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Christopher J L Murray, Ryan M Barber, Kyle J Foreman, Ayşe Abbasoğlu Özgören et al.

Background The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age–sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development. Methods We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time. Findings Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6–6·6), from 65·3 years (65·0–65·6) in 1990 to 71·5 years (71·0–71·9) in 2013, HALE at birth rose by 5·4 years (4·9–5·8), from 56·9 years (54·5–59·1) to 62·3 years (59·7–64·8), total DALYs fell by 3·6% (0·3–7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6–29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non–communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries. Interpretation Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition—in which increasing sociodemographic status brings structured change in disease burden—is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

Salim Yusuf, Philip Joseph, Sumathy Rangarajan, Shofiqul Islam et al.

Background: Global estimates of the impact of common modifiable risk factors on cardiovascular disease (CVD) and mortality are largely based on data from separate studies, using different methodologies. The Prospective Urban Rural Epidemiology (PURE) study overcomes these limitations by using similar methodology to prospectively evaluate the impact of modifiable risk factors on CVD and mortality across 21 countries (spanning five continents) at different economic levels. Methods: In a multi-national, prospective cohort study, we examined associations for 14 potentially modifiable risk factors with mortality and major CVD in 155,722 community-dwelling participants (ages 35–70 years at enrollment) from 21 high-, middle-, or low-income countries (HIC, MIC or LIC) followed for a median of 9·5 years. We describe the prevalence, hazard ratios, and population attributable fractions (PAFs) for CVD and mortality associated with a cluster of behavioural factors (i.e. tobacco, alcohol, diet, physical activity and sodium intake), metabolic factors (i.e. lipids, blood pressure, diabetes, obesity), socioeconomic and psychosocial factors (i.e. education, symptoms of depression), strength, household (solid fuel for cooking) and ambient PM 2·5 air pollution. Findings: Mean age of the population was 50·2 years of age, 58·3% were female, 52·6% were from urban areas, 11·1% from HIC, 65·9% from MIC, and 23·0% from LIC. Over 70% of CVD cases and deaths in the overall cohort were attributed to modifiable risk factors. Metabolic factors were the predominant risk factors for CVD (41·2% of the PAF), with hypertension being the largest (22·3% of the PAF). As a cluster, behavioural risk factors contributed most to deaths (26·3% of the PAF), although the single largest risk factor was a low education level (12.5% of the PAF). Ambient air pollution was associated with 13·9% of the PAF for CVD (although different statistical methods were used for this analysis). In MIC and LIC, the importance of household air pollution, poor diet, low education, and low grip strength were larger compared with HIC. Interpretation: The majority of CVD cases and deaths can be attributed to a small number of common, modifiable risk factors. While some factors have extensive global impacts (e.g. hypertension, education), others (e.g. household air pollution, poor diet) vary by a country’s economic level. Health policies should focus on risk factors that have the greatest effects on averting CVD and death globally, with additional emphasis on risk factors of greatest importance in specific groups of countries.

Gilles R. Dagenais, Darryl P. Leong, Sumathy Rangarajan, Fernando Laņas et al.

BACKGROUND To our knowledge, no previous study has prospectively documented the incidence of common diseases and related mortality in high-income countries (HICs), middle-income countries (MICs), and low-income countries (LICs) with standardised approaches. Such information is key to developing global and context-specific health strategies. In our analysis of the Prospective Urban Rural Epidemiology (PURE) study, we aimed to evaluate differences in the incidence of common diseases, related hospital admissions, and related mortality in a large contemporary cohort of adults from 21 HICs, MICs, and LICs across five continents by use of standardised approaches. METHODS The PURE study is a prospective, population-based cohort study of individuals aged 35-70 years who have been enrolled from 21 countries across five continents. The key outcomes were the incidence of fatal and non-fatal cardiovascular diseases, cancers, injuries, respiratory diseases, and hospital admissions, and we calculated the age-standardised and sex-standardised incidence of these events per 1000 person-years. FINDINGS This analysis assesses the incidence of events in 162 534 participants who were enrolled in the first two phases of the PURE core study, between Jan 6, 2005, and Dec 4, 2016, and who were assessed for a median of 9·5 years (IQR 8·5-10·9). During follow-up, 11 307 (7·0%) participants died, 9329 (5·7%) participants had cardiovascular disease, 5151 (3·2%) participants had a cancer, 4386 (2·7%) participants had injuries requiring hospital admission, 2911 (1·8%) participants had pneumonia, and 1830 (1·1%) participants had chronic obstructive pulmonary disease (COPD). Cardiovascular disease occurred more often in LICs (7·1 cases per 1000 person-years) and in MICs (6·8 cases per 1000 person-years) than in HICs (4·3 cases per 1000 person-years). However, incident cancers, injuries, COPD, and pneumonia were most common in HICs and least common in LICs. Overall mortality rates in LICs (13·3 deaths per 1000 person-years) were double those in MICs (6·9 deaths per 1000 person-years) and four times higher than in HICs (3·4 deaths per 1000 person-years). This pattern of the highest mortality in LICs and the lowest in HICs was observed for all causes of death except cancer, where mortality was similar across country income levels. Cardiovascular disease was the most common cause of deaths overall (40%) but accounted for only 23% of deaths in HICs (vs 41% in MICs and 43% in LICs), despite more cardiovascular disease risk factors (as judged by INTERHEART risk scores) in HICs and the fewest such risk factors in LICs. The ratio of deaths from cardiovascular disease to those from cancer was 0·4 in HICs, 1·3 in MICs, and 3·0 in LICs, and four upper-MICs (Argentina, Chile, Turkey, and Poland) showed ratios similar to the HICs. Rates of first hospital admission and cardiovascular disease medication use were lowest in LICs and highest in HICs. INTERPRETATION Among adults aged 35-70 years, cardiovascular disease is the major cause of mortality globally. However, in HICs and some upper-MICs, deaths from cancer are now more common than those from cardiovascular disease, indicating a transition in the predominant causes of deaths in middle-age. As cardiovascular disease decreases in many countries, mortality from cancer will probably become the leading cause of death. The high mortality in poorer countries is not related to risk factors, but it might be related to poorer access to health care. FUNDING Full funding sources are listed at the end of the paper (see Acknowledgments).

Annika Rosengren, Andrew Smyth, Sumathy Rangarajan, Chinthanie Ramasundarahettige et al.

BACKGROUND: Socioeconomic status is associated with differences in risk factors for cardiovascular disease incidence and outcomes, including mortality. However, it is unclear whether the associations between cardiovascular disease and common measures of socioeconomic status-wealth and education-differ among high-income, middle-income, and low-income countries, and, if so, why these differences exist. We explored the association between education and household wealth and cardiovascular disease and mortality to assess which marker is the stronger predictor of outcomes, and examined whether any differences in cardiovascular disease by socioeconomic status parallel differences in risk factor levels or differences in management. METHODS: In this large-scale prospective cohort study, we recruited adults aged between 35 years and 70 years from 367 urban and 302 rural communities in 20 countries. We collected data on families and households in two questionnaires, and data on cardiovascular risk factors in a third questionnaire, which was supplemented with physical examination. We assessed socioeconomic status using education and a household wealth index. Education was categorised as no or primary school education only, secondary school education, or higher education, defined as completion of trade school, college, or university. Household wealth, calculated at the household level and with household data, was defined by an index on the basis of ownership of assets and housing characteristics. Primary outcomes were major cardiovascular disease (a composite of cardiovascular deaths, strokes, myocardial infarction, and heart failure), cardiovascular mortality, and all-cause mortality. Information on specific events was obtained from participants or their family. FINDINGS: <0·0001). Medical care (eg, management of hypertension, diabetes, and secondary prevention) seemed to play an important part in adverse cardiovascular disease outcomes because such care is likely to be poorer in people with the lowest levels of education compared to those with higher levels of education in low-income countries; however, we observed less marked differences in care based on level of education in middle-income countries and no or minor differences in high-income countries. INTERPRETATION: Although people with a lower level of education in low-income and middle-income countries have higher incidence of and mortality from cardiovascular disease, they have better overall risk factor profiles. However, these individuals have markedly poorer health care. Policies to reduce health inequities globally must include strategies to overcome barriers to care, especially for those with lower levels of education. FUNDING: Full funding sources are listed at the end of the paper (see Acknowledgments).

Colin McCord, Harold P. Freeman

In recent decades mortality rates have declined for both white and nonwhite Americans, but national averages obscure the extremely high mortality rates in many inner-city communities. Using data from the 1980 census and from death certificates in 1979, 1980, and 1981, we examined mortality rates in New York City's Central Harlem health district, where 96 percent of the inhabitants are black and 41 percent live below the poverty line. For Harlem, the age-adjusted rate of mortality from all causes was the highest in New York City, more than double that of U.S. whites and 50 percent higher than that of U.S. blacks. Almost all the excess mortality was among those less than 65 years old. With rates for the white population as the basis for comparison, the standardized (adjusted for age) mortality ratios (SMRs) for deaths under the age of 65 in Harlem were 2.91 for male residents and 2.70 for female residents. The highest ratios were for women 25 to 34 years old (SMR, 6.13) and men 35 to 44 years old (SMR, 5.98). The chief causes of this excess mortality were cardiovascular disease (23.5 percent of the excess deaths; SMR, 2.23), cirrhosis (17.9 percent; SMR, 10.5), homicide (14.9 percent; SMR, 14.2), and neoplasms (12.6 percent; SMR, 1.77). Survival analysis showed that black men in Harlem were less likely to reach the age of 65 than men in Bangladesh. Of the 353 health areas in New York, 54 (with a total population of 650,000) had mortality rates for persons under 65 years old that were at lest twice the expected rate. All but one of these areas of high mortality were predominantly black or Hispanic. We conclude that Harlem and probably other inner-city areas with largely black populations have extremely high mortality rates that justify special consideration analogous to that given to natural-disaster areas.

Louis Niessen, Diwakar Mohan, Jonathan Kweku Akuoku, Andrew J. Mirelman et al.

Five Sustainable Development Goals (SDGs) set targets that relate to the reduction of health inequalities nationally and worldwide. These targets are poverty reduction, health and wellbeing for all, equitable education, gender equality, and reduction of inequalities within and between countries. The interaction between inequalities and health is complex: better economic and educational outcomes for households enhance health, low socioeconomic status leads to chronic ill health, and non-communicable diseases (NCDs) reduce income status of households. NCDs account for most causes of early death and disability worldwide, so it is alarming that strong scientific evidence suggests an increase in the clustering of non-communicable conditions with low socioeconomic status in low-income and middle-income countries since 2000, as previously seen in high-income settings. These conditions include tobacco use, obesity, hypertension, cancer, and diabetes. Strong evidence from 283 studies overwhelmingly supports a positive association between low-income, low socioeconomic status, or low educational status and NCDs. The associations have been differentiated by sex in only four studies. Health is a key driver in the SDGs, and reduction of health inequalities and NCDs should become key in the promotion of the overall SDG agenda. A sustained reduction of general inequalities in income status, education, and gender within and between countries would enhance worldwide equality in health. To end poverty through elimination of its causes, NCD programmes should be included in the development agenda. National programmes should mitigate social and health shocks to protect the poor from events that worsen their frail socioeconomic condition and health status. Programmes related to universal health coverage of NCDs should specifically target susceptible populations, such as elderly people, who are most at risk. Growing inequalities in access to resources for prevention and treatment need to be addressed through improved international regulations across jurisdictions that eliminate the legal and practical barriers in the implementation of non-communicable disease control.

Masayuki Teramoto, Kanyin Liane Ong, Damian Santomauro, A Bhoomadevi et al.

BACKGROUND: For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. METHODS: The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. FINDINGS: Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). INTERPRETATION: Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. FUNDING: Gates Foundation and Bloomberg Philanthropies.

Eugenio Proto, Climent Quintana‐Domeque

We use the UK Household Longitudinal Study and compare pre-COVID-19 pandemic (2017-2019) and during-COVID-19 pandemic data (April 2020) for the same group of individuals to assess and quantify changes in mental health as measured by changes in the GHQ-12 (General Health Questionnaire), among ethnic groups in the UK. We confirm the previously documented average deterioration in mental health for the whole sample of individuals interviewed before and during the COVID-19 pandemic. In addition, we find that the average increase in mental distress varies by ethnicity and gender. Both women -regardless of their ethnicity- and Black, Asian, and minority ethnic (BAME) men experienced a higher average increase in mental distress than White British men, so that the gender gap in mental health increases only among White British individuals. These ethnic-gender specific changes in mental health persist after controlling for demographic and socioeconomic characteristics. Finally, we find some evidence that, among men, Bangladeshi, Indian and Pakistani individuals have experienced the highest average increase in mental distress with respect to White British men.

Roy Burstein, Nathaniel J Henry, Michael L. Collison, Laurie B. Marczak et al.

Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.

Stephanie R Psaki, Jessica C. Seidman, Mark Miller, Michael Gottlieb et al.

BACKGROUND: There is no standardized approach to comparing socioeconomic status (SES) across multiple sites in epidemiological studies. This is particularly problematic when cross-country comparisons are of interest. We sought to develop a simple measure of SES that would perform well across diverse, resource-limited settings. METHODS: A cross-sectional study was conducted with 800 children aged 24 to 60 months across eight resource-limited settings. Parents were asked to respond to a household SES questionnaire, and the height of each child was measured. A statistical analysis was done in two phases. First, the best approach for selecting and weighting household assets as a proxy for wealth was identified. We compared four approaches to measuring wealth: maternal education, principal components analysis, Multidimensional Poverty Index, and a novel variable selection approach based on the use of random forests. Second, the selected wealth measure was combined with other relevant variables to form a more complete measure of household SES. We used child height-for-age Z-score (HAZ) as the outcome of interest. RESULTS: Mean age of study children was 41 months, 52% were boys, and 42% were stunted. Using cross-validation, we found that random forests yielded the lowest prediction error when selecting assets as a measure of household wealth. The final SES index included access to improved water and sanitation, eight selected assets, maternal education, and household income (the WAMI index). A 25% difference in the WAMI index was positively associated with a difference of 0.38 standard deviations in HAZ (95% CI 0.22 to 0.55). CONCLUSIONS: Statistical learning methods such as random forests provide an alternative to principal components analysis in the development of SES scores. Results from this multicountry study demonstrate the validity of a simplified SES index. With further validation, this simplified index may provide a standard approach for SES adjustment across resource-limited settings.

River Chun‐Wai Wong, Chun Shing Kwok, Aditya Narain, Martha Gulati et al.

BACKGROUND: The influence of marital status on the incidence of cardiovascular disease (CVD) and prognosis after CVD is inconclusive. We systematically reviewed the literature to determine how marital status influences CVD and prognosis after CVD. METHODS: A search of MEDLINE and Embase in January 2018 without language restriction was performed to identify studies that evaluated the association between marital status and risk of CVD. Search terms related to both marital status and CVD were used and included studies had to be prospective in design. The outcomes of interest were CVD, coronary heart disease (CHD) or stroke incidence and mortality. We performed random effects meta-analysis stratified by the types of population by calculating odds ratios (OR) and 95% confidence intervals (95% CI). RESULTS: Our analysis included 34 studies with more than two million participants. Compared with married participants, being unmarried (never married, divorced or widowed) was associated with increased odds of CVD (OR 1.42; 95% CI 1.00 to 2.01), CHD (OR 1.16,95% CI 1.04 to 1.28), CHD death (OR 1.43,95% CI 1.28 to 1.60) and stroke death (OR 1.55,95% 1.16 to 2.08). Being divorced was associated with increased odds of CHD (P<0.001) for both men and women while widowers were more likely to develop a stroke (P<0.001). Single men and women with myocardial infarction had increased mortality (OR 1.42, 95% CI 1.14 to 1.76) compared with married participants. CONCLUSIONS: Marital status appears to influence CVD and prognosis after CVD. These findings may suggest that marital status should be considered in the risk assessment for CVD and outcomes of CVD based on marital status merits further investigation.

Masayuki Teramoto, Hmwe Hmwe Kyu, A Bhoomadevi, Mohammad Amin Aalipour et al.

BACKGROUND: Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. METHODS: GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. FINDINGS: The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. INTERPRETATION: We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. FUNDING: Gates Foundation.

Krishna Palipudi, Prakash C. Gupta, Dhirendra Narain Sinha, Linda J. Andes et al.

BACKGROUND: Tobacco use has been identified as the single biggest cause of inequality in morbidity. The objective of this study is to examine the role of social determinants on current tobacco use in thirteen low-and-middle income countries. METHODOLOGY/PRINCIPAL FINDINGS: We used nationally representative data from the Global Adult Tobacco Survey (GATS) conducted during 2008-2010 in 13 low-and-middle income countries: Bangladesh, China, Egypt, India, Mexico, Philippines, Poland, Russian Federation, Thailand, Turkey, Ukraine, Uruguay, and Viet Nam. These surveys provided information on 209,027 respondent's aged 15 years and above and the country datasets were analyzed individually for estimating current tobacco use across various socio-demographic factors (gender, age, place of residence, education, wealth index, and knowledge on harmful effects of smoking). Multiple logistic regression analysis was used to predict the impact of these determinants on current tobacco use status. Current tobacco use was defined as current smoking or use of smokeless tobacco, either daily or occasionally. Former smokers were excluded from the analysis. Adjusted odds ratios for current tobacco use after controlling other cofactors, was significantly higher for males across all countries and for urban areas in eight of the 13 countries. For educational level, the trend was significant in Bangladesh, Egypt, India, Philippines and Thailand demonstrating decreasing prevalence of tobacco use with increasing levels of education. For wealth index, the trend of decreasing prevalence of tobacco use with increasing wealth was significant for Bangladesh, India, Philippines, Thailand, Turkey, Ukraine, Uruguay and Viet Nam. The trend of decreasing prevalence with increasing levels of knowledge on harmful effects of smoking was significant in China, India, Philippines, Poland, Russian Federation, Thailand, Ukraine and Viet Nam. CONCLUSIONS/SIGNIFICANCE: These findings demonstrate a significant but varied role of social determinants on current tobacco use within and across countries.

Michael Marmot

Walk the slums of Dhaka, in Bangladesh, or Accra, in Ghana, and it is not difficult to see how the urban environment of poor countries could be responsible for bad health. Walk north from Manhattan's museum district to Harlem, or east from London's financial district to its old East End, and you will be struck by the contrast between rich and poor, existing cheek by jowl. It is less immediately obvious why there should be health differences between rich and poor areas of the same city. It is even less obvious, from casual inspection of the physical environment, why life . . .

Akanksha A. Marphatia, Gabriel S. Ambale, Alice Reid

In many traditional societies, women's age at marriage acts simultaneously as a gateway to new family roles and the likelihood of producing offspring. However, inadequate attention has previously been given to the broader health and social implications of variability in women's marriage age for public health. Biomedical scientists have primarily been concerned with whether the onset of reproduction occurs before the woman is adequately able to nurture her offspring and maintain her own health. Social scientists have argued that early marriage prevents women from attaining their rightful education, accessing employment and training opportunities, developing social relationships with peers, and participating in civic life. The aim of this review article is to provide comprehensive research evidence on why women's marriage age, independent of age at first childbirth, is a crucial issue for public health. It focuses on data from four South Asian countries, Bangladesh, India, Nepal, and Pakistan, in which marriage is near universal and where a large proportion of women still marry below the United Nations prescribed minimum marriage age of 18 years. Using an integrative perspective, we provide a comprehensive synthesis of the physiological, bio-demographic, and socio-environmental drivers of variable marriage age. We describe the adverse health consequences to mothers and to their offspring of an early age at marriage and of childbearing, which include malnutrition and high rates of morbidity and mortality. We also highlight the complex association of marriage age, educational attainment, and low societal status of women, all of which generate major public health impact. Studies consistently find a public health dividend of increased girls' education for maternal and child nutritional status and health outcomes. Paradoxically, recent relative increases in girls' educational attainment across South Asia have had limited success in delaying marriage age. This evidence suggests that in order for public health initiatives to maximize the health of women and their offspring, they must first address the factors that shape the age at which women marry.

Zunaid Ahsan Karar, Nurul Alam, Peter Kim Streatfield

BACKGROUND: For understanding epidemiological transition, Health and Demographic Surveillance System plays an important role in developing and resource-constraint setup where accurate information on vital events (e.g. births, deaths) and cause of death is not available. METHODS: This study aimed to assess existing level and trend of causes of 18,917 deaths in Matlab, a rural area of Bangladesh, during 1986-2006 and to project future scenarios for selected major causes of death. RESULTS: The results demonstrated that Matlab experienced a massive change in the mortality profile from acute, infectious, and parasitic diseases to non-communicable, degenerative, and chronic diseases during the last 20 years. It also showed that over the period 1986-2006, age-standardized mortality rate (for both sexes) due to diarrhea and dysentery reduced by 86%, respiratory infections by 79%, except for tuberculosis which increased by 173%. On the other hand, during the same period, mortality due to cardiovascular and cerebrovascular diseases increased by a massive 3,527% and malignant neoplasms by 495%, whereas mortality due to chronic obstructive pulmonary disease and injury remained in the similar level (12-13% increase). CONCLUSION: The trend of selected causes of death demonstrates that in next two decades, deaths due to communicable diseases will decline substantially and the mortality due to non-communicable diseases (NCDs) will increase at massive proportions. Despite Matlab's significant advances in socio-demographic indicators, emergence of NCDs and mortality associated with it would be the major cause for concern in the coming years.

Chandrashekhar T Sreeramareddy, Pranil Man Singh Pradhan, Imtiyaz Ali Mir, Shwe Sin

BACKGROUND: In South and Southeast Asian countries, tobacco is consumed in diverse forms, and smoking among women is very low. We aimed to provide national estimates of prevalence and social determinants of smoking and smokeless tobacco use among men and women separately. METHODS: Data from Demographic and Health Surveys completed in nine countries (India, Pakistan, Nepal, Bangladesh, Maldives, Philippines, Cambodia, Indonesia, and Timor Leste) were analyzed. Current smoking or smokeless tobacco use was assessed as response "yes" to one or more of three questions, such as "Do you currently smoke cigarettes?" Weighted country-level prevalence rates for socio-economic subgroups were calculated for smoking and smokeless tobacco use. Binary logistic regression analyses were done on STATA/IC (version 10) by 'svy' command. RESULTS: Prevalence and type of tobacco use among men and women varied across the countries and among socio-economic sub groups. Smoking prevalence was much lower in women than men in all countries. Smoking among men was very high in Indonesia, Maldives, and Bangladesh. Smokeless tobacco (mainly chewable) was used in diverse forms, particularly in India, among both men and women. Chewing tobacco was common in Nepal, Bangladesh, Maldives, and Cambodia. Both smoking and smokeless tobacco use were associated with higher age, lower education, and poverty, but their association with place of residence and marital status was not uniform between men and women across the countries. CONCLUSION: Policymakers should consider type of tobacco consumption and their differentials among various population subgroups to implement country-specific tobacco control policies and target the vulnerable groups. Smokeless tobacco use should also be prioritized in tobacco control efforts.

Mary Ann McColl, Peter M. Carlson, Jane Johnston, Patricia Minnes et al.

Despite considerable attention to community integration and related topics in the past decades, a clear definition of community integration continues to elude researchers and service providers. Common to most discussions of the topic, however, are three ideas: that integration involves relationships with others, independence in one's living situation and activities to fill one's time. The present study sought to expand this conceptualization of community integration by asking people with brain injuries for their own perspectives on community integration. This qualitative study resulted in a definition of community integration consisting of nine indicators: orientation, acceptance, conformity, close and diffuse relationships, living situation, independence, productivity and leisure. These indicators were empirically derived from the text of 116 interviews with people with moderate-severe brain injuries living in the community. Eighteen adults living in supported living programmes were followed for 1 year, to track their evolving definition of integration and the factors they felt were related to integration. The study also showed a general trend toward more positive evaluation over the year, and revealed that positive evaluation was frequently related to meeting new people and freedom from staff supervision. These findings are interpreted in the light of recommendations for community programmes.

Masuma Akter Khanam, Peter Kim Streatfield, Zarina Nahar Kabir, Chengxuan Qiu et al.

Data on multimorbidity among the elderly people in Bangladesh are lacking. This paper reports the prevalence and distribution patterns of multimorbidity among the elderly people in rural Bangladesh. This cross-sectional study was conducted among persons aged ≥60 years in Matlab, Bangladesh. Information on their demographics and literacy was collected through interview in the home. Information about their assets was obtained from a surveillance database. Physicians conducted clinical examinations at a local health centre. Two physicians diagnosed medical conditions, and two senior geriatricians then evaluated the same separately. Multimorbidity was defined as suffering from two or more of nine chronic medical conditions, such as arthritis, stroke, obesity, signs of thyroid hypofunction, obstructive pulmonary symptoms, symptoms of heart failure, impaired vision, hearing impairment, and high blood pressure. The overall prevalence of multimorbidity among the study population was 53.8%, and it was significantly higher among women, illiterates, persons who were single, and persons in the non-poorest quintile. In multivariable logistic regression analyses, female sex and belonging to the non-poorest quintile were independently associated with an increased odds ratio of multimorbidity. The results suggest that the prevalence of multimorbidity is high among the elderly people in rural Bangladesh. Women and the non-poorest group of the elderly people are more likely than men and the poorest people to be affected by multimorbidity. The study sheds new light on the need of primary care for the elderly people with multimorbidity in rural Bangladesh.