India makes progress against some risk factors, but disease burden due to high blood pressure, high blood sugar and high cholesterol increase

Fewer Indians are having health loss from ailments associated with childhood undernutrition and unsafe water sources, but more Indians are having health loss from diseases attributable to high blood pressure, high blood sugar and high cholesterol according to a new analysis of 79 risk factors in 188 countries. 

“Global, regional, and national comparative risk assessment of 79 behavioral, environmental and occupational, and metabolic risks or clusters of risks in 188 countries 1990-2013: a systematic analysis for the GBD 2013” examines the extent, pattern, and trends of risk factors’ contributions to death and health loss across countries. Published in The Lancet on September 11, the study was conducted by an international consortium of researchers working on the Global Burden of Disease (GBD) study, including from the Public Health Foundation of India (PHFI), and led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.

The study examines which risk factors contribute to health loss as well as death. Researchers used DALYs, or disability-adjusted life years, to measure overall health loss. One DALY equals one lost year of healthy life. DALYs are measured as the sum of years of life lost due to early death and years of healthy life lost due to disability.

High blood pressure, high blood sugar and household air pollution from solid fuels were estimated to cause 7.8%, 5.2% and 4.7% of the total health loss in India in 2013, respectively. These three risk factors together contributed to 3.3 million premature deaths in India in 2013.  The other major contributors to health loss in India are unsafe water sources, tobacco smoking, alcohol use, high blood cholesterol and outside air pollution.  The contribution of unsafe water sources and poor sanitation, as well as child and maternal undernutrition, to health loss have dropped significantly since 1990, but these are still substantial contributors to health loss in India.

The risk factors examined in the study contributed to a total of 30.8 million deaths worldwide in 2013, up by one-fifth from 25.1 million deaths in 1990. The top risks associated with the deaths among both men and women globally are high blood pressure, smoking, high body mass index, and high fasting plasma glucose. But the greatest cumulative impact on health comes from poor diet. A combination of 14 dietary risk factors contributes to the highest number of deaths worldwide through ailments like ischemic heart disease, stroke, and diabetes. 

  “It is remarkable that the contribution of metabolic risk factors such as high blood pressure, blood sugar and cholesterol, and that of poor diet and alcohol use, to health loss has doubled in India over the past quarter of a century,” said study co-author Dr. Vivekanand Jha, who is the Executive Director of the George Institute for Global Health in. India.  “On the other hand, the contribution of unsafe water and sanitation, and child and maternal undernutrition, to health loss has halved in India but these are still significant causes of disease burden. Parallel to this, air pollution and tobacco smoking continue to be major contributors to health loss in India. The findings from this study provide useful pointers for where policy emphasis is needed to improve population health in India.”

“Metabolic risk factors that include high blood pressure, blood sugar and cholesterol, along with unhealthy dietary habits and smoking are responsible for about 5.2 million premature deaths in India every year,” said Dr. K. Srinath Reddy who is President of PHFI and member of the GBD Scientific Council. “This trend will continue to increase unless effective prevention strategies to address these risk factors are implemented in India rapidly.”

“Since 1990, Improvements in unsafe water sources and sanitation, and in undernutrition of children and mothers, have reduced their contribution to the disease burden in India but these risk factors continue to be significant contributors to ill health. High blood pressure, high blood sugar and indoor air pollution are the leading causes of health loss in India at present,” said Dr. Soumya Swaminathan who is Director-General of the Indian Council of Medical Research. “Further multi-disciplinary and cross-sectoral action is essential in India to minimize the continuing burden caused by these risk factors. Behavioral and social science research will play an increasingly important role."

“Air pollution inside the home due to use of solid fuels as well as outdoor air pollution have continued to be major contributors to ill health and premature deaths in India for over two decades,” said study co-author Dr. Kalpana Balakrishnan, who is Professor and Director of WHO Collaborating Center for Occupational and Environmental Health at Sri Ramachandra University. “The findings from this study highlight the need to develop integrated approaches to reduce air pollution in both rural and urban populations.”

India is part of a global landscape with tremendous regional variations. In much of the Middle East and Latin America, high body mass index is the number-one risk associated with health loss. In South and Southeast Asia, household air pollution is a leading risk, and India also grapples with high risks of unsafe water and childhood undernutrition. Alcohol is the number-two risk in Russia, and smoking is the number-one risk in many high-income countries, including the United Kingdom. The most marked differences are found in sub-Saharan Africa, which, unlike other regions, is dominated by a toxic combination of childhood undernutrition, unsafe water and sanitation, unsafe sex, and alcohol use.
 
The GBD study includes several risk factors – wasting, stunting, unsafe sex, no hand-washing with soap – in its analysis for the first time. Another first is the factoring of HIV into the calculation of intimate partner violence. The addition of wasting, which was associated with about one out of every five deaths in children under 5 in 2013, and stunting, which contributed to 3.5% of under-5 deaths, highlights the importance of child undernutrition as a risk factor. Unsafe sex took a huge toll on global health, contributing to 82% of HIV/AIDS deaths and 94% of HIV/AIDS deaths among 15- to 19-year-olds in 2013. This has a greater impact on South Africa than any other country; 38% of South African deaths were attributed to unsafe sex. The global burden of unsafe sex grew from 1990 and peaked in 2005.

“There’s great potential to improve health by avoiding certain risks like smoking and poor diet as well as tackling environmental risks like air pollution,” said IHME Director Dr. Christopher Murray who leads the GBD study globally. “The challenge for policymakers will be to use what we know to guide prevention efforts and health policies.”

Risks associated with the highest health loss (DALYs) in India for both sexes in 2013

1    High systolic blood pressure
2    High fasting plasma glucose
3    Household air pollution from solid fuels
4    Unsafe water source
5    Smoking
6    Alcohol use
7    High total cholesterol
8    Ambient particulate matter pollution
9    Diet low in fruits
10    High body mass index

Risks associated with the highest health loss (DALYs) in India for men in 2013 

1    High systolic blood pressure
2    Smoking
3    Alcohol use
4    High fasting plasma glucose
5    Household air pollution from solid fuels
6    High total cholesterol
7    Unsafe water source
8    Ambient particulate matter pollution
9    Diet low in fruits
10    Diet high in sodium


Risks associated with the highest health loss (DALYs) in India for women in 2013

1    High systolic blood pressure
2    Unsafe water source
3    Household air pollution from solid fuels
4    High fasting plasma glucose
5    Unsafe sanitation
6    Iron Deficiency
7    Ambient particulate matter pollution
8    High body mass index
9    High total cholesterol
10    Diet low in fruits

Download the study abstract at: http://www.healthdata.org/research-article/global-regional-and-national-comparative-risk-assessment-188-countries-2013 

The full study is available by contacting the Lancet press office at: pressoffice@lancet.com 

The Institute for Health Metrics and Evaluation (IHME) is an independent global health research organization at the University of Washington that provides rigorous and comparable measurement of the world’s most important health problems and evaluates the strategies used to address them. IHME makes this information widely available so that policymakers have the evidence they need to make informed decisions about how to allocate resources to best improve population health. For more information please visit www.healthdata.org