NCDs and Suicides State-Level Disease Burden Estimates

New evidence released on the trends of non-communicable diseases and suicide over a quarter century for every state of India to inform policy and action

The India State-level Disease Burden Initiative, a joint initiative of the Indian Council of Medical Research (ICMR), Public Health Foundation of India (PHFI), and Institute for Health Metrics and Evaluation (IHME) in collaboration with the Ministry of Health and Family Welfare, Government of India, along with experts and stakeholders associated with over 100 Indian institutions, has released today comprehensive analysis of several major non-communicable diseases (NCDs) and suicide for every state in India, based on analysis of all identifiable epidemiological data from India since 1990 as part of the Global Burden of Disease study. These findings are reported in a series of five research papers published in The Lancet Global Health, The Lancet Public Health, and The Lancet Oncology, along with a commentary in The Lancet.

Commentary and scientific papers published on 12 Sept 2018:

Bhargava B, Paul VK. Informing NCD control efforts in India on the eve of Ayushman Bharat. The Lancet 2018. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32172-X/fulltext

India State-Level Disease Burden Initiative CVD Collaborators. The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990-2016. The Lancet Global Health 2018. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30407-8/fulltext

India State-Level Disease Burden Initiative Diabetes Collaborators. The increasing trend of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016. The Lancet Global Health 2018. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30387-5/fulltext

India State-Level Disease Burden Initiative CRD Collaborators. The burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990-2016. The Lancet Global Health 2018. https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(18)30409-1/fulltext

India State-Level Disease Burden Initiative Cancer Collaborators. The burden of cancers and their variations across the states of India: the Global Burden of Disease Study 1990–2016. The Lancet Oncology 2018. https://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(18)30447-9/fulltext

India State-Level Disease Burden Initiative Suicide Collaborators. Gender differentials and state variations in suicide deaths in India: the Global Burden of Disease Study 1990–2016. The Lancet Public Health 2018. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30138-5/fulltext

Key findings from the cardiovascular diseases paper

Published in The Lancet Global Health:

  • CVDs were responsible for 28% of the total deaths in India in 2016 as compared with 15% in 1990.
  • Among all causes of health loss in India in 2016, ischemic heart disease was the leading individual cause and stroke was the fifth leading cause.
  • Prevalence of ischemic heart disease and stroke has increased by over 50% from 1990 to 2016, with an increase observed in every state of India. The number of ischemic heart disease cases increased from 10 million in 1990 to 24 million in 2016, and of stroke from 3 million to 7 million.
  • Though the prevalence of and health loss due to ischemic heart disease is highest in the more advanced states, the age-standardised increase over time is the highest in the less advanced states.
  • The DALY rate of ischemic heart disease varied by 9-fold, and stroke by 6-fold across the states of India in 2016.
  • Among the total CVD deaths in India in 2016, more than half were in persons aged less than 70 years; this proportion was highest in the less advanced states.
  • With 18% of the global population in 2016, India has 23% of the global disease burden for ischemic heart disease.
  • While the DALY rate of rheumatic heart disease has decreased considerably over time, India still has 38% of the global disease burden for rheumatic heart disease.
  • The prevalence of CVD risk factors such as high blood pressure, high total cholesterol, high fasting plasma glucose, and overweight increased across all states since 1990.
  • Urgent policy action is needed to control the increasing prevalence of ischemic heart disease, stroke and their risk factors in all states of India, with particular attention to the less advanced states where the rate of increase in the highest.

First author: Prof Dorairaj Prabhkaran

Spokespersons for the findings:

  • Prof Dorairaj Prabhkaran and Prof K Srinath Reddy, Public Health Foundation of India, Gurugram
  • Dr Meenakshi Sharma, Dr R S Dhaliwal and Dr D K Shukla, Indian Council of Medical Research, New Delhi
  • Dr Panniyammakal Jeemon and Prof Sivadasanpillai Harikrishnan, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
  • Dr Rajeev Gupta, Rajasthan University of Health Sciences, Jaipur
  • Prof Jeyaraj D Pandian, Christian Medical College, Ludhiana
  • Prof Nitish Naik and Prof Ambuj Roy, All India Institute of Medical Sciences, New Delhi
  • Prof Denis Xavier, St. John’s Medical College, Bengaluru
  • Dr Raman K Kumar, Amrita Institute of Medical Sciences and Research Centre, Cochin
  • Dr Prashant Mathur, Indian Council of Medical Research, Bengaluru

Key findings from the diabetes paper

published in The Lancet Global Health:

  • Among the major non-communicable diseases, diabetes has had the highest increase in disease burden measured in term of DALYs since 1990.
  • The number of persons with diabetes increased from 26 million in 1990 to 65 million in 2016.
  • The prevalence of and DALY rate from diabetes has substantially increased in every state from 1990 to 2016 with 4-fold variation of DALY rate between the states of India in 2016.
  • The age-standardised increase in diabetes prevalence and DALY rate has been the highest in the relatively less developed states.
  • Overweight, the major risk factor of diabetes, has almost doubled in every state of India since 1990.
  • For every 100 overweight persons in 2016, there are twice as many persons with diabetes in India compared to the global average, indicating the higher risk of diabetes in India.
  • These findings could serve as a guide for policy planning to address this public health challenge across the states of India.

First author: Prof Nikhil Tandon

Spokespersons for the findings:

  • Prof Nikhil Tandon and Prof Anand Krishnan, All India Institute of Medical Sciences, New Delhi
  • Dr Tanvir Kaur, Dr R S Dhaliwal and Dr D K Shukla, Indian Council of Medical Research, New Delhi
  • Dr Ranjit M Anjana and Dr Vishwanathan Mohan, Madras Diabetes Research Foundation, Chennai Prof Satinath Mukhopadhyay, Institute of Postgraduate Medical Education and Research, Kolkata
  • Prof Nihal Thomas, Christian Medical College, Vellore
  • Prof Eesh Bhatia, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow
  • Prof Anil Bhansali, Postgraduate Institute of Medical Education and Research, Chandigarh
  • Prof Paturi V Rao, Ramdevrao Hospital, Hyderabad
  • Prof Chittaranjan S Yajnik, King Edward Memorial Hospital Research Centre, Pune
  • Dr Prashant Mathur, Indian Council of Medical Research, Bengaluru
  • Prof Dorairaj Prabhkaran and Prof K Srinath Reddy, Public Health Foundation of India, Gurugram

Key findings from the chronic respiratory diseases paper

published in The Lancet Global Health:

  • India has a disproportionate burden of chronic respiratory diseases, with 32% of the global DALYs or health loss from these diseases.
  • The number of chronic obstructive lung disease cases in India increased from 28 million to 55 million over a 26-year period.
  • The prevalence and age-standardised DALY rate of chronic obstructive lung disease were highest in the relatively less developed north Indian states in 2016, with a 4-fold variation in DALY rate across the states of India.
  • Most states had higher chronic obstructive lung disease DALY rates than what would be expected for their sociodemographic level, with the rates generally highest in several north Indian states.
  • In 2016, the case-fatality rate of chronic obstructive lung disease was two times higher in the less developed Indian states.
  • Air pollution was the leading risk factor for chronic obstructive lung disease in India in 2016, followed by smoking.
  • The time trends in chronic respiratory disease burden in the states of India emphasise the urgency for strategies to prevent and control these diseases, including multi-sectoral efforts to reduce risk factors such as exposure to ambient air pollution.

First author: Dr Sundeep Salvi

Spokespersons for the findings:

  • Dr Sundeep Salvi, Chest Research Foundation, Pune
  • Dr R S Dhaliwal and Dr D K Shukla, Indian Council of Medical Research, New Delhi
  • Prof Anurag Agrawal, CSIR-Institute of Genomics and Integrative Biology, New Delhi
  • Dr Parvaiz A Koul, Sher-i-Kashmir Institute of Medical Sciences, Srinagar
  • Prof P A Mahesh, JSS Medical College, Mysuru
  • Dr Sanjeev Nair, Medical College, Trivandrum
  • Dr Virendra Singh, Asthma Bhavan, Jaipur
  • Prof Ashutosh N Aggarwal, Postgraduate Institute of Medical Education and Research, Chandigarh
  • Prof D J Christopher, Christian Medical College, Vellore
  • Prof Randeep Guleria, All India Institute of Medical Sciences, New Delhi
  • Prof B V Murali Mohan, Narayana Health, Bengaluru
  • Prof Surya K Tripathi, King George’s Medical University, Lucknow
  • Prof Aloke G Ghoshal, National Allergy Asthma Bronchitis Institute, Kolkata
  • Prof Lalit Dandona, Public Health Foundation of India, Gurugram

Key findings from the cancer paper

published in The Lancet Oncology:

  • The proportional contribution of cancers to the total health loss in India has doubled from 1990 to 2016.
  • The crude incidence rate of all cancers in India increased by 28% from 1990 to 2016, with the number of new cancer cases increasing from 548,000 in 1990 to 1.1 million in 2016.
  • The cancers causing the highest health loss in India in 2016 in terms of DALYs were stomach (9%), breast (8%), lung (7%), lip and oral cavity (7%), pharynx other than nasopharynx (7%), colon and rectum (6%), leukaemia (5%), cervical (5%), oesophageal (4%), and brain and nervous system (3%)
  • Over the past quarter century in India, there have been increases in age-standardised incidence rates of some cancers such as breast (41%), prostate (30%), and liver (32%) cancer, and decreases in others such as stomach (40%), lip and oral cavity (6%), cervical (40%), oesophageal cancer (31%), and leukaemia (16%).
  • There are wide variations in the incidence rates of different types of cancers across the states of India in 2016, ranging 3-fold to 12-fold for common cancers such as lip and oral cavity, breast, lung, and stomach.
  • Among females, breast cancer was the first or second leading cause of cancer deaths in most Indian states, while lung cancer was the first or second leading cause of cancer deaths in more than half of the Indian states among males.
  • The age-standardised death rates from all cancers together in 2016 were highest in the north-eastern states of Mizoram, Meghalaya, Arunachal Pradesh, and Assam.
  • Tobacco use was the leading risk factor for cancer health loss in India in 2016.
  • Additional collaborative research efforts are needed to understand the varying drivers of cancer burden in different parts of India.
  • Besides attempts at earlier detection of breast, cervical and oral cancers that is being attempted in India, detection and management of other leading types of cancer should also be enhanced.

Joint first authors: Dr Preet K Dhillon, Dr Prashant Mathur and Dr A Nandakumar

Spokespersons for the findings:

  • Dr Prashant Mathur and Dr A Nandakumar, Indian Council of Medical Research, Bengaluru
  • Dr Preet K Dhillon and Prof Lalit Dandona, Public Health Foundation of India, Gurugram
  • Prof Ravi Mehrotra, Indian Council of Medical Research, Noida
  • Dr D K Shukla, Dr R S Dhaliwal and Dr Tanvir Kaur, Indian Council of Medical Research, New Delhi
  • Prof G K Rath, All India Institute of Medical Sciences, New Delhi
  • Prof Rajaraman Swaminathan, Cancer Institute (WIA), Chennai
  • Prof J S Thakur, Postgraduate Institute of Medical Education and Research, Chandigarh
  • Prof R A Badwe and Prof Rajesh Dikshit, Tata Memorial Centre, Mumbai
  • Dr Amal C Kataki, Dr B Borooah Cancer Institute, Guwahati

Key findings from the suicide paper

published in The Lancet Public Health:

  • Suicide death rate was 1 times higher among women and 1.4 times higher among men in India than the global average in 2016.
  • India had 18% of the global population in 2016, but accounted for 37% of the global suicide deaths among women and 24% among men.
  • Suicide was the leading cause of death in India among 15-39 year-olds in 2016; with 71·2% of the suicide deaths among women and 57·7% among men in this age group.
  • Most states had suicide death rate much higher than would be expected for their sociodemographic level among both women and men.
  • The national level estimates mask the large variations seen in suicide deaths at the state level in India; there was a 10-fold variation between the states in the suicide death rate for women and 6-fold variation for men in 2016.
  • Increasing suicide death rate among the elderly has also been observed over the past quarter century.
  • If the trends observed so far continue, the majority of states in India that have 80% of the country’s population are unlikely to achieve the SDG suicide death rate target of one-third reduction from 2015 to 2030.
  • These time trend data provide guidance for suicide prevention in each state of India, which can be utilised to develop approaches suitable for each state within a national suicide prevention strategy in order to reduce suicide deaths across India.

 First author: Prof Rakhi Dandona

Spokespersons for the findings:

  • Prof Rakhi Dandona, Public Health Foundation of India, Gurugram
  • Dr R S Dhaliwal and Dr D K Shukla, Indian Council of Medical Research, New Delhi
  • Prof Lakshmi Vijayakumar, SNEHA India and Voluntary Health Services, Chennai
  • Prof G Gururaj and Prof Mathew Varghese, National Institute of Mental Health and Neuro Sciences, Bengaluru
  • Prof J S Thakur, Postgraduate Institute of Medical Education and Research, Chandigarh
  • Prof Rajesh Sagar, All India Institute of Medical Sciences, New Delhi

The first set of findings by the India State-Level Disease Burden Initiative on the variations in epidemiological transition across the states of India were presented in a Report released by the Vice-President and Health Minister of India and in a scientific paper published in The Lancet in November 2017:

https://icmr.nic.in/reports?title=&page=1

https://phfi.org/the-work/research/the-india-state-level-disease-burden-initiative/

http://www.healthdata.org/disease-burden-India

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32804-0/fulltext

Glossary of key terms

Age-standardisation: A statistical technique used to compare populations with different age structures, in which the characteristics of the populations are statistically transformed to match those of a reference population. Useful because relative over- or underrepresentation of different age groups can obscure comparisons of age-dependent diseases (e.g., ischaemic heart disease or neonatal disorders) across populations.

Disability-adjusted life-years (DALYs): Years of healthy life lost to premature death and suffering. DALYs are the sum of years of life lost and years lived with disability.

Epidemiological transition level (ETL): Based on the ratio of the number of DALYs in a population due to communicable, maternal, neonatal, and nutritional diseases to the number of DALYs due to non-communicable diseases and injuries together. A decreasing ratio indicates advancing epidemiological transition with an increasing relative burden from non-communicable diseases as compared with communicable, maternal, neonatal, and nutritional diseases.

Socio-demographic Index (SDI): A summary measure that identifies where countries or other geographic areas fall on the spectrum of development. Expressed on a scale of 0 to 1, SDI is a composite average of the rankings of the per capita income, average educational attainment, and fertility rates of all areas in the GBD study.

Uncertainty interval (UI): A range of values that is likely to include the correct estimate of health loss for a given cause. Narrow uncertainty intervals indicate that evidence is strong, while wide uncertainty intervals show that evidence is weaker.

Years of life lost (YLLs): Years of life lost due to premature mortality.

Years lived with disability (YLDs): Measure of years lived with disability due to a disease or injury, weighted for the severity of the disability.