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.
Bibliographical noteFunding Information:
BDG works for AMP, which receives grant-specific support from Crucell, GlaxoSmithKline, Merck, Novartis, Pfizer, and Sanofi Pasteur; however, none of this support is for work related to the present report. MGS received a speaking honorarium from Ethicon for work unrelated to this manuscript. MBS is a paid consultant to Janssen, Pfizer, and Tonix Pharmaceuticals and is also paid for his editorial work on Up-to-Date and on the journal Biological Psychiatry . PJ is supported by a career development fellowship from the Wellcome Trust, Public Health Foundation of India and a Consortium of UK Universities. SIH is funded by a Wellcome Trust Grant. JAS has received grant support from Takeda and Savient Pharmaceuticals and consultant fees from Takeda, Regeneron, Allergan, and Savient. JAS is an executive member of OMERACT, an organisation that received arms-length funding from 36 pharmaceutical companies. KJL was funded by WHO to conduct the review of HSV-2 seroprevalence which informs this study. During the study, KJL received funding from Health Protection Scotland, the National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, and Sexual Health 24: the funding sources had no role in the writing of the manuscript or the decision to submit it for publication. FP-R is a consultant for AstraZeneca, Cimabay, Menarini, and Pfizer, and has received investigation grants from the Spanish Health Ministry, Spanish Foundation for Rheumatology, and Cruces Hospital Rheumatology Association. PJH is principal investigator on vaccines in clinical trials against hookworm and schistosomiasis as well as several other neglected tropical disease vaccines in development. CKi receives research grants from Brazilian public funding agencies Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (FAPERGS). CKi has also received authorship royalties from publishers Artmed and Manole. KBG received the NHMRC-Gustav Nossal scholarship sponsored by CSL in 2012. This award is peer-reviewed through the standard NHMRC peer-review process; CSL played no part in selection of the awardee. HAW, AJF, FJC, and HEE are all affiliated with the Queensland Centre for Mental Health Research, which receives funding from the Queensland Department of Health. DJS has received research grants and consultancy honoraria in the past three years from AMBRF, Biocodex, Cipla, Lundbeck, National Responsible Gambling Foundation, Novartis, Servier, and Sun. DJS is also supported by the Medical Research Council of South Africa. DM reports being on the scientific advisory board of Unilever North America and ad hoc honoraria or consulting from Bunge, Nutrition Impact, Amarin, AstraZeneca, and Life Sciences Research Organization. DAQ was supported by The Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number 5T32HD057822. RAL receives funding through the Farr Institute of Health Informatics Research. The Farr Institute is supported by a consortium of ten UK research organisations: Arthritis Research UK, the British Heart Foundation, Cancer Research UK, the Economic and Social Research Council, the Engineering and Physical Sciences Research Council, the Medical Research Council, the National Institute of Health Research, the National Institute for Social Care and Health Research (Welsh Government), and the Chief Scientist Office (Scottish Government Health Directorates). KeS is affiliated with Grant in Aid for Scientific Research from the Ministry of Education, Culture, Sports and Technology in Japan. JM received a fellowship from the Wellcome Trust. AKau acknowledges that she receives funding from Oklahoma Center for the Advancement of Science and Technology (OCAST) as co-principal investigator. HoC acknowledges that the study was in part supported by the intramural research program of the NIH, the National Institute of Environmental Health Sciences. SS received research support and funding from the NIH and NRF and an honorarium from Pharmaceutical companies and is an employee at the NRF. VC acknowledges the following conflicts of interest: Speaker Bureau Boehringer Ingelheim, BMS Pfizer Advisory board: Boehringer Ingelheim Mindmaze. All other authors declare no competing interests.
On behalf of the GBD 2010 Genitourinary Diseases Expert Group, GR, NoP, and BB would like to acknowledge that their activities within the GBD 2013 have been made on the behalf of the International Society of Nephrology (ISN). ATA received institutional support and grants from the Graduate School of Medical Sciences, University Medical Center Groningen (UMCG). JM has received support from the National Health and Medical Research Council. LLY is also supported by the National Natural Sciences Foundation of China. UOM would like to acknowledge his funding by the German National Cohort Consortium. RB was provided funding support by the Brien Holden Vision Institute. INA would like to acknowledge her funding support from the National Health and Medical Research Council Public Health (Australian) Early Career Fellowship. KD is supported by a Wellcome Trust Fellowship in Public Health and Tropical Medicine ( grant number 099876 ). The funding sources had no role in the writing of the manuscript or the decision to submit it for publication. JS was supported by the National Natural Science Foundation for Young Scholars of China , ( number 81200051 ); Research Fund for the Doctoral Program of Higher Education of China (number 20110071120060); Science Foundation for Young Scholars in Zhongshan Hospital ( number 2012ZSQN04 ); and the Scientific Project for Fudan University ( number 20520133474 ). RB is funded by an Australian National Health and Medical Research Council Senior Principal Research Fellow. TF is grateful to the Swiss National Science Foundation for an Early and an Advanced Postdoc Mobility fellowship (project numbers PBBSP3-146869 and P300P3-154634). SJY and IHO received funding for their work in a grant from the Korean Health Technology R&D Project (Ministry of Health & Welfare, Republic of Korea; grant number HI13C0729). ALT-L was supported by the CGIAR Research Program on Aquatic Agricultural Systems.
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