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Aging, Health, and Chronic Conditions in China and India: Results from the Multinational Study on Global AGEing and Adult Health (SAGE)1

Paul Kowal, Sharon Williams, Yong Jiang, Wu Fan, P. Arokiasamy, and Somnath Chatterji

China and India are the two most populous countries in the world. Combined, they were home to more than 34% of the world’s 784 million people aged 60 and older in 2011. China’s proportion of older people will grow from over 12% of its total population currently to 34% in 2050. Meanwhile, India’s older population will grow from close to 8% to almost 20% over the same time period. The proportion of people aged 60 and older will exceed that of people aged 0-14 years by 2019 in China and by 2050 in India (United Nations, 2011a). In 2050, more than three-quarters of 1 billion people aged 60 and older will live in China and India, constituting 38% of the world’s 60-plus population.

Population aging in China and India will likely be accompanied by an increase in chronic disease burden. An estimated 66% of the Chinese health burden and 45% of the Indian health burden are expected to be in older adults by 2030 (Chatterji et al., 2008). Furthermore, population aging will result in an estimated 200% increase in deaths from cardio-

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1 The World Health Organization’s Study on Global AGEing and Adult Health (SAGE) is supported by the U.S. National Institute on Aging through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01) and through an NIH research grant (R01-AG034479). The National Institute on Aging’s Division of Behavioral and Social Research, under the directorship of Dr. Richard Suzman, has been instrumental in providing continuous intellectual and other technical support to SAGE and has made the entire endeavor possible. The Chinese government and the Shanghai Metropolitan Center for Disease Control and Prevention contributed financial and in-kind support for SAGE China. The China and India SAGE teams conducted the interviews and produced high-quality results. We would like to acknowledge Jesse Cramer, who assisted with the literature search for this chapter.



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17 Aging, Health, and Chronic Conditions in China and India: Results from the Multinational Study on Global AGEing and Adult Health (SAGE)1 Paul Kowal, Sharon Williams, Yong Jiang, Wu Fan, P. Arokiasamy, and Somnath Chatterji C hina and India are the two most populous countries in the world. Combined, they were home to more than 34% of the world’s 784 million people aged 60 and older in 2011. China’s proportion of older people will grow from over 12% of its total population currently to 34% in 2050. Meanwhile, India’s older population will grow from close to 8% to almost 20% over the same time period. The proportion of people aged 60 and older will exceed that of people aged 0–14 years by 2019 in China and by 2050 in India (United Nations, 2011a). In 2050, more than three-quarters of 1 billion people aged 60 and older will live in China and India, constituting 38% of the world’s 60-plus population. Population aging in China and India will likely be accompanied by an increase in chronic disease burden. An estimated 66% of the Chinese health burden and 45% of the Indian health burden are expected to be in older adults by 2030 (Chatterji et al., 2008). Furthermore, population aging will result in an estimated 200% increase in deaths from cardio - 1 The World Health Organization’s Study on Global AGEing and Adult Health (SAGE) is supported by the U.S. National Institute on Aging through Interagency Agreements (OGHA 04034785; YA1323-08-CN-0020; Y1-AG-1005-01) and through an NIH research grant (R01- AG034479). The National Institute on Aging’s Division of Behavioral and Social Research, under the directorship of Dr. Richard Suzman, has been instrumental in providing continu - ous intellectual and other technical support to SAGE and has made the entire endeavor pos - sible. The Chinese government and the Shanghai Metropolitan Center for Disease Control and Prevention contributed financial and in-kind support for SAGE China. The China and India SAGE teams conducted the interviews and produced high-quality results. We would like to acknowledge Jesse Cramer, who assisted with the literature search for this chapter. 415

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416 AGING IN ASIA vascular disease in China between 2000 and 2040 (Leeder et al., 2005). In addition, the rapid economic growth in these countries accompanied by rapid urbanization may also contribute to the increase of noncommuni - cable diseases. Urbanization is associated with unhealthy nutrition and physical inactivity, leading to obesity and increases in the prevalence of chronic diseases such as diabetes (Wang et al., 2005, 2007). The number of people with diabetes in China is estimated to be more than 92 million, with another 148 million pre-diabetic (Yang et al., 2010). India has the second largest estimated number of people with diabetes currently, at 51 million (International Diabetes Federation, 2009). Mean life expectancies at birth and age 60 were higher in China (74 years and 20 years) than India (65 years and 17 years) in 2010, with the differences between the countries projected to shrink over the next two decades (see Table 17-1). The most recent healthy life expec- tancy (HALE) at birth estimates for China were 65.0 years for men and 67.8 years for women in 2007 (World Health Organization, 2008). At age 60, HALE is 13.7 years for Chinese men and 15.5 years for women. HALE at birth in India is 55.9 years for men and 56.7 years for women. The dif- ference in HALE between the genders at age 60 in India is small, with 11.1 years for men and 11.9 years for women. In comparison to HALE at 60 years for both sexes combined of 14.6 years in China and 11.5 years in India, older people living in Indonesia can expect 11.9 years of healthy life remaining at age 60; in the United States, 17.3 years; and in Japan, 20.2 years. Recent Global Burden of Disease estimates show a higher age- standardized overall disease burden in India than China, but with a higher proportion of noncommunicable disease (NCD) burden to overall burden in China than India (Abegunde et al., 2007; World Health Organization, 2008) (see Figure 17-1). The composition of NCDs across the countries is also notable, with considerable differences in cerebrovascular and ischemic heart diseases and unipolar depressive disorders. It is estimated that 44% of the total burden of disease in China in 2004 was from adults aged 45 and older (Chatterji, 2008), which is expected to increase to more than 65% by 2030. In India, the figure was 26% in 2004, rising to 46% by 2030. In light of the demographic and health changes occurring in China and India, and in response to conferences in 2010 and 2011 to address pop- ulation aging in Asia hosted by five national science academies, includ - ing the Chinese Academy of Social Sciences and Indian National Science Academy, this chapter summarizes selected health results from the World Health Organization’s (WHO) Study on Global AGEing and Adult Health (SAGE) Wave 1 for the two nations with the largest numbers of older persons. Health state and chronic condition patterns are compared and contrasted across the two countries to further improve the understanding

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TABLE 17-1 Population Aged 60 and Older, Life Expectancy (LE) at Birth and Age 60, China and India, 2010 and 2030 2010 2030 LE at LE at Median birth LE at 60 Median birth LE at 60 Country Total, N* Age 60+, N* (%) (yrs) (yrs) Total, N* Age 60+, N* (%) (yrs) (yrs) World 6 895 29.2 759.0 (11.0) 68.9 20.1 8 321 34.1 1 378 73.1 21.6 (16.6) China 1 341 34.5 165.2 (12.3) 74.0 19.9 1 393 42.5 340 77.4 21.6 (24.4) India 1 224 25.1 92.7 (7.6) 65.2 17.4 1 523 31.2 188 70.5 19.0 (12.3) NOTE: * in millions (000,000). SOURCES: Data from United Nations (2011a) and World Health Organization (2008). 417

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418 AGING IN ASIA Communicable, Maternal, Perinatal, and Nutritional Conditions Noncommunicable Diseases Injuries China India 12% 13% 18% 38% 50% 69% Other 100 Unipolar Depressive Disorders 90 Osteoarthritis 80 54 Ischaemic Heart Disease 70 60 Hypertensive Heart Disease 60 Percentage 50 Edentulism 40 Diabetes Mellitus 30 Chronic Obstructive Pulmonary Disease 14 4 20 Cerebrovascular Disease 10 Cataracts 10 6 0 Asthma India China FIGURE 17-1 Percentage of age-standardized Disability-Adjusted Life Years (DALY) by Global Burden of Disease cause categories and percentage of overall noncommunicable disease burden contributed by selected health conditions in China and India, 2004. NOTE: DALY is a health gap measure that combines the time lived with disability and the time lost due to premature mortality. SOURCE: Data from World Health Organization (2008). R02177 Figure 17-1 (combined) vectors, editable

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419 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI of age gradients and gender differences in health outcomes in China and India. The results also describe the approach to measurement of health and chronic diseases used by WHO, to highlight differences in reporting bias across countries and the methods SAGE employs to account for these biases. STUDY METHODS SAGE Wave 1 SAGE is a longitudinal study with nationally representative cohorts of persons aged 50 and older in China, Ghana, India, Mexico, the Russian Federation, and South Africa, with comparison samples of younger adults aged 18–49 years in each country. The study focuses on health and health- related outcomes and their determinants. SAGE was implemented as a face-to-face household interview in China (2008–2010) and India (2007–2008). The samples were drawn from a current frame using a stratified, multistage cluster design so as to allow each household and individual respondent to be assigned a known non- zero probability of selection. Half the interviews in China were completed using a computer-assisted personal interview. In both China and India, the samples were selected to be nationally representative, using multi- stage sampling plans. In China, the survey was carried out in Guandong, Hubei, Jilin, Shaanxi, Shandong, Shanghai, Yunnan, and Zhejiang, cover- ing four regions. The entire sample of India was followed up from house- holds included in SAGE Wave 0 conducted in 2003, and was collected in the states of Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh, and West Bengal. The SAGE survey instruments cover a broad range of topics, includ- ing health and its determinants, disability, subjective well-being, emo- tional and financial well-being, health care utilization, and health sys - tems responsiveness. SAGE has included methodologies to improve cross-population comparability of self-reported health and well-being data through the inclusion of biomarkers, performance tests, anchor- ing vignettes, and additional validation studies. The anchoring vignettes approach included a short story that describes a concrete level of health in a given health domain, such as mobility (King et al., 2004; Salomon, Tandon, and Murray, 2004). Respondents are asked to rate the vignettes using the same questions and response categories that they use to describe their own health state along the same domain.

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420 AGING IN ASIA SAGE2 has also worked to harmonize methods and results with a number of studies, including the U.S. Health and Retirement Study, Chinese Health and Retirement Longitudinal Study, and Longitudinal Aging Study in India. Variables Gender and age were collected, as well as area of residence, educa- tion, marital status, and income and consumption information. Four age groups were used for the analyses, 18–49, 50–59, 60–69, and 70-plus years. Education variables were mapped to an international standard classifi- cation in each country to improve comparability (United Nations Edu - cational, Scientific and Cultural Organization, 2006). Income or wealth quintiles were derived from the household ownership of durable goods, dwelling characteristics (type of floors, walls, and cooking stove), and access to services for the dwelling, such as improved water, sanitation, and type of cooking fuel used. Durable goods included number of chairs, tables, or cars, and if, for example, the household has electricity, a televi - sion, fixed line or mobile phone, and a bucket or washing machine. A total of 21 assets and wealth indicators were included with overlaps and differences in the asset lists by country. The income and wealth data were recoded into dichotomous vari- ables, with the resulting data set being reshaped, as though each house - hold had multiple observations for wealth (each item being one observa - tion). A pure random effect model was fit based on the multiple items per household. The result provides indicator-specific thresholds on the latent income scale such that a household is more likely to respond affirmatively than not when its permanent income exceeds this threshold (Ferguson et al., 2003). This “asset ladder” was generated and is country-specific. Using a Bayesian post-estimation (empirical Bayes) method, households were arranged on the asset ladder, where the raw continuous income estimates are transformed in the final step into quintiles. The survey instrument asked about difficulties in functioning in eight domains of health (mobility, self-care, pain/discomfort, cognition, inter- personal activities, vision, sleep/energy, and affect) and related vignettes, behavioral risk factors (tobacco use, alcohol use, physical inactivity, diet), disability, happiness, chronic conditions (asthma, angina, arthritis, depression, and diabetes), and healthcare utilization. In addition, objec- tively observed performance tests (including grip strength and a four- meter timed walk) and anthropometric measurements (including weight, 2 More information, survey materials and results for SAGE are available at http://www. who.int/healthinfo/systems/sage/en/index.html.

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421 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI height, and waist circumference) were conducted. However, the latter results are not reported in this chapter. OVERALL SELF-REPORTED GENERAL HEALTH A single overall self-rated general health question is used in SAGE: “In general, how would you rate your health today?” with a five-point response scale from very good to very bad. A single general health ques- tion has been shown to be a good predictor of numerous health out- comes, but raises concerns about comparability and inconsistency of results, which is why a multidimensional approach to measuring health state, combined with vignette methodologies, is also used in SAGE (Bowling, 2005; Fayers and Sprangers, 2002; Salomon et al., 2009; Sen, 2002; Subramanian et al., 2009). Health State The 16 questions asked about difficulties in functioning across multi - ple health domains. In this approach to measuring health, an individual’s health state is considered a vector of capacities to function across a parsi - monious set of domains in day-to-day life. As noted above, these domains included mobility, self-care, pain/discomfort, cognition, interpersonal activities, vision, sleep/energy, and affect. Examples of the questions asked about one domain (mobility) are below: Q2002: Overall in the last 30 days, how much difficulty did you have moving around? Q2003: Overall in the last 30 days, how much difficulty did you have in vigorous activities (“vigorous activities” require hard physical effort and cause large increases in breathing or heart rate)? Respondents could answer using a five-point scale: 1 = None; 2 = Mild; 3 = Moderate; 4 = Severe; 5 = Extreme/Cannot do. A single health state score is generated using the Binormal Hierarchical Ordered Probit (BiHOPIT) method. Vignette adjustments of the composite health state scores were used to improve comparability of results across the two countries. The anchoring vignette technique used the same questions and response cat- egories as used for self-assessment. The vignettes are used to fix the level of ability on a given health domain so that when analyzing the results, the variation in categorical responses can be attributed to variation in response category cut-points: that is, at what point a respondent moves from mild to moderate, or severe to extreme on the categorical response scales (Hopkins and King, 2010; Salomon et al., 2004). The additional information provided by the vignette ratings helps to describe the effects of different covariates on two important issues: (1) the level of the underlying latent variable

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422 AGING IN ASIA and (2) the cut-points on the latent variable scale. Scores were normalized and then transformed to a scale of 0 to 100, with zero representing worst health and 100, best health. Chronic Conditions In this chapter, five chronic conditions are summarized. Respondents were asked if they had been diagnosed with any of the following chronic medical conditions: angina, arthritis, asthma, diabetes, or depression. The question format used was, “Have you ever been told by a health profes- sional that you have . . . ?”, or “Have you ever been diagnosed with . . . ?” for each health condition. In addition to self-reported diagnosis, a set of symptomatic questions based on each condition was also asked, except for diabetes where a vali - dated set of symptomatic questions are not currently available. The set of symptoms for each condition was derived from standard instruments, such as the World Mental Health Survey version of the Composite Inter- national Diagnostic Interview for the diagnosis of depression (Kessler and Ustun, 2004) or the Rose questionnaire for angina (Rose, 1962). The pattern of responses to the symptom questions for the four conditions (angina, arthritis, asthma, and depression) was combined with results from a separate diagnostic item probability study implemented in 2003 by WHO (Moussavi et al., 2007). This study used Receiver Operating Characteristic (ROC) analysis to create the symptom-reporting algorithm- based estimates. The method describes the sensitivity and specificity of an instrument, in this case an algorithm combining responses to different symptomatic questions. The ROC curve combines the true-positive rate and the false-positive rate of each algorithm, and the one with the highest area under the curve (“AUC statistic”) is ultimately selected to derive the estimated rates. Respondents were also asked if they were ever treated for each chronic condition they reported, if they had received treatment in the past one year (an estimate of being on longer-term regular therapy for the chronic condi- tion), and if they were currently on treatment at the time of the interview. These two combined give an estimate of healthcare coverage and disease chronicity. Statistical Analyses The analyses focused on sex and age differences in health and chronic conditions. For the single overall general health question, an ordered logistic regression produced proportional odds ratios. A composite health state score in SAGE was generated using the 16 questions asked in eight

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423 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI health domains. A BiHOPIT model, a modification of the Compound Hierarchical Ordered Probit (CHOPIT) (Tandon et al., 2003), was used to take into account the responses to the vignettes that adjusted for response biases across the countries. BiHOPIT and CHOPIT are both generaliza - tions of the ordered probit model, and allow the model cut-points to vary by the same covariates that the ordinal health response variables do. This means that the covariates have a two-way effect, one from the model and one from the cut-points. The latter is driven by the vignette responses. This more analytically intensive approach enables modeling to account for different health expectations, for example based on wealth, and cor- responding health. BiHOPIT is computationally more efficient than CHO- PIT, but provides similar results. The prevalence of each condition was estimated separately and was generated using probability weights based on WHO’s World Standard Population and the UN Statistical Division (Ahmad et al., 2001; United Nations, 2009). Results were age-standardized to improve the validity of comparisons across the two countries. Cases with age, gender, or resi - dence variables missing were dropped from the analyses. STATA 11.2 was used for all analyses. RESULTS The samples included 14,793 respondents in China and 11,230 respon- dents in India (see Table 17-2). The Indian sample included a large num - ber of younger (18–49) women from SAGE Wave 0 added to the Wave 1 sample as part of a nested study to meet the add-on sampling targets and study objectives. Otherwise, the percentages of men and women at older ages were similar in the two countries. A higher percentage of respon- dents in India resided in rural areas as compared to China; the India sample also had a slightly lower percentage in the lowest wealth quintile and slightly higher percentage in the highest wealth quintile. The weighted results are also included in Table 17-2, with more men than women and more than 80% currently married/cohabiting in both countries. China had more older and wealthier adults than India. Overall Health Using the single overall self-rated general health question, male sex, younger age, urban residence, higher wealth, and living in China had sig- nificantly higher log odds of better health (see Table 17-3). Differences in the odds of good health categories, as compared to the lowest level health category, were statistically significant between the countries, as well as

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424 AGING IN ASIA TABLE 17-2 Demographic Characteristics, Weighted and Unweighted Sample Sizesa with Percentage, SAGE China and India, 2007–2010. China India Unweighted Weighted Unweighted Weighted Nb (%) Nb (%) Nb (%) Nb (%) Gender Men 6 883 (46.5) 7 525 (50.9) 4 349 (38.7) 5 714 (50.9) Women 7 910 (53.5) 7 268 (49.1) 6 881 (61.3) 5 516 (49.1) Age Group 18-49 1 636 (11.1) 10 980 (74.2) 4 670 (41.6) 8 448 (75.2) 50–59 5 701 (38.5) 1 713 (11.6) 2 939 (26.2) 1 353 (12.0) 60–69 3 919 (26.5) 1 215 (8.2) 2 235 (19.9) 860 (7.7) 70–79 2 770 (18.7) 709 (4.8) 1 058 (9.4) 445 (4.0) 80+ 773 (5.2) 176 (1.2) 328 (2.9) 126 (1.1) Residence Urban 7 205 (48.7) 7 172 (48.5) 2 845 (25.3) 2 861 (25.5) Rural 7 588 (51.3) 7 621 (51.5) 8 385 (74.7) 8 369 (74.5) Marital Status Never married 279 (1.9) 849 (5.7) 621 (5.5) 1 057 (9.4) Currently married 12 295 (83.1) 13 116 (88.7) 8 715 (77.6) 9 194 (81.9) Cohabiting 27 (0.2) 36 (0.2) — — Separated or divorced 267 (1.8) 225 (1.5) 79 (0.7) 60 (0.5) Widowed 1 911 (12.8) 554 (3.7) 1 814 (16.2) 917 (8.2) Missing 14 (0.1) 15 (0.1) 1 (0.0) 2 (0.0) Wealth Quintile Lowest 2 948 (19.9) 1 531 (10.4)) 2 232 (19.9) 2 565 (22.8) Second 2 949 (19.9) 2 477 (16.8) 2 232 (19.9) 2 431 (21.7) Middle 2 948 (19.9) 2 672 (18.1) 2 232 (19.9) 2 269 (20.2) Fourth 2 947 (19.9) 3 290 (22.2) 2 234 (19.9) 1 887 (16.8) Highest 2 948 (19.9) 4 764 (32.2) 2 229 (19.9) 2 028 (18.1) Missing 53 (0.4) 59 (0.4) 71 (0.6) 50 (0.4) Total 14 793 (100) 14 793 (100) 11 230 (100) 11 230 (100) aSAGE samples are representative of the 50+ population, with a smaller group of younger adults selected for comparison purposes. In India, the sample of 18- to 49-year-old women was supplemented to meet the objectives of a nested study. bIn millions (000,000). SOURCE: Data from SAGE Wave 1. clear differences by gender and gradients by age and income quintiles. Marital status did not significantly impact health reporting. Using the continuous composite health state measure, a decline in health state with increasing age is seen in both countries; however, the level of health is higher at all age points in China as compared to India (see Figure 17-2). The differences were more pronounced between the countries in the ages from about 40 to 60 years, possibly indicating a cohort effect.

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425 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI TABLE 17-3 Ordered Logistic Regression Results for Overall Self- Rated General Health Independent Variables Ordered Logit Standard (referent group) Coefficient Error Gender (male) 1.45* 0.04 Age Group (18−49) 50−59 2.59* 0.09 60−69 3.90* 0.14 70+ 5.97* 0.25 Residence (urban) 1.10* 0.03 Marital Status (married/cohabiting) 1.05 0.03 Wealth Quintile (lowest) Second 0.75* 0.03 Middle 0.65* 0.03 Fourth 0.56* 0.02 Highest 0.40* 0.02 Country (China) 1.25* 0.03 NOTE: * denotes p = 0.00. N = 25640; chi-square (df = 11) = 3169; pseudo R-squared = 0.05. SOURCE: Data from SAGE Wave 1. 100 80 Adjusted Health 60 40 20 0 20 40 60 80 100 Age China Male China Female India Male India Female FIGURE 17-2 Vignette-adjusted health scores by age, gender, and country. SOURCE: Data from SAGE Wave 1.

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427 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI None One Two Plus 100 80 Percentage 60 40 20 0 n en + ia, + + + n en -49 -59 -69 -49 -59 -69 -49 -59 -69 -49 -59 -69 Me Me 70 70 70 70 om om 18 50 60 18 50 60 18 50 60 18 50 60 a, W W in In d ia, a, Ch in In d Ch FIGURE 17-3 Percentage (%) with chronic conditions and co-morbidities by age, gender, and country. SOURCE: Data from SAGE Wave 1. R02177 Figure 17-3 by self-report and 3.6% by symptom reporting, compared to 5.9% and 7.9%, respectively, for women. Women hadeditable of angina than men at all vectors, higher rates age groups. Current and longer-term treatment levels were similar in men scaled for portrait above, landscape below and women and increased with age. India The percentages of men with angina increased with increasing age in both men and women in India. Angina self-report versus symptom- None One Two Plus reporting in India resulted in significantly different rates for men and women. Using the 50–59 age group as an example, the differences by 100 method of ascertainment between men (5.9% by self-report and 12.3% by symptom-reporting) and women (4.0% and 20.4%) in India were large. Using self-report, men had higher rates of angina than women; however, 80 using symptom-reporting, a larger percentage of women had angina than men. In addition, men were more likely to be on longer-term and current (in past two weeks) therapy than women. Percentage 60 40 20

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428 AGING IN ASIA Arthritis Twenty-two percent of Chinese and 25% of Indians aged 50 and older had arthritis based on symptom-reporting. Using this method, rates of arthritis were slightly higher in India than China but lower in India than China using self-report. Percentages receiving current or ongoing thera - pies for arthritis were higher in China than India. China Arthritis increased steadily with age in China for men and women. Both methods of assessing arthritis prevalence produced similar results in both men and women. Rates of arthritis were higher in women (30.3%) than men (20.6%) for the 70-plus age group, but similar in the 18–49 age group (10.3% in women and 8.3% in men). Levels of treatment were again similar for the genders across the different age groups, with slightly more men receiving longer-term treatments in the 70-plus age group. India Levels of arthritis increased with age in men in India, but remained at about 28% across the older three age groups (50–59, 60–69, and 70-plus) in women. The percentage with arthritis for both genders was slightly higher using the symptom-reporting method as compared to self-report. The dif- ferences between men and women were similar using either method. The percentage of men aged 50–59 with arthritis was 19.5%; it was 28.4% for women. Women reported higher levels of ongoing treatment over the past year compared to men. Younger men were more likely to be on current therapy (in the two weeks prior to interview) than younger women. Asthma The percentage with asthma in the 50-plus population was lower in China (3.9%) than in India (11.0%). Asthma increased with age in both countries, and higher levels were reported in India than China at all age groups using either method. Longer-term and current treatment levels were typically higher in India than China for asthma. China Younger (18–49) and older (70-plus) women in China reported lower levels of asthma compared to men in the same age groups. Less than 1%

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429 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI (0.6%) of younger women and 6.0% of older women had asthma as com - pared to 1.4% of younger men and 7.7% of older men. The middle-age groups had similar percentages for both genders. Levels were higher in the symptom-reporting method than the self-report at all ages and in both sexes. The percentages receiving current (more than 20%) and longer-term (more than 30%) treatment were similar in men and women. India The percentage with asthma increased from 4.9% in younger men to 16.9% in older men in India, and from 3.5% in younger women to 11.1% in older women. Men in India reported higher levels of asthma than women across all age groups, based on either self-report or symptom-reporting. Levels of current (close to 30%) and longer-term (over 40%) treatment of asthma were similar in both genders. Diabetes The percentage reporting diabetes was similar in China (6.6%) and India (6.9%) in the 50-plus population. The patterns of diabetes by age and gender between the two countries were more mixed than for any of the other conditions. Diabetes rates increased with age in China but showed somewhat variable patterns in India. Rates are higher in the younger two age groups for Indian men (2.9% in the 18–49 age group and 8.8% in the 50–59 group) compared to Chinese men (1.4% and 3.3%, respectively), but the percentages were similar for older Indians (7.2% in the 60–69 and 8.2% in the 70-plus age groups) and Chinese men (7.5% and 8.4%, respectively). A higher percentage of women than men in China had diabetes, but a lower percentage of women than men in India had diabetes. Current and longer-term treatment rates for diabetes are higher in China than in India. China The percentage with diabetes increased with age for Chinese men and women: from 1.4% of younger men to 8.4% of older men, and from 1.8% of younger women to 10.0% of older women. The percentage of younger men receiving current (94.2%) or longer-term (86.4%) treatment was higher than in younger women (75.7% and 67.6%, respectively); otherwise, the treatment rates were high (more than 80%) and comparable between the genders.

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430 AGING IN ASIA India The age pattern for diabetes was less clear for both men and women in India, with a higher percentage reporting diabetes in the 50–59 age group for men (8.8%) and women (5.5%) than the 60–69 age group for men (7.2%) and women (5.1%). As with asthma, a higher percentage of Indian men reported diabetes as compared to Indian women. Longer- term treatment rates were typically above 70% for men and women and current treatment rates above 50%. Depression Compared with the other conditions, depression showed the largest differences in reporting by country, with much lower reported levels in China than in India. Just 2.0% of Chinese people aged 50-plus reported depression using the CIDI questions, while 19.3% of Indians had depres - sion. The differences in depression by age were small in both countries. Not surprisingly, the levels of depression by symptom-reporting were much higher than by self-report. Undertreatment of depression was rife: the percentage on current or longer-term therapy was less than 20% in each age group for men and women in China and India. China The percentage of women reporting depression was slightly higher than men, with only slight differences in depression by age group. Treat- ment levels were low overall, with higher rates in younger age groups than older age groups. India Depression increased with increasing age in India, with slightly higher percentages in women than men in each age group. For example, 15.8% of men aged 50–59 and 21.2% of men aged 70 and older had depression, as compared to 18.9% and 25.3% of women. Current and ongoing treatment levels were low at all ages and in men and women. Co-Morbidity A substantially larger proportion of Indian respondents reported mul- tiple morbidities than Chinese respondents at each age group for both men and women. For example, 5.7% of Chinese men and 11.9% of Chinese women aged 60–69 reported multiple chronic diseases, compared to 23.3%

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431 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI of Indian men and 24.3% of Indian women in the same age group. The two countries had similar percentages of persons reporting one chronic condition at each age group, for both males and females. DISCUSSION WHO’s SAGE, Wave 1 data provide cross-country comparable health results. Differences in levels of health states are evident when comparing China and India, even after correcting for possible reporting biases using vignette methodologies. A striking result is that health state scores for women aged 50–59 were similar to men aged 60–69, and women aged 60–-69 similar to men aged 70+ in both countries. This finding suggests a decade difference in health levels for women as compared to men. This difference may shrink drastically because of highly skewed gender ratios in both countries and the positive impact of women on men’s longevity and health (Economist, 2010a, 2010b). Given the difference in morbidity, women still live longer than men in both countries. Differences in self-reported health levels between the genders have been well documented but inconsistent (Bath, 2003; Benyamini et al., 2003; Fang et al., 2003; Hairi et al., 2010). Here the differences were significant within the countries, as well as between China and India. Some of this could be due to the differences in composition of the sample in each country, with a higher proportion of rural dwellers in the India sample, more people in the wealthier income quintiles in China, and more people in the poorer income quintiles in India. The reporting of health condi - tions was also different by gender and country, with the biggest differ- ence seen for the reporting of depression. Despite the measures taken in SAGE to overcome reporting biases, the well-documented low reporting of depression in China was also found here, and will prompt a revisit of the measurement technique used for depression for Wave 2 in China in 2012 (Bromet et al., 2011). The declines in overall self-reported health with increasing age were clear using either the single overall general health question or the multi- dimensional approach to measuring health. A more consistent gradient was clearly shown using the continuous measure, and can be decon- structed to identify the determinants driving the differences at different ages, levels of income, and between the two countries. The health status of respondents in China, for both males and females, was consistently better across all ages as compared to respondents in India. The vignette adjust- ment narrows this difference somewhat as compared to the unadjusted results. Respondents in China report fewer difficulties in health domains as compared to respondents in India; however, respondents in India have vignette-rating patterns suggesting that they identify health problems at

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432 AGING IN ASIA lower thresholds, that is, they have stricter standards (detailed results not shown, available from authors). Nonetheless, the differences in health status between China and India are validated by the levels and differ- ences in healthy life expectancy (HALE) at age 60 in China (14.6 years) and India (11.5 years). With increasing longevity in China and India, and the rise in obesity and NCDs so striking that even large multinational corporations are taking note (JWT Intelligence, 2010), the steady decline in health using the health state measures has implications for disability in older age and the compression or expansion of morbidity in these middle- income countries (Gu et al., 2009; Tyagi and Kapoor, 2010). Longitudinal data and improved measurement methods are needed to provide valid measures of health and to disentangle the complexities of health in older age (National Research Council, 2001). SAGE is providing the data and methodologies to address aging and health across a number of countries, including health measures, modifiable risk factors, and health-related outcomes that will form the basis of future studies. It is estimated that 80% of cardiovascular disease deaths occur in lower- and middle-income countries, including China and India (Bonow et al., 2002). Considerable underreporting of the five chronic diseases presented here was demonstrated through comparing self-reports and symptom-reporting. For example, the low levels and under-reporting of mental health conditions and depression in China, through a variety of measurement techniques, is noted (Lee et al., 2006; Parker, Gladstone, and Chee, 2001; Shen et al., 2006). The rate of major depressive disorder in SAGE (2.0%) matches that found in a study in metropolitan China (Shen et al., 2006). The technique used in SAGE to measure this affective dis- order was informed by the World Mental Health Survey Initiative (http:// www.hcp.med.harvard.edu/wmh/). Understanding the limitations of the current estimates and employing methods to improve measurement have further implications for the true burden of NCDs in China and India, and the health systems’ response to chronic conditions. Furthermore, co-morbidity has a large impact on health and well- being (Haagsma et al., 2011; Moussavi, 2007), yet complexities of multiple chronic conditions are understudied and not well understood (Tinetti and Studenski, 2011). In an effort to improve the evidence base for planning and policymaking, SAGE measures are attempting to reduce well-known reporting biases for chronic conditions in epidemiological health studies to improve the understanding about impacts of co-morbidity on health. India currently has much higher levels of people with multiple chronic conditions than China; however, China’s underreporting of conditions, particularly mental health conditions, is well documented. China’s levels of treatment for the different chronic health conditions were generally higher than India, with the highest levels of treatment for

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433 KOWAL, WILLIAMS, JIANG, FAN, AROKIASAMY, and CHATTERJI angina and diabetes. Overall though, and in particular for depression, the healthcare coverage for patients with these NCDs is strikingly low. The levels and treatment of NCDs will need to be tracked over time to assess the burden on governments, the labor force, and healthcare systems. SAGE has incorporated biomarker measurements to independently assess risks for and levels of chronic disease (from height, weight and waist circumference, to glycosylated hemoglobin and C-reactive protein from dried blood spots) and will be reported separately. The concern over NCDs in lower- and middle-income countries was raised in WHO’s Moscow Declaration (World Health Organization, 2011) in April 2011 with specific statements about the huge burden in devel- oping countries. Moving towards universal health coverage (Gwatkin and Ergo, 2010; World Health Organization, 2010a), especially targeting poorer and vulnerable population groups at the outset, and addressing the burden of increasing urbanization (Dobbs and Sankhe, 2010; WHO, 2010b) and the social determinants of health (Marmot, 2009) are mecha - nisms to shift the ongoing health transitions. The topics raised in this chapter are also a timely follow-up to the United Nations General Assem- bly High-level Meeting on Non-communicable Diseases (United Nations, 2011b) held in September 2011. SAGE has many strengths, including nationally representative sam- ples with large numbers in different older age groups, a method for measuring health and related techniques for improving cross-national comparability, and assessment of angina, arthritis, asthma, and depression through self-report and validated symptom-reporting methods (Moussavi et al., 2007; Tandon, Murray, and Shengalia, 2004). While the accuracy of self-reported health conditions is robust in high-income countries and wealthier populations, the same is not true in situations where low access to healthcare and low literacy levels reduce the reliability of self-report (Sen, 2002). In low- and middle-income countries, validated algorithms of disease symptoms offer a method to generate reliable prevalence esti - mates (Rose, 1962; Sembajwe et al., 2010). SAGE has also included bio - marker and anthropometric measurements to help minimize biases in prevalence rates based on self-report and will complement these results in future studies. Increasingly, objective health outcomes, such as grip strength, timed walk, and results from collected blood samples, are used to improve our understanding of subjective or perceived health, although they may also mirror or deviate from the self-reported measures (Cooper et al., 2011). In this case, the results from the blood tests and performance tests are forthcoming from each country team. The need for improved data collection has been noted as an issue for healthcare equity even in high-income countries (Weissman and Hasnain-Wynia, 2011). SAGE

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