Review
Globalisation of inflammatory bowel disease: perspectives from the evolution of inflammatory bowel disease in the UK and China

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Summary

The UK and China provide unique historical perspectives on the evolution of the incidence of inflammatory bowel disease, which might provide insight into its pathogenesis. Historical records from the UK document the emergence of ulcerative colitis during the mid-1800s, which was later followed by the recognition of Crohn's disease in 1932. During the second half of the 20th century, the incidence of inflammatory bowel disease rose dramatically in high-income countries. Globalisation at the turn of the 21st century led to rapid economic development of newly industrialised countries such as China. In China, the modernisation of society was accompanied by the recognition of a sharp rise in the incidence of inflammatory bowel disease. The prevalence of inflammatory bowel disease is expected to continue to rise in high-income countries and is also likely to accelerate in the developing world. An understanding of the shared and different environmental determinants underpinning the pathogenesis of inflammatory bowel disease in western and eastern countries is essential to implement interventions that will blunt the rising global burden of inflammatory bowel disease.

Introduction

Inflammatory bowel disease—including Crohn's disease and ulcerative colitis—describes chronic inflammatory conditions of the gastrointestinal tract that are believed to arise in genetically susceptible individuals exposed to environmental exposures, resulting in an abnormal immune response to the intestinal microbiome.1 More than 200 susceptibility loci have been associated with development of Crohn's disease or ulcerative colitis.2 Many of these genes are involved with the interplay between the gastrointestinal immune systems and the intestinal microbiome.3 Numerous environmental exposures influence the development of inflammatory bowel disease, with evidence suggesting that factors such as smoking and diet might confer a risk through manipulation of the intestinal microbiome.4, 5

Historically, inflammatory bowel disease was described as a disease of white people of European descent who were raised in highly affluent western countries such as the UK, North America, and Australia.6 In the last decade, these notions have been shattered as numerous epidemiological studies have shown that diagnosis of inflammatory bowel disease is not limited by socioeconomic status, race and ethnicity, or geographical borders. This realisation indicates that the disease is not genetically imprinted, but manifests through environmental pressures driven by the westernisation of society—defined as the alteration of society towards increased urbanisation, more hygienic environments, industrialisation, and diets lower in dietary fibre and higher in meat. The major drivers of westernisation need to be understood to develop interventional strategies that can mitigate the development of inflammatory bowel disease and reduce its burden among afflicted individuals.6

The UK represents a prime example of the westernisation of society, additionally offering the possibility of correlating societal changes to the emergence and rise of inflammatory bowel disease in high-income countries. Since the early descriptions of ulcerative colitis in the 1800s, a rich history of case descriptions, hospital records, and modern epidemiological studies have been recorded in the UK.7 This 200-year body of work provides clues to the origin of inflammatory bowel disease. Unfortunately, the environmental drivers of inflammatory bowel disease remain a mystery because the disease has largely been studied in nations where the westernisation of society was established generations ago. The rise of inflammatory bowel disease in newly industrialised countries such as China offers an unprecedented opportunity to essentially travel back in time and study the origin of a disease using 21st-century knowledge and techniques.8, 9, 10 The purpose of this Review is to contrast the evolution of inflammatory bowel disease in the UK and China to understand the common patterns driving its incidence and to prepare for its global rise.

Section snippets

200-year history of inflammatory bowel disease in the UK

Inflammatory bowel disease is considered a relatively new disease. In 1859, Sir Samuel Wilks of England recognised a gastrointestinal disease distinct from infectious gastroenteritis, which was subsequently named ulcerative colitis in 1875.11 By contrast, Crohn, Ginzburg, and Oppenheimer12 first described regional ileitis—now known as Crohn's disease—in 1932. The UK's health system includes a robust historical record of medical conditions through time that can paint a picture of the evolution

100-year history of inflammatory bowel disease in China

China is home to 20% of the world's population. In 2015, approximately 1·4 billion people lived in China. Inflammatory bowel disease was previously thought to be rare in China, but is now rapidly increasing. Incidence and prevalence of inflammatory bowel disease in China is mimicking the rapid evolution of inflammatory bowel disease in the developed world as a result of a rapid society transition culminating in a westernised environment (figure 1).29

In China, the first case of ulcerative

Lessons learned from history

The historical perspective on the rise of inflammatory bowel disease in the UK and China highlights common patterns that give clues into the pathogenesis of the disease. Inflammatory bowel disease emerges in parallel with industrialisation and economic societal advancement. In the UK, ulcerative colitis emerged at the turn of the 19th century and was soon joined by Crohn's disease in the early 20th century. The epidemiological study tracing the incidence of Crohn's disease from 1934 to 1977 in

Contrasting environmental risk factors

Crohn's disease and ulcerative colitis are polyphenotypic diseases. Genetic research has shown that inflammatory bowel disease is associated with 200 susceptible loci.2, 3 However, one of the most commonly identified Crohn's disease loci in white individuals which regulates autophagy—ATG16L1—is not genetically linked to Asians with Crohn's disease.52 By contrast, NOD2 is associated with Crohn's disease in both white individuals living in the UK and Asians residing in China, but different single

Future global evolution of inflammatory bowel disease

The prevalence of inflammatory bowel disease continues to steadily rise in western countries.8 The young age of onset and low mortality of the disease, in conjunction with natural population growth, causes compounding prevalence over time.6 Predictive modelling estimates the prevalence of inflammatory bowel disease in Canada will rise by 2·8% per year from 2015 to 2025, which corresponds to a predicted prevalence of 0·9% of the population living with the disease in 2025.71 Gastroenterology

Conclusion

Over the past 200 years, inflammatory bowel disease has become entrenched in modern society. Although incidence might be beginning to level off, the prevalence of disease continues to rise exponentially. Higher volumes of ageing patients mean western clinics will be challenged with rising burden and cost over the next generation. With increased urbanisation and economic advancement, newly industrialised countries such as China are experiencing a rapid rise in the incidence of inflammatory bowel

Search strategy and selection criteria

We searched MEDLINE and Embase from their origin up to March 31, 2016 for the following keywords: “inflammatory bowel disease”, “Crohn's disease”, “ulcerative colitis”, “China”, “United Kingdom” without language restrictions. We focused on original articles, reviews, and meta-analyses. We included literature and other data sources that we judged to be important and timely contributions to this topic. We also identified articles through searches of our own files. We generated the final reference

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