154,050 men and 136,282 women)occurred during 1974-2014.Group 1 causes,group 2 causes,and group 3 causes accounted for 3.80%,86.50%,and 5.56%of all-cause mortality,respectively.Cardio-cerebrovascular disease(stroke,ischaemic heart disease,and hypertensive heart disease),cancer,respiratory disease including chronic obstructive pulmonary disease(COPD)and asthma,diabetes mellitus,and digestive disease including liver cirrhosis and peptic ulcer disease were the top 5 leading causes of death during 1974-2015,accounting for 35.05%,28.36%,11.35%,3.45%,and 3.22%of all-cause mortality,respectively.Cancer-related death occurred 7.70 years earlier than did cardio-cerebrovascular disease-related death.In working population younger than 60 years,cancer,cardio-cerebrovascular disease,injury,infectious/parasitic disease,and digestive disease were the top 5 leading causes of death,accounting for 40.20%,19.66%,11.70%,5,93%,and 3.29%of all-cause mortality,respectively.With the use of APC model,we analyzed the effects of age,birth cohort and period on the mortality.The mortality of cardio-cerebrovascular disease,cancer,and diabetes greatly decreased since 1990,especially after 2000,in the age groups from 60 to 70 years old;while that of respiratory disease decreased in almost all age groups.Birth cohort analysis indicated that all-cause mortality,the mortalities of group 2 causes including cardio-cerebrovascular disease,cancer,diabetes,and digestive disease and that of injury increased evidently in the population born on 1955-1965,covering the Chinese famine period(1959-1961).From the fitting trend of birth cohort in APC model,we found that the risks of death caused by cardio-cerebrovascular disease,cancer,diabetes,and respiratory disease reached the tops in the populations born on 1921,1928,1928,and 1911,and then declined,respectively.However,the risks of death caused by cancer and diabetes turned to increase in these born after 1949.The aged(65 years and older)accounted for 4.59%of total population in 1974 and this proportion increased to 19.15%in 2015.The number of the aged is expected to peak during 2021-2025,accounting for 33.15%.The proportion will reduce thereafter.According to the proportionate distribution of cause-specific mortality by sex in 1976-1980,2011-2015,and 2026-2030.It is speculated that a total of 11,354 women and 20,996 men will died during 2026-2030.The proportionate distribution of groups 1 and 3 causes will keep decreasing(the proportion of group 1 causes:6.67%in 1976-1980,2.43%in 2011-2015,and 2.31%in 2026-2030;that of injury:7.83%in 1976-1980,3.71%in 2011-2015,and 3.08%in 2026-2030).Cardio-cerebrovascular disease and cancer will remain the top two killers.Furthermore,their proportionate distributions keep increasing in both sexes.The proportion of diabetes keeps increasing and will become the 3rd most common cause of death in women and the 4th position in men in 2026-2030.InterpretationThis study had3 main findings.First,age-standardized mortalities of groups 1,2,and 3 causes decreased rapid after 1988.,1994,and 1995,respectively.Second,the risks of the major group 2 causes-related deaths reached the tops in those born on 1911-1928,and then declined,however,the risks of cancer-and diabetes-related death turned to increase in those born after 1949.Third,cardio-cerebrovascular disease and cancer remain to be the top two killers,while the proportion of diabetes keeps increasing,in 2026-2030.The trends in age-standardized mortalities reflect the effect of public health effort and nature of life-threating diseases.The mortality of group 1 cause after 1988 because the municipal government greatly enhanced public health infrastructure for controlling infectious diseases since the outbreak of hepatitis A in January 1988.The mortalities of groups 1 and 3 causes were evidently lower in Shanghai than in mainland China and the world,because groups 1 and 3 causes in Shanghai had been effectively controlled via improving medical service.Similarly,COPD has been effectively controlled.Smoking and air pollution are the well-established risk factors of COPD.Improved air quality andimproved medical service since the 1980s effectively reduced the mortality.However,it is difficult to reduce the burden of group 2 causes.Age-standardized mortality of cancer started to decrease since 1991,possibly because polluting industries were removed from urban Shanghai since the 1980s.The mortalities of cardio-cerebrovascular disease and diabetes turned to decrease after 1998 and 2005,possibly because the improvement in medical service since the 1980s and health education,especially the World Bank-supported mass health promotion program carried out since 1996,played active roles.The risks of death by cardio-cerebrovascular disease,cancer,and diabetes reached thetops in those born on 1920-1930,which was related to poor medical condition during 1960-1980.Medical system was attacked during the Great Cultural Revolution(1966-1976).Previous studies have shown that exposure to the Chinese famine in early life increases the risks of obesity,hyperglycemia,type 2 diabetes,hypertension,and fatty liver disease in adulthood,and also increases schizophrenia risk and stomach cancer mortality in later life.Our findings further suggested that the famine exposed at perinatal stage increased the mortalities of cardio-cerebrovascular disease including stroke,cancer,diabetes,digestive disease,and injury.Metabolic syndrome is an important risk factor of stroke,particularly among women and those with ischemic stroke.The associations between the famine exposure and metabolic syndrome may be partially explained by insulin resistance.Exposure to extreme starvation leads to poor development of pancreaticβ-cell mass and function,which may persist in later life.Adverse social environments exposed in early life increase the risk of chronic diseases in later life.In addition,people born around the famine might have compensatory mental orientation of over consumption.The risks of death caused by the chronic diseases of those born after 1940 declined,however,the risks of death caused by cancer and diabetes increased in those born after 1949,indicating that exposure of their risk factors kept increasing.High red and processed meat intake,tobacco smoking,overweight or obesity,physical inactivity,low vegetable intake,and alcohol drinking increased the risk of cancer.According to the dietary survey in urban Shanghai,the proportion of read meat increased from 9%in 1982 to 26%in 2002,whereas,the proportion rate of cereal declined from 65%to 40%.Tobacco smoking has increased substantially since the 1980s.Over 50%of adult Chinese men were smokers in 2010,with a high male uptake rates before the age of 20 years.Diabetes shares the risk factors with some cancers and also serves as an independent predictor of mortality from some cancers.Conclusion:The demographic of Yangpu District aging rapidly during the period of 1974-2014,and will continue in the near future.The epidemiological transition has occurred and the main causes of death changed from infectious,maternal and nutritious diseases into chronic non-communicable diseases and injury.Circulatory disease,cancer,chronic respiratory disease have been the top 3 leading causes of all death,while the rank of endocrnne and nutritional metabolic diseases go upwards and that of urnnary diseases low down.The rising of the mortality rate of non-communicable diseases was driven largely by demographic factors(aging),while the deceasing of the mortality rate of infectious,maternal and nutritious diseases was driven by non-demographic factors.The risk factors of non-communicable diseases(smoking,obesity,high blood pressure)were not significantly improved,and the decrease of mortality rate of injury was related to the strict constriction of drunk driving,the usage of safety helmet.The risk factors of cancer have been transferred from pollution and/or infection to consumption of tobacco and alcohol,excessive nutrition,and physical inactivity,the latters also promote diabetes-and cardio-cerebrovascular disease-related death,possibly via inducing systemic inflammation.33,34 The proportion of cardio-cerebrovascular disease-and cancer-related deaths keep increasing in the past 42 years.The trends are projected to continue in the future.Our projections of all-cause and cause-specific mortality provide an estimate of the future disease burden and are fundamental to the process of planning for programs of disease control.The mortality rate of non-communicable diseases in Yangpu District will continue to rise in the future,after the peak in 2015-2020 and then decreased.Suggestion:1.Promote healthy lifestyle and eating habbits,such as good sleeping habbits,moderate physical exercises,no smoking,moderate alcohol drinking,follow recommendations of cgagoda of Chinese residents’,limit excessive intake of suger and salt to prevent chronic non-communicable diseases.2.With the transformation of epidemiology,the social health care system should change from the traditional "hospital-based treatment",model to"community oriented medical care"model.3.In order to extending the coverage of social insurance pension,it is necessary to strengthen the use of personal pension account funds,issue medical welfare bonds and encourage the purchase of commercial insurance,in addition to expanding the scope of participation of social insurance personnel. |
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