India's escalating burden of non-communicable diseases
Authors: Perianayagam Arokiasamy
Journal: The Lancet Global Health (2018)

India's burden of non-communicable diseases (NCDs) is escalating. NCDs typically present in individuals aged 55 years or older in many developed countries, but their onset occurs in India a decade earlier (≥45 years of age).1WHOIndrayan A. Forecasting vascular disease and associated mortality in India. Burden of Disease in India. National Commission on Macroeconomics and Health. Ministry of Health and Family Welfare, Government of India, New Delhi2015Google Scholar, 2Seigel KR Patel SA Ali MK Non-communicable diseases in South Asia: contemporary perspectives.Br Med Bull. 2014; 111: 31-44Crossref PubMed Scopus (70) Google Scholar Exacerbating this problem are the issues of multiple chronic conditions and the fact many remain undiagnosed due to lack of awareness and insufficient health-care access. At the same time, infectious and parasitic diseases still pose substantial challenges to the public health system in India, resulting in a double burden of disease and an important share of the global burden of disease. Although the NCD burden has grown, India still does not have sufficiently detailed data on NCDs for research and policy purposes. In 2017, as a part of the Global Burden of Diseases, Risk Factors, and Injuries (GBD) Study,3GBD 2016 Causes of Death CollaboratorsGlobal, regional, and national age-sex specific mortality for 264 causes of death, 1980–2016: a systematic analysis for the Global Burden of Disease Study 2016.Lancet. 2017; 390: 1151-1210Summary Full Text Full Text PDF PubMed Scopus (2927) Google Scholar the India State-Level Disease Burden Initiative Collaborators produced an analysis of state variations in epidemiological transition levels (ETL) during 1990–2016.4India State-Level Disease Burden Initiative CollaboratorsNations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the global burden of disease study.Lancet. 2017; 390: 2437-2460Summary Full Text Full Text PDF PubMed Scopus (461) Google Scholar In three separate papers published in The Lancet Global Health, these India GBD Collaborators present additional results of their more detailed exploration of the burden of cardiovascular diseases,5India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar respiratory diseases,6India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden Of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar and diabetes.7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden Of Disease Study 2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar All three papers analyse long-term trends from 1990 to 2016, state variations, and risk factors that more or less coincide with the onset and rise of NCDs in India. To construct long-term trends, the authors use multiple relevant sources of data: the Sample Registration System (SRS), dietary surveys, household surveys, population-based health surveys, government publications, and other published data and reports. For the India disease burden estimates, the authors use the universally accepted DisMOD-MR model, a recommended meta-regression approach. This approach provides data inclusion criteria and methodological steps of calculation: determining crude prevalence rates (of cardiovascular diseases, respiratory diseases, and diabetes) and ETL and computing years lived with disability (YLDs), years of life lost (YLLs), disability-adjusted life years (DALYs), and attributable risk burden of disease. The India GBD Collaborators' success in executing detailed state-level analysis is laudable and represents a substantial improvement on previous attempts to conduct state-level disease burden analysis in India. What new insights do these papers report on the mortality burden of India and its states? They offer a more fine-grained picture of long-term trends of cardiovascular diseases, respiratory diseases, and diabetes mortality in India. The India GBD Collaborators found that leading cardiovascular diseases—ischaemic heart disease and stroke—made the largest contribution to the total burden of mortality in India in 2016, at 28·1% (95% uncertainty interval [UI] 26·5–29·1).5India State-Level Disease Burden Initiative CVD CollaboratorsThe changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30407-8Google Scholar Furthermore, the contribution of cardiovascular diseases to mortality increased by 34·3% (26·6–43·7) from 1990 to 2016, which is not surprising given rapid population ageing and significantly increasing levels of the main risk factors for cardiovascular diseases—high systolic blood pressure, air pollution, high total cholesterol, high fasting plasma glucose, and high body-mass index—during that period. Prevalence of cardiovascular diseases and their share of mortality are predictably higher in the high and higher-middle ETL-level states of Andhra Pradesh, Goa, Himachal Pradesh, Kerala, Maharashtra, Punjab, Tamil Nadu, and West Bengal. When assessing chronic respiratory diseases,6India State-Level Disease Burden Initiative CRD CollaboratorsThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden Of Disease Study 1990–2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30409-1Google Scholar the India GBD Collaborators show that these diseases—mainly chronic obstructive pulmonary disease (COPD) and asthma—make the second largest contribution to the total mortality burden of India, at 10·9% (95% UI 10·0–12·0). The crude prevalence rates of these diseases increased by 29·2% (27·9–30·4) for COPD and 8·6% (6·1–11·4) for asthma in the studied period. The study reports higher crude COPD prevalence in the northern states of Jammu and Kashmir, Himachal Pradesh, Uttarakhand, and Haryana, which were a mix of lower-middle, higher-middle, and high ETL groups. Finally, the diabetes analysis7India State-Level Disease Burden Initiative Diabetes CollaboratorsThe increasing burden of diabetes and variations among the states of India: the Global Burden Of Disease Study 2016.Lancet Glob Health. 2018; (published online Sept 12.)http://dx.doi.org/10.1016/S2214-109X(18)30387-5Google Scholar shows that diabetes contributes 3·1% (95% UI 2·9–3·3) of the total mortality burden, with slightly higher contributions among women (3·4%, 95% UI 3·0–3·7) than men (2·9%, 2·7–3·0). The age-standardised diabetes prevalence rose by 29·7% (26·5–32·6) in 1990–2016. Diabetes is especially prevalent in southern states. What are the key takeaways from these three comprehensive analyses? The three leading causes of mortality—cardiovascular diseases, respiratory diseases, and diabetes—together account for a substantial proportion of total deaths in India in 2016 with considerable cross-state variation. In absolute terms, cardiovascular diseases, respiratory diseases, and diabetes kill around 4 million Indians annually (as in 2016), and most of these deaths are premature, occurring among Indians aged 30–70 years. Furthermore, they represent some of the world's largest health losses, with enormous policy ramifications. India's Ministry of Health and Family Welfare is making efforts to establish policies and intervention strategies to prevent and control NCDs. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke, launched in 2010, and the National Programme for Health Care of Elderly, launched in 2010–11, are examples of such efforts. However, these results are not free from data constraints and limitations. First, the crude prevalence rates of cardiovascular diseases, COPD, asthma, and diabetes are presumably population-based self-reports. Self-reported health data fail to capture those with undiagnosed conditions, who represent a significant proportion of people with NCDs in India.8Arokiasamy P Uttamacharya Kowal P et al.Chronic noncommunicable diseases in 6 low- and middle-income countries: findings from wave 1 of the World Health Organization's study on global ageing and adult health (SAGE).Am J Epidemiol. 2017; 185: 414-428Crossref PubMed Scopus (128) Google Scholar, 9Arokiasamy P Bloom DE Lee J O'Brien J Parasuraman S Uttamacharya Biological markers and the health of older Indians: results from the 2010 LASI pilot.Econ Polit Wkly. 2016; 51: 47-58Google Scholar Furthermore, self-reports lack comparability over time, across data sources, and nationally and internationally. Potential future improvements in survey data quality could alter some if not many of the findings: results differentiated by age and sex and even the total estimates could change, and the true burden of NCDs could be higher than that estimated. Therefore, India needs to come up with a major policy agenda to tackle the escalating burden of NCDs. I declare no competing interests. The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016The burden from the leading cardiovascular diseases in India—ischaemic heart disease and stroke—varies widely between the states. Their increasing prevalence and that of several major risk factors in every part of India, especially the highest increase in the prevalence of ischaemic heart disease in the less developed low ETL states, indicates the need for urgent policy and health system response appropriate for the situation in each state. Full-Text PDF Open AccessThe increasing burden of diabetes and variations among the states of India: the Global Burden of Disease Study 1990–2016The increase in health loss from diabetes since 1990 in India is the highest among major non-communicable diseases. With this increase observed in every state of the country, and the relative rate of increase highest in several less developed low ETL states, policy action that takes these state-level differences into account is needed urgently to control this potentially explosive public health situation. Full-Text PDF Open AccessThe burden of chronic respiratory diseases and their heterogeneity across the states of India: the Global Burden of Disease Study 1990–2016India has a disproportionately high burden of chronic respiratory diseases. The increasing contribution of these diseases to the overall disease burden across India and the high rate of health loss from them, especially in the less developed low ETL states, highlights the need for focused policy interventions to address this significant cause of disease burden in India. Full-Text PDF Open Access