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Nations within a nation: variations in epidemiological transition across the states of India, 1990–2016 in the Global Burden of Disease Study

2017; Elsevier BV; Volume: 390; Issue: 10111 Linguagem: Inglês

10.1016/s0140-6736(17)32804-0

1474-547X

Lalit Dandona, Rakhi Dandona, G Anil Kumar, Deepak Shukla, Vinod K Paul, Kalpana Balakrishnan, Dorairaj Prabhakaran, Nikhil Tandon, Sundeep Salvi, Aditya Prasad Dash, A Nandakumar, Kavumpurathu Raman Thankappan, Sanjay Kumar Agarwal, Prakash Chandra Gupta, Rupinder Singh Dhaliwal, Prashant Mathur, Avula Laxmaiah, Preet K. Dhillon, Subhojit Dey, Manu Raj Mathur, Ashkan Afshin, Christina Fitzmaurice, Emmanuela Gakidou, Peter W. Gething, Simon I Hay, Nicholas J Kassebaum, Hmwe Hmwe Kyu, Stephen S Lim, Mohsen Naghavi, Gregory A. Roth, Jeffrey D Stanaway, Harvey Whiteford, Vineet K Chadha, Sunil D. Khaparde, Raghuram Rao, Kiran Rade, Puneet Dewan, Melissa Furtado, Eliza Dutta, Chris M Varghese, Ravi Mehrotra, P Jambulingam, Tanvir Kaur, Meenakshi Sharma, Shalini Singh, Rashmi Arora, Reeta Rasaily, Ranjit Mohan Anjana, Viswanathan Mohan, Anurag Agrawal, Arvind Chopra, Ashish Jacob Mathew, Deeksha Bhardwaj, Pallavi Muraleedharan, Parul Mutreja, Kelly Bienhoff, Scott Glenn, Rizwan Suliankatchi Abdulkader, Ashutosh N. Aggarwal, Rakesh Aggarwal, Sandra Albert, Atul Ambekar, Monika Arora, Damodar Bachani, Ashish Bavdekar, Gufran Beig, Anil Bhansali, Anurag Bhargava, Eesh Bhatia, Bilali Camara, Devasahayam Jesudas Christopher, Siddharth Kumar Das, Paresh Dave, Sagnik Dey, Aloke Gopal Ghoshal, N Gopalakrishnan, Randeep Guleria, Rajeev Gupta, Subodh S. Gupta, Tarun Gupta, M D Gupte, Gopalkrishna Gururaj, S Harikrishnan, Veena Iyer, Sudhir K. Jain, Panniyammakal Jeemon, Vasna Joshua, Rajni Kant, Anita Kar, Amal Kataki, Kiran Katoch, Tripti Khanna, Ajay Khera, Sanjay Kinra, Parvaiz A Koul, Anand Krishnan, Avdhesh Kumar, Raman Kumar, Rashmi Kumar, Anura V. Kurpad, Laishram Ladusingh, Rakesh Lodha, P A Mahesh, Rajesh Malhotra, Matthews Mathai, Dileep Mavalankar, Murali Mohan Bv, Satinath Mukhopadhyay, Manoj Murhekar, G. V. S. Murthy, Sanjeev Nair, Sreenivas Achuthan Nair, Lipika Nanda, Romi S Nongmaithem, Anu Mary Oommen, Jeyaraj Pandian, Sapan C Pandya, Sreejith Parameswaran, Sanghamitra Pati, Kameshwar Prasad, Narayan Prasad, Manorama Purwar, Asma Rahim, Sree Bhushan Raju, Siddarth Ramji, R. Thara, Goura Kishor Rath, Ambuj Roy, Yogesh Sabde, Kamna Sachdeva, Harsiddha G. Sadhu, Rajesh Sagar, Mari Jeeva Sankar, R. K. Sharma, Anita Shet, Shreya Shirude, Rajan Shukla, Sharvari Shukla, Gagandeep Singh, Narinder Pal Singh, Virendra Singh, Anju Sinha, Dhirendra Narain Sinha, Rakesh Srivastava, A Srividya, Vanita Suri, Rajaraman Swaminathan, PN Sylaja, Babasaheb V. Tandale, JS Thakur, Giang Thu Vu, Nihal Thomas, Srikanth Tripathy, Mathew Varghese, Santosh Varughese, S Venkatesh, Kamalesh Venugopal, Lakshmi Vijayakumar, Denis Xavier, Chittaranjan S. Yajnik, Geevar Zachariah, Sanjay Zodpey, J. V. R. Prasada Rao, Theo Vos, K. Srinath Reddy, Christopher J L Murray, Soumya Swaminathan,

Global Health and Epidemiology

18% of the world's population lives in India, and many states of India have populations similar to those of large countries. Action to effectively improve population health in India requires availability of reliable and comprehensive state-level estimates of disease burden and risk factors over time. Such comprehensive estimates have not been available so far for all major diseases and risk factors. Thus, we aimed to estimate the disease burden and risk factors in every state of India as part of the Global Burden of Disease (GBD) Study 2016.Using all available data sources, the India State-Level Disease Burden Initiative estimated burden (metrics were deaths, disability-adjusted life-years [DALYs], prevalence, incidence, and life expectancy) from 333 disease conditions and injuries and 84 risk factors for each state of India from 1990 to 2016 as part of GBD 2016. We divided the states of India into four epidemiological transition level (ETL) groups on the basis of the ratio of DALYs from communicable, maternal, neonatal, and nutritional diseases (CMNNDs) to those from non-communicable diseases (NCDs) and injuries combined in 2016. We assessed variations in the burden of diseases and risk factors between ETL state groups and between states to inform a more specific health-system response in the states and for India as a whole.DALYs due to NCDs and injuries exceeded those due to CMNNDs in 2003 for India, but this transition had a range of 24 years for the four ETL state groups. The age-standardised DALY rate dropped by 36·2% in India from 1990 to 2016. The numbers of DALYs and DALY rates dropped substantially for most CMNNDs between 1990 and 2016 across all ETL groups, but rates of reduction for CMNNDs were slowest in the low ETL state group. By contrast, numbers of DALYs increased substantially for NCDs in all ETL state groups, and increased significantly for injuries in all ETL state groups except the highest. The all-age prevalence of most leading NCDs increased substantially in India from 1990 to 2016, and a modest decrease was recorded in the age-standardised NCD DALY rates. The major risk factors for NCDs, including high systolic blood pressure, high fasting plasma glucose, high total cholesterol, and high body-mass index, increased from 1990 to 2016, with generally higher levels in higher ETL states; ambient air pollution also increased and was highest in the low ETL group. The incidence rate of the leading causes of injuries also increased from 1990 to 2016. The five leading individual causes of DALYs in India in 2016 were ischaemic heart disease, chronic obstructive pulmonary disease, diarrhoeal diseases, lower respiratory infections, and cerebrovascular disease; and the five leading risk factors for DALYs in 2016 were child and maternal malnutrition, air pollution, dietary risks, high systolic blood pressure, and high fasting plasma glucose. Behind these broad trends many variations existed between the ETL state groups and between states within the ETL groups. Of the ten leading causes of disease burden in India in 2016, five causes had at least a five-times difference between the highest and lowest state-specific DALY rates for individual causes.Per capita disease burden measured as DALY rate has dropped by about a third in India over the past 26 years. However, the magnitude and causes of disease burden and the risk factors vary greatly between the states. The change to dominance of NCDs and injuries over CMNNDs occurred about a quarter century apart in the four ETL state groups. Nevertheless, the burden of some of the leading CMNNDs continues to be very high, especially in the lowest ETL states. This comprehensive mapping of inequalities in disease burden and its causes across the states of India can be a crucial input for more specific health planning for each state as is envisioned by the Government of India's premier think tank, the National Institution for Transforming India, and the National Health Policy 2017.Bill & Melinda Gates Foundation; Indian Council of Medical Research, Department of Health Research, Ministry of Health and Family Welfare, Government of India; and World Bank.