High Fasting Plasma Glucose, Diabetes, and Its Risk Factors in the Eastern Mediterranean Region, 1990-2013: Findings From the Global Burden of Disease Study 2013

OBJECTIVE

The prevalence of diabetes in the Eastern Mediterranean Region (EMR) is among the highest in the world. We used findings from the Global Burden of Disease 2013 study to calculate the burden of diabetes in the EMR.

RESEARCH DESIGN AND METHODS

The burden of diabetes and burden attributable to high fasting plasma glucose (HFPG) were calculated for each of the 22 countries in the EMR between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, deaths, and disability-adjusted life years (DALYs).

RESULTS

The diabetes death rate increased by 60.7%, from 12.1 per 100,000 population (95% uncertainty interval [UI]: 11.2-13.2) in 1990 to 19.5 per 100,000 population (95% UI: 17.4-21.5) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 (95% UI: 498.0-698.0) in 1990 to 883.5 per 100,000 population (95% UI: 732.2-1,051.5) in 2013. In 2013, HFPG accounted for 4.9% (95% UI: 4.4-5.3) of DALYs from all causes. Total DALYs from diabetes increased by 148.6% during 1990-2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8% and 53.9%, respectively.

CONCLUSIONS

Our findings show that diabetes causes a major burden in the EMR, which is increasing. Aging and population growth do not fully explain this increase in the diabetes burden. Programs and policies are urgently needed to reduce risk factors for diabetes, increase awareness of the disease, and improve diagnosis and control of diabetes to reduce its burden.

Burden of Diarrhea in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.

Alcohol-attributed disease burden in four Nordic countries: a comparison using the Global Burden of Disease, Injuries and Risk Factors 2013 study

AIMS

(1) To compare alcohol-attributed disease burden in four Nordic countries 1990-2013, by overall disability-adjusted life years (DALYs) and separated by premature mortality [years of life lost (YLL)] and health loss to non-fatal conditions [years lived with disability (YLD)]; (2) to examine whether changes in alcohol consumption informs alcohol-attributed disease burden; and (3) to compare the distribution of disease burden separated by causes.

DESIGN

A comparative risk assessment approach.

SETTING

Sweden, Norway, Denmark and Finland.

PARTICIPANTS

Male and female populations of each country.

MEASUREMENTS

Age-standardized DALYs, YLLs and YLDs per 100 000 with 95% uncertainty intervals (UIs).

FINDINGS

In Finland, with the highest burden over the study period, overall alcohol-attributed DALYs were 1616 per 100 000 in 2013, while in Norway, with the lowest burden, corresponding estimates were 634. DALYs in Denmark were 1246 and in Sweden 788. In Denmark and Finland, changes in consumption generally corresponded to changes in disease burden, but not to the same extent in Sweden and Norway. All countries had a similar disease pattern and the majority of DALYs were due to YLLs (62-76%), mainly from alcohol use disorder, cirrhosis, transport injuries, self-harm and violence. YLDs from alcohol use disorder accounted for 41% and 49% of DALYs in Denmark and Finland compared to 63 and 64% in Norway and Sweden 2013, respectively.

CONCLUSIONS

Finland and Denmark has a higher alcohol-attributed disease burden than Sweden and Norway in the period 1990-2013. Changes in consumption levels in general corresponded to changes in harm in Finland and Denmark, but not in Sweden and Norway for some years. All countries followed a similar pattern. The majority of disability-adjusted life years were due to premature mortality. Alcohol use disorder by non-fatal conditions accounted for a higher proportion of disability-adjusted life years in Norway and Sweden, compared with Finland and Denmark.

Health in times of uncertainty in the eastern Mediterranean region, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

Background

The eastern Mediterranean region is comprised of 22 countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, the United Arab Emirates, and Yemen. Since our Global Burden of Disease Study 2010 (GBD 2010), the region has faced unrest as a result of revolutions, wars, and the so-called Arab uprisings. The objective of this study was to present the burden of diseases, injuries, and risk factors in the eastern Mediterranean region as of 2013.

Methods

GBD 2013 includes an annual assessment covering 188 countries from 1990 to 2013. The study covers 306 diseases and injuries, 1233 sequelae, and 79 risk factors. Our GBD 2013 analyses included the addition of new data through updated systematic reviews and through the contribution of unpublished data sources from collaborators, an updated version of modelling software, and several improvements in our methods. In this systematic analysis, we use data from GBD 2013 to analyse the burden of disease and injuries in the eastern Mediterranean region specifically.

Findings

The leading cause of death in the region in 2013 was ischaemic heart disease (90·3 deaths per 100 000 people), which increased by 17·2% since 1990. However, diarrhoeal diseases were the leading cause of death in Somalia (186·7 deaths per 100 000 people) in 2013, which decreased by 26·9% since 1990. The leading cause of disability-adjusted life-years (DALYs) was ischaemic heart disease for males and lower respiratory infection for females. High blood pressure was the leading risk factor for DALYs in 2013, with an increase of 83·3% since 1990. Risk factors for DALYs varied by country. In low-income countries, childhood wasting was the leading cause of DALYs in Afghanistan, Somalia, and Yemen, whereas unsafe sex was the leading cause in Djibouti. Non-communicable risk factors were the leading cause of DALYs in high-income and middle-income countries in the region. DALY risk factors varied by age, with child and maternal malnutrition affecting the younger age groups (aged 28 days to 4 years), whereas high bodyweight and systolic blood pressure affected older people (aged 60–80 years). The proportion of DALYs attributed to high body-mass index increased from 3·7% to 7·5% between 1990 and 2013. Burden of mental health problems and drug use increased. Most increases in DALYs, especially from non-communicable diseases, were due to population growth. The crises in Egypt, Yemen, Libya, and Syria have resulted in a reduction in life expectancy; life expectancy in Syria would have been 5 years higher than that recorded for females and 6 years higher for males had the crisis not occurred.

Interpretation

Our study shows that the eastern Mediterranean region is going through a crucial health phase. The Arab uprisings and the wars that followed, coupled with ageing and population growth, will have a major impact on the region's health and resources. The region has historically seen improvements in life expectancy and other health indicators, even under stress. However, the current situation will cause deteriorating health conditions for many countries and for many years and will have an impact on the region and the rest of the world. Based on our findings, we call for increased investment in health in the region in addition to reducing the conflicts.

Funding

Bill & Melinda Gates Foundation.

Proceedings of the International Workshop ‘From Global Burden of Disease Studies to National Burden of Disease Surveillance'

I1 Introduction and aims of the workshop

Christa Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich Plass

S1 History, concept, and current results of GBD for Germany

Tom Achoki, Katherine Leach-Kemon, Peter Speyer, William E. Heisel, Emmanuela Gakidou, Theo Vos

S2 Methodology of the GBD 2013 Study–Mortality, Morbidity, Risk-Factors

Mohammad Hossein Forouzanfar

S3 National burden of disease surveillance examples of good practice: the case of Public Health England

Jürgen C. Schmidt

S4 Critical aspects of the burden of disease methodology and country-specific challenges

Claudia E. Stein

S5 Non-communicable disease surveillance in Germany – public health and data challenges

Christa Scheidt-Nave, Elena von der Lippe, Benjamin Barnes, Markus Busch, Nina Buttmann-Schweiger, Judith Fuchs, Christin Heidemann, Klaus Kraywinkel, Enno Nowossadeck, Thomas Ziese

S6 Different approaches in estimating the burden of communicable diseases using the examples of the healthcare associated infections and influenza

Udo Buchholz, Matthias an der Heiden, Tim Eckmanns, Sebastian Haller

S7 Behavioral and environmental attributable risk estimation

Mohammad Hossein Forouzanfar

S8 Environmental Burden of Disease (EBD) in Germany – past achievements and future perspectives

Dietrich Plass, Myriam Tobollik, Dagmar Kallweit, Dirk Wintermeyer

C1 Conclusions of the workshop

Christa Scheidt-Nave, Thomas Ziese, Judith Fuchs, Dietrich Plass

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Young people's health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people's health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors.

METHODS

The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories.

FINDINGS

The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs.

INTERPRETATION

Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people's health risk factors and their determinants in health information systems.

FUNDING

Bill & Melinda Gates Foundation.

Burden of Gastrointestinal and Liver Diseases in Middle East and North Africa: Results of Global Burden of Diseases Study from 1990 to 2010

BACKGROUND Gastrointestinal and liver diseases (GILDs) are major causes of death and disability in Middle East and North Africa (MENA). However, they have different patterns in countries with various geographical, cultural, and socio-economic status. We aimed to compare the burden of GILDs in Iran with its neighboring countries using the results of the Global Burden of Disease (GBD) Study in 2010. METHODS Classic metrics of GBD have been used including: age-standardized rates (ASRs) of death, years of life lost due to premature death (YLL), years of life lost due to disability (YLD), and disability adjusted life years (DALY). All countries neighboring Iran have been selected. In addition, all other countries classified in the MENA region were included. Five major groups of gastrointestinal and hepatic diseases were studied including: infections of gastrointestinal tract, gastrointestinal and pancreatobilliary cancers, acute hepatitis, cirrhosis, and other digestive diseases. RESULTS The overall burden of GILDs is highest in Afghanistan, Pakistan, and Egypt. Diarrheal diseases have been replaced by gastrointestinal cancers and cirrhosis in most countries in the region. However, in a number of countries including Afghanistan, Pakistan, Turkmenistan, Egypt, and Yemen, communicable GILDs are still among top causes of mortality and morbidity in addition to non-communicable GILDs and cancers. These countries are experiencing the double burden. In Iran, burden caused by cancers of stomach and esophagus are considerably higher than other countries. Diseases that are mainly diagnosed in outpatient settings have not been captured by GBD. CONCLUSION Improving the infrastructure of health care system including cancer registries and electronic recording of outpatient care is a necessity for better surveillance of GILDs in MENA. In contrast to expensive treatment, prevention of most GILDs is feasible and inexpensive. The health care systems in the region can be strengthened for prevention and control.

Trend of Gastrointestinal and Liver Diseases in Iran: Results of the Global Burden of Disease Study, 2010

BACKGROUND The general pattern of epidemiologic transition from communicable to noncommunicable diseases is also observed for gastrointestinal and liver diseases (GILD), which constitute a heterogeneous array of causes of death and disability. We aimed to describe the trend of GILD in Iran based on the global burden of disease (GBD2010) study from 1990 to 2010. METHODS The trend of number of deaths, disability, adjusted life years (DALYs) and their age-standardized rates caused by 5 major GILD have been reported. The change in the rankings of major causes of death and DALY has been described as well. RESULTS The age standardized rates of death and DALYs in both sexes have decreased from 1990 to 2010 for most GILD. The most prominent decreases in death rates are observed for diarrheal diseases, gastritis and duodenitis, and peptic ulcer disease. Positive trends are observed for liver cancer, pancreatic cancer, and gall bladder cancer. Diarrheal diseases have retained their 1st rank among children under 5. Among adults, decreased ranks are observed for diarrheal diseases, appendicitis, gastritis and duodenitis, gall bladder diseases, pancreatitis, and all types of cirrhosis. The trends in age standardized rates of DALYs, deaths, and YLLs are negative for almost all GILD, and especially for diarrheal diseases. However, there is no upward or downward trend in rates of years lost due to disability (YLDs) for most diseases. Total numbers of DALYs and deaths due to acute hepatitis C, stomach cancer, and liver cancers are rising. The total DALYs due to overall digestive diseases except cirrhosis and DALYs due to cirrhosis are both somehow stable. No data has been reported for GILD that are mainly diagnosed in outpatient settings, including gastroesophageal reflux disease, irritable bowel syndrome, and non-alcoholic fatty liver disease. CONCLUSION The results of GBD 2010 demonstrate that the rates of most GILD are decreasing in Iran but total DALYs are somehow stable. However, as diseases detected in outpatient settings have not been captured, the burden of GILD seems to be underestimated. Population-based studies at national level are required for accurate reports.

Burden of Gastrointestinal and Liver Diseases in Iran: Estimates Based on the Global Burden of Disease, Injuries, and Risk Factors Study, 2010

BACKGROUND Gastrointestinal and liver diseases (GILD) constitute a noteworthy portion of causes of death and disability in Iran. However, data on their prevalence and burden is sparse in Iran. The Global Burden of Disease (GBD) study in 2010 has provided invaluable comprehensive data on the burden of GILD in Iran. METHODS Estimations of death, years of life lost due to premature death (YLL), years of life lost due to disability (YLD), disability-adjusted life years (DALY), life expectancy, and healthy life expectancy have been reported for 291 diseases, 67 risk factors, 1160 sequelae, for both sexes and 19 age groups, form 1990 to 2010 for 187 countries. In the current paper, 5 major categories of gastrointestinal (GI) and liver diseases have been investigated as follows: GI infectious diseases, GI and liver cancers, liver infections, chronic end stage liver disease, and other digestive diseases. RESULTS Among women, 7.6% of all deaths and 3.9% of all DALYs were due to digestive and liver diseases in 2010. The respective figures in men were 7.8% of deaths and 4.6% of DALYs. The most important cause of death among children under 5 is diarrhea. Among adults between 15 to 49 years old, the main causes of death are GI and liver cancers and cirrhosis, while diarrhea still remains a major cause of DALY. Among adults 50 years and above, GI and liver cancers and cirrhosis are the main causes of both deaths and DALYs. Gastritis and duodenitis, diarrheal diseases, gall bladder and bile duct diseases, acute hepatitis A, peptic ulcer disease, appendicitis, and acute hepatitis A mainly cause disability rather than death. CONCLUSION GBD study provides invaluable source of data on burden of GILD in Iran. However, there exist limitations, namely overestimation of burden of liver cancer and underestimation of the burden of GI diseases that are usually diagnosed in outpatient settings. The collaboration of scientists across the world and specifically those from developing countries is necessary for improving the accuracy of future updates of GBD in these countries.

Health transition in Iran toward chronic diseases based on results of Global Burden of Disease 2010

BACKGROUND

Drawing on the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study, we attempted to investigate the drivers of change in the healthcare system in terms of mortality and morbidity due to diseases, injuries, and risk factors for the two decades from 1990 to 2010.

METHODS

We decomposed trends in mortality, cause of death, years of life lost due to disability, disability-adjusted life years (DALYs), life expectancy, health-adjusted life expectancy, and risk factors into the contribution of total increase in population size, aging of the population, and changes in age-specific and sex-specific rates.

RESULTS

We observed a decrease in age-specific mortality rate for both sexes, with a higher rate for women. The ranking of causes of death and their corresponding number of years of life lost remained unchanged between 1990 and 2010. However, the percentages of change indicate patterns of reduction for most causes, such as ischemic and hemorrhagic stroke, hypertensive heart disease, stomach cancer, lower respiratory infections, and congenital anomalies. The number of years lost due to disability caused by diabetes and drug use disorders has significantly increased in the last two decades. Major causes of DALYs, such as injuries, interpersonal violence, and suicide, showed increasing trends, while rates of communicable diseases, neonatal disorders, and nutritional deficiencies have declined significantly. Life expectancy and health-adjusted life expectancy increased for both sexes by approximately 7 years, with the highest rate of increase pertaining to females over the age 30.

CONCLUSIONS

Time trend information presented in this paper can be used to evaluate problems and policies specific to medical conditions or risk factors. Despite recent improvements, implementing policies to reduce the number of deaths and years of life lost due to road traffic injury remains the highest priority for Iranian policymakers. Immediate action by Iranian researchers is required to match Iran's decreasing mortality rate due to liver and stomach cancers to a rate comparable to the global level. Prevention and treatment plans for mental disorders, such as major depressive disorder, anxiety disorder, and particularly drug use disorders, should be considered in reforms of the health, education, and judiciary systems in Iran.

Population health and burden of disease profile of Iran among 20 countries in the region: from Afghanistan to Qatar and Lebanon

BACKGROUND

Population health and disease profiles are diverse across Iran's neighboring countries. Borrowing the results of the country-level Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), we aim to compare Iran with 19 countries in terms of an important set of population health and disease metrics. These countries include those neighboring Iran and a few other countries from the Middle East and North Africa (MENA) region.

METHODS

We show the pattern of health transition across the comparator countries from 1990 through 2010. We use classic GBD metrics measured for the year 2010 to indicate the rank of Iran among these nations. The metrics include disability-adjusted life years (DALYs), years of life lost as a result of premature death (YLLs), years of life lost due to disability (YLDs), health-adjusted life expectancy (HALE), and age-standardized death rate (ASD).

RESULTS

Considerable and uniform transition from communicable, maternal, neonatal, and nutritional (CMMN) conditions to non-communicable diseases (NCDs) was seen between 1990 and 2010. On average, ischemic heart disease, lower respiratory infections, and road injuries were the three principal causes of YLLs, while low back pain and major depressive disorders were the top causes of YLDs in these countries. Iran ranked 13th in HALE and 12th in ASD. The function of Iran's health care, measured by DALYs, was somewhat in the middle of the HALE spectrum for the comparator countries. This intermediate position becomes rather highlighted when Afghanistan, as outlier, is taken out of the comparison.

CONCLUSION

Effective policies to reduce NCDs need to be formulated and implemented through an integrated health care system. Our comparison shows that Iran can learn from the experience of a number of these countries to devise and execute the required strategies.

Evaluating causes of death and morbidity in Iran, global burden of diseases, injuries, and risk factors study 2010

BACKGROUND

we aimed to recap and highlight the major results of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 by mortality and morbidity to clarify the current health priorities and challenges in Iran.

METHODS

We estimated Iran's mortality and burden of 289 diseases with 67 risk factors and 1160 sequelae, which were used to clinically present each disease and its disability or cause of death. We produced several measures to report health loss and status: all-cause mortality, cause-specific mortality, years of life lost due to death (YLL), healthy years of life lost due to disability (YLD), disability-adjusted life years (DALYs), life expectancy, and healthy life expectancy, for three time periods: 1990, 2005, and 2010.

RESULTS

We found out that life expectancy at birth was 71.6 years in men and 77.8 years in women. Almost 350 thousand deaths occurred in both sexes and all age groups in 2010. In both males and females and all age groups, ischemic heart disease was the main cause of death, claiming about 90 thousand lives. The main contributors to DALYs were: ischemic heart disease (9.1%), low back pain (9.0%), road injuries (7.3%), and unipolar depressive disorders (6.3%). The main causes of death under 5 years of age included: congenital anomalies (22.4%), preterm birth complications (18.3%), and other neonatal disorders (13.5%). The main causes of death among 15 - 49 year olds in both sexes included: injuries (23.6%) and ischemic heart disease (12.7%) The highest rates of YLDs were observed among 70+ year olds for both sexes (27,365 per 100,000), mainly due to low back pain, osteoarthritis, diabetes, falls, and major depressive disorder. The main risk factors to which deaths were attributable among children under 5 years included: suboptimal breast feeding, ambient PM pollution, tobacco smoking, and underweight. The most important risk factors among 15 to 49 year olds were: dietary risks, high blood pressure, high body mass index, physical inactivity, smoking, and ambient PM pollution. The pattern was similar among 50+ year olds.

CONCLUSION

Although non-communicable diseases had the greatest burden in 2010, the challenge of communicable and maternal diseases for health system is not over yet. Diet and physiological risk factors appear to be the most important targets for public health policy in Iran. Moreover, Iranians would greatly benefit from effective strategies to prevent injury and musculoskeletal disorders and expand mental care. Persistent improvement is possible by strengthening the health information system to monitor the population health and evaluate current programs.

The state of health in the Arab world, 1990-2010: an analysis of the burden of diseases, injuries, and risk factors

BACKGROUND

The Arab world has a set of historical, geopolitical, social, cultural, and economic characteristics and has been involved in several wars that have affected the burden of disease. Moreover, financial and human resources vary widely across the region. We aimed to examine the burden of diseases and injuries in the Arab world for 1990, 2005, and 2010 using data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010).

METHODS

We divided the 22 countries of the Arab League into three categories according to their gross national income: low-income countries (LICs; Comoros, Djibouti, Mauritania, Yemen, and Somalia), middle-income countries (MICs; Algeria, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, occupied Palestinian territory, Sudan, Syria, and Tunisia), and high-income countries (HICs; Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates). For the whole Arab world, each income group, and each individual country, we estimated causes of death, disability-adjusted life years (DALYs), DALY-attributable risk factors, years of life lived with disability (YLDs), years of life lost due to premature mortality (YLLs), and life expectancy by age and sex for 1990, 2005, and 2010.

FINDINGS

Ischaemic heart disease was the top cause of death in the Arab world in 2010 (contributing to 14·3% of deaths), replacing lower respiratory infections, which were the leading cause of death in 1990 (11·0%). Lower respiratory infections contributed to the highest proportion of DALYs overall (6·0%), and in female indivduals (6·1%), but ischaemic heart disease was the leading cause of DALYs in male individuals (6·0%). DALYs from non-communicable diseases--especially ischaemic heart disease, mental disorders such as depression and anxiety, musculoskeletal disorders including low back pain and neck pain, diabetes, and cirrhosis--increased since 1990. Major depressive disorder was ranked first as a cause of YLDs in 1990, 2005, and 2010, and lower respiratory infections remained the leading cause of YLLs in 2010 (9·2%). The burden from HIV/AIDS also increased substantially, specifically in LICs and MICs, and road injuries continued to rank highly as a cause of death and DALYs, especially in HICs. Deaths due to suboptimal breastfeeding declined from sixth place in 1990 to tenth place in 2010, and childhood underweight declined from fifth to 11th place.

INTERPRETATION

Since 1990, premature death and disability caused by communicable, newborn, nutritional, and maternal disorders (with the exception of HIV/AIDS) has decreased in the Arab world--although these disorders do still persist in LICs--whereas the burden of non-communicable diseases and injuries has increased. The changes in the burden of disease will challenge already stretched human and financial resources because many Arab countries are now dealing with both non-communicable and infectious diseases. A road map for health in the Arab world is urgently needed.

FUNDING

Bill & Melinda Gates Foundation.

Evaluation of current guthrie TSH cut-off point in Iran congenital hypothyroidism screening program: a cost-effectiveness analysis

BACKGROUND

The threshold of thyroid-stimulating hormone (TSH) in current screening for congenital hypothyroidism (CH) from the heel prick test is 5 mU/l. This study uses cost-effective analysis to evaluate increasing the threshold to minimize false-positive results and recall rates.

METHODS

Cost of screening, diagnosis and treatment, education, and care of mentally retarded patients were gathered from the Ministry of Health State Welfare Organization and Department of Education in Tehran. Screening data were obtained from 34,007 neonates in the Central Health Laboratory of Tehran University of Medical Sciences in 2009. Sensitivity analysis and calculation of confidence interval for incremental costs and effects (gained disability adjusted life years - DALYs) and incremental cost-effectiveness ratios (ICER) were performed by Monte Carlo simulation with Ersatz software.

RESULTS

ICER for screening programs with different TSH cut-off points versus no screening was similar, and approximately -4.5 ± 0.2 thousand US dollars per gained DALY. In the proposed cohort (10,000 neonates), gained DALYs were 316 ± 50 for a cut off point of 5 mU/l, 251 ± 40 for 10 mU/l, 146 ± 23 for 15 mU/l, and 113 ± 18 for a cut-off point of 20 mU/l. Sensitivity analysis showed that the model remained the same when the input parameters were changed.

CONCLUSION

This study demonstrates that the current threshold of TSH in the national CH screening program in terms of cost-effectiveness is the most appropriate threshold. However, more studies are needed to examine new strategies and methods to reduce recall rates and related consequences such as repeated thyroid testing in neonates.

Waist Circumference, Weight, and Body Mass Index of Iranians based on National Non-Communicable Disease Risk Factors Surveillance

BACKGROUND

Obesity is an important and life-threatening disease, associated with different chronic conditions such as cardiovascular disease, diabetes, and dyslipidemia. We sought to address the paucity of information on the trends of anthropometric indices such as weight, waist circumference, and body mass index in the adult population of Iran.

METHODS

We drew upon data from the First Non-communicable Disease Survey in Iran in 2005. In total, 79,611 participants between 20 and 64 years old were selected via the random multistage cluster sampling. The Lambda Median Scale method was applied to construct normal curves for anthropometric indices.

RESULTS

The mean of waist circumference in both genders increased with age and in all the age groups except those between 20 and 24 years old was higher in the women. The mean of body mass index was higher in all the age brackets in the women, but the means of weight and height were higher in the men. The association of theses indices with diabetes, hypertension, and dyslipidemia was stronger in men.

CONCLUSION

The ranges of waist circumference and body mass index in Iranian population are different from those of other countries. The higher body mass index and waist circumference in females and the direct association between obesity and chronic diseases, is advisable that the effects of this phenomenon be fully investigated and due heed be paid to the importance of lifestyle modification.

Patients' Perspectives on Factors that Influence Diabetes Self-Care

BACKGROUND

Although diabetes mellitus is of high concern in Iran, and the level of control is unacceptable, few qualitative studies have been carried out to reflect the experiences of patients on the barriers and motivators to self-care. This study aimed to explore a culturally based experience of Iranian diabetic patients regarding the personal and environmental barriers to and facilitating factors for diabetes self-care.

METHODS

Six focus groups were conducted among type 2 diabetic patients in the Charity Foundation for Special Diseases' diabetes clinic. Purposeful sampling was used. Newly diagnosed patients (less than six months) and all type 1 diabetic patients were excluded. Three focus groups were held on for each sex. A total of 43 patients participated in the study. Frame-work analysis was used to extract the themes from the data.

RESULTS

DATA ANALYSIS SHOWED FIVE MAIN BARRIERS: physical barriers (such as physical effects of diabetes); psychological barriers (such as health beliefs); educational barriers (such as lack of knowledge about diabetes); social barriers (such as group pressure); and care system barriers (such as service availability). Along with the barriers, there were some motivators that the participants mentioned as a stimuli to control their diabetes. They include beliefs about diabetes, perceived responsibility for family, religious beliefs, and the views of significant others.

CONCLUSION

Culturally based interventions are needed to improve diabetes care management in Iran. In addition to personal factors, diabetes health educators should pay attention to the environmental factors when they develop programs.

Decomposing socioeconomic inequality in self-rated health in Tehran

BACKGROUND

Measuring the distribution of health is a part of assessing health system performance. This study aims to estimate health inequality between different socioeconomic groups and its determinants in Tehran, the capital of Iran.

METHODS

Self-rated health (SRH) and demographic characteristics, including gender, age, marital status, educational years, and assets, were measured by structured interviews of 2464 residents of Tehran in 2008. A concentration index was calculated to measure health inequality by economic status. The association of potential determinants and SRH was assessed through multivariate logistic regression. The contribution to concentration index of level of education, marital status and other determining factors was assessed by decomposition.

RESULTS

The mean age of respondents was 41.4 years (SD 17.7) and 49% of them were men. The mean score of SRH status was 3.72 (range: 1-5; SD 0.93). 282 respondents (11.5%) rated their health status as poor or very poor. The concentration index was -0.29 (SE 0.03; p<0.001). Age, marital status, level of education and household economic status were significantly associated with SRH in both the crude and adjusted analyses. The main contributors to inequality in SRH were economic status (47.8%), level of education (29.2%) and age (23.0%).

CONCLUSIONS

Sub-optimal SRH was more in lower than in higher economic status. After controlling for age, the levels of education and household wealth have the greatest contributions to SRH inequality.

First nationwide study of the prevalence of the metabolic syndrome and optimal cutoff points of waist circumference in the Middle East: the national survey of risk factors for noncommunicable diseases of Iran

OBJECTIVE

The purpose of this study was to provide the first national estimate on the prevalence of the metabolic syndrome and its components and the first ethnic-specific cutoff point for waist circumference in the Eastern Mediterranean Region.

RESEARCH DESIGN AND METHODS

This national survey was conducted in 2007 on 3,024 Iranians aged 25-64 years living in urban and rural areas of all 30 provinces in Iran. The metabolic syndrome was defined by different criteria, namely the definition of the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III), the International Diabetes Federation (IDF) criteria, and the modified definition of the NCEP/ATP III (ATP III/American Heart Association [AHA]/National Heart, Lung, and Blood Institute [NHLBI]).

RESULTS

The age-standardized prevalence of the metabolic syndrome was about 34.7% (95% CI 33.1-36.2) based on the ATP III criteria, 37.4% (35.9-39.0%) based on the IDF definition, and 41.6% (40.1-43.2%) based on the ATP III/AHA/NHLBI criteria. By all definitions, the prevalence of the metabolic syndrome was higher in women, in urban areas, and in the 55- to 64-year age-group compared with the prevalence in men, in rural areas, and in other age-groups, respectively. The metabolic syndrome was estimated to affect >11 million Iranians. The optimal cutoff point of waist circumference for predicting at least two other components of the metabolic syndrome as defined by the IDF was 89 cm for men and 91 cm for women.

CONCLUSIONS

The high prevalence of the metabolic syndrome with its considerable burden on the middle-aged population mandates the implementation of national policies for its prevention, notably by tackling obesity. The waist circumference cutoff points obtained can be used in the region.

WHO-ILAR COPCORD Study (Stage 1, Urban Study) in Iran

OBJECTIVE

To find the prevalence of musculoskeletal complaints and rheumatic disorders in Iran.

METHODS

Tehran, with one-ninth of the population of Iran and of mixed ethnic origins, was selected as the field. Subjects were randomly selected from the 22 districts. Interviews were conducted once a week, on the weekend. The 3 phases of stage 1 were done on the same day, in parallel, like the fast-track Community Oriented Program for Control of Rheumatic Diseases (COPCORD).

RESULTS

Four thousand ninety-six houses were visited and 10,291 persons were interviewed. Musculoskeletal complaints during the past 7 days were detected in 41.9% of the interviewed subjects. The distribution was: shoulder 14.5%, wrist 10%, hands and fingers 9.4%, hip 7.1%, knee 25.5%, ankle 9.8%, toes 6.1%, cervical spine 13.4%, and dorsal and lumbar spine 21.7%. Degenerative joint diseases were detected in 16.6% of subjects: cervical spondylosis 1.8%, knee osteoarthritis (OA) 15.3%, hand OA 2.9%, and hip OA 0.32%. Low back pain was detected in 15.4% and soft tissue rheumatism in 4.6%. Inflammatory disorders were rheumatoid arthritis 0.33%, seronegative spondyloarthropathies 0.23%, ankylosing spondylitis 0.12%, systemic lupus erythematosus 0.04%, and Behçet's disease 0.08%. Fibromyalgia was detected in 0.69% and gout in 0.13% of the studied population.

CONCLUSION

The large urban COPCORD study in Iran showed a high prevalence of rheumatic complaints in the population over the age of 15 years, 41.9%. Knee OA and low back pain were the most frequent complaints.

Noninvasive markers of liver fibrosis and inflammation in chronic hepatitis B-virus related liver disease

BACKGROUND/AIMS

Noninvasive markers for predicting significant fibrosis and inflammation have not yet been validated in an unselected group of chronic hepatitis B virus (HBV) carriers. The aim of this study was to create noninvasive models to predict significant fibrosis and inflammation in chronic HBV carriers.

METHODS

A total of 276 (229 HBeAg negative, 47 HBeAg positive) unselected consecutive treatment naïve patients chronically infected with HBV who attended our center over a 36-month period underwent liver biopsy. HBeAg negative patients were randomly divided into two cohorts: training group (N = 130) and validation group (N = 99). HBeAg positive patients were analyzed as a whole without separation. Thirteen parameters were analyzed separately in HBeAg negative and HBeAg positive patients to predict significant fibrosis (Ishak stage >or=3) and inflammation (Ishak grade >or=7).

RESULTS

In HBeAg negative patients significant liver fibrosis was best predicted using the variables HBV DNA levels, alkaline phosphatase, albumin, and platelet counts with an area under ROC curve (AUC) of 0.91 for the training group and 0.85 for the validation group. Using the low cutoff probability of 4.72, significant fibrosis could be excluded with negative predictive value of 99% in the entire cohort, and liver biopsy would have been avoided in 52% of patients. The best model for predicting significant inflammation included the variables age, HBV DNA levels, AST, and albumin with an AUC of 0.93 in the training and 0.82 in the validation group. In HBeAg positive patients no factor could predict accurately stages of liver fibrosis, but the best factor for predicting significant inflammation was AST with an AUC of 0.87.

CONCLUSIONS

Significant hepatic fibrosis and necroinflammation can reliably be predicted using routinely checked tests and HBV DNA levels.

Acute symptoms related to air pollution in urban areas: a study protocol

Background

The harmful effects of urban air pollution on general population in terms of annoying symptoms are not adequately evaluated. This is in contrast to the hospital admissions and short term mortality. The present study protocol is designed to assess the association between the level of exposure to certain ambient air pollutants and a wide range of relevant symptoms. Awareness of the impact of pollution on the population at large will make our estimates of the pertinent covert burden imposed on the society more accurate.

Methods/design

A cross sectional study with spatial analysis for the addresses of the participants was conducted. Data were collected via telephone interviews administered to a representative sample of civilians over age four in the city. Households were selected using random digit dialling procedures and randomization within each household was also performed to select the person to be interviewed. Levels of exposure are quantified by extrapolating the addresses of the study population over the air pollution matrix of the city at the time of the interview and also for different lag times. This information system uses the data from multiple air pollution monitoring stations in conjunction with meteorological data. General linear models are applied for statistical analysis.

Discussion

The important limitations of cross-sectional studies on acute effects of air pollution are personal confounders and measurement error for exposure. A wide range of confounders in this study are controlled for in the statistical analysis. Exposure error may be minimised by employing a validated geographical information system that provides accurate estimates and getting detailed information on locations of individual participants during the day. The widespread operation of open air conditioning systems in the target urban area which brings about excellent mixing of the outdoor and indoor air increases the validity of outdoor pollutants levels that are taken as exposure levels.

Air pollution and hospitalization due to angina pectoris in Tehran, Iran: a time-series study

BACKGROUND

Health effects of air pollution have been studied in many different parts of the world. Although a fairly large number of studies have explored the cardiovascular impacts of air pollution, because of its unique location we studied the association between air pollutants and hospital admissions due to angina pectoris in Tehran for the first time.

METHODS

This is a retrospective time-series study. The variables of the study include the levels of five air pollutants-nitrogen dioxide (NO(2)), carbon monoxide (CO), ozone (O(3)), sulfur dioxide (SO(2)), and particulate matter <10 microm in aerodynamic diameter (PM(10))-as independent variables; daily hospitalizations due to angina pectoris in 25 academic hospitals in Tehran as the dependent variable; and mean daily temperature and humidity, seasonality, time trend, and day of the week as potential confounders. All variables were measured during a 5-year period from 21 March 1996 to 20 March 2001. The data of mean daily levels of NO(2), CO, O(3), SO(2), and PM(10) were collected from one of the stations of Tehran's Air Quality Control Corp. Data were analyzed using Poisson regression models. Relative risks of angina pectoris admissions were calculated for an increase in 1mg/m(3) for CO and 10 microg/m(3) for the other pollutants.

RESULTS

Daily admissions due to angina pectoris were significantly related to the CO level, after controlling for confounder effects. Each unit increase in the CO level caused a 1.00934 increase in the number of admissions (95% CI, 1.00359--1.01512). This association was verified with a lag of 1 day. There was no significant association between the other air pollutants and the number of daily admission due to angina pectoris.

CONCLUSIONS

We found that with increasing levels of the pollutant CO, the number of admissions due to cardiac angina rose. Ischemic heart disease is the leading cause of death in Iran. Air pollution control will reduce the number of this preventable disease and resulting deaths.