Diabetes mellitus and chronic kidney disease in the Eastern Mediterranean Region: findings from the Global Burden of Disease 2015 study
Abstract
Objectives
We used findings from the Global Burden of Disease 2015 study to update our previous publication on the burden of diabetes and chronic kidney disease due to diabetes (CKD-DM) during 1990–2015.
Methods
We extracted GBD 2015 estimates for prevalence, mortality, and disability-adjusted life years (DALYs) of diabetes (including burden of low vision due to diabetes, neuropathy, and amputations and CKD-DM for 22 countries of the EMR from the GBD visualization tools.
Results
In 2015, 135,230 (95% UI 123,034–148,184) individuals died from diabetes and 16,470 (95% UI 13,977–18,961) from CKD-DM, 216 and 179% increases, respectively, compared to 1990. The total number of people with diabetes was 42.3 million (95% UI 38.6–46.4 million) in 2015. DALY rates of diabetes in 2015 were significantly higher than the expected rates based on Socio-demographic Index (SDI).
Conclusions
Our study showed a large and increasing burden of diabetes in the region. There is an urgency in dealing with diabetes and its consequences, and these efforts should be at the forefront of health prevention and promotion.
Keywords
Diabetes Chronic kidney disease Burden of disease Eastern Mediterranean RegionIntroduction
Diabetes is an important cause of disability and death around the world and is a major risk factor for other diseases (GBD 2015 DALYs/HALE Collaborators 2016; Moradi-Lakeh et al. 2016b). The World Health Organization Eastern Mediterranean Region (EMR) has the highest age-standardized rate of disability-adjusted life years (DALYs) from diabetes (GBD 2015 DALYs/HALE Collaborators 2016; Institute for Health Metrics and Evaluation 2016). Analysis of the global burden of disease (GBD) 2013 study showed that the increasing burden of diabetes in the EMR in recent decades is beyond that expected based on the demographic changes of population growth and aging, and is also due to increases in age-specific DALY rates (Mokdad et al. 2016; Moradi-Lakeh et al. 2016b). This increasing trend has been reported by other studies as well (Sozmen et al. 2015) and is mainly because of the epidemics of obesity and physical inactivity as the main risk factors for type 2 diabetes mellitus (Mokdad et al. 2014, 2016; Sozmen et al. 2015).
Tracking of personal health spending in the United States shows that diabetes imposes the highest health care spending (Dieleman et al. 2016). International Diabetes Federation estimated US $17.1–27.7 billion is spent annually in the Middle East and North Africa on diabetes, an amount which is expected to double by 2040 (IDF 2015). In this report, we present estimates of the burden of diabetes mellitus and chronic kidney disease due to diabetes mellitus (CKD-DM) from the Global Burden of Disease 2015 study.
Methods
GBD 2015 covers 195 countries, 21 regions, and seven super-regions from 1990 to 2015 for 315 diseases and injuries, 2619 sequelae, and 79 risk factors by age and sex. Detailed descriptions of GBD 2015 methodology and specific diabetes mellitus methodology have been provided elsewhere (GBD 2015 DALYs/HALE Collaborators 2016; GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016; Duncan et al. 2017; Moradi-Lakeh et al. 2016b; GBD 2015 Causes of Death Collaborators 2016).
We evaluated the burden of diabetes and CKD-DM in 22 EMR countries: Afghanistan, Bahrain, Djibouti, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Pakistan, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates (UAE) and Yemen. The total population of the EMR is over 580 million people.
Diabetes mellitus in GBD is considered both as a disease and a metabolic risk factor. In this study, we focus on its burden as a disease. The burden of uncomplicated diabetes, vision loss caused by diabetes (moderate low vision, severe low vision, and blindness), diabetic neuropathy, diabetic foot due to neuropathy, and amputation are included in the burden of diabetes (Duncan et al. 2017; Moradi-Lakeh et al. 2016b). Also, we estimated burden of CKD-DM as part of the chronic kidney disease burden.
All-cause mortality envelopes (total number of deaths) were first estimated for each country during the period of 1990–2015. For this purpose, we used all accessible data from vital registration systems, sibling history surveys, sample registration data, and household recall of deaths. We extracted causes of death data from the same sources, as well as available verbal autopsies, and then used cause of death ensemble modeling to estimate the number of deaths from diabetes and CKD-DM by age, sex, country, and year (GBD 2015 DALYs/HALE Collaborators 2016; Duncan et al. 2017; Moradi-Lakeh et al. 2016b). In this approach, a large variety of possible models are explored to estimate trends in causes of death. Possible models are identified based on a covariate selection algorithm that yields several plausible combinations of covariates; they are then run through different model classes, including mixed effects linear models and spatiotemporal Gaussian process regression models for cause fractions and death rates. All models for each cause of death are then assessed using out-of-sample predictive validity and combined into an ensemble with optimal out-of-sample predictive performance (Foreman et al. 2012).
We updated our previous systematic review for the GBD study separately for non-fatal outcomes of diabetes mellitus and CKD-DM. Data on incidence, prevalence, and excess mortality were extracted from data sources. We assumed no remission for diabetes. Bayesian meta-regression analysis through DisMod-MR 2.1 was used for disease modeling. Model-based epidemiological estimates in combination with disability weights were used to calculate cause-specific years lived with disability (YLDs) for each age, sex, location, and year. DALYs were calculated through summation of years of life lost (YLLs) and YLDs (GBD 2015 DALYs/HALE Collaborators 2016; GBD 2015 Disease and Injury Incidence and Prevalence Collaborators 2016).
In GBD 2015, we used country-location estimates of a composite Socio-demographic Index (SDI) based on the geometric mean of income per capita, average years of schooling in individuals older than 15 years, and total fertility rate. The numbers were rescaled to a number between zero and one, based on highest and lowest country-location measures. In 2015, SDI had a range between 0.1506 (Somalia) and 0.8747 (United Arab Emirates) in the EMR. We used SDI to estimate expected burden for each disease based on the demographic and social conditions of each country in each year (GBD 2015 DALYs/HALE Collaborators 2016).
We report 95% uncertainty intervals (UI) for each estimate, including rates, numbers of deaths, and DALYs. We estimated UIs by taking 1000 samples from the posterior distribution of each quantity and using the 25th and 975th-ordered draw of the uncertainty distribution.
Results
Trend of number of deaths, all-age and age-standardized mortality of diabetes mellitus (DM) and chronic kidney disease due to diabetes mellitus (CKD-DM). (Global Burden of Disease 2015 study, Eastern Mediterranean Region, 1990–2015)
Number and rate of prevalence cases of diabetes mellitus(DM) and chronic kidney disease due to diabetes mellitus(CKD-DM) in the Eastern Mediterranean Region, 2015. (Global Burden of Disease 2015 study, Eastern Mediterranean Region, 2015)
Total DALYs from diabetes were 6,708,539 (95% UI 5,451,990–8,148,834) in 2015 and 2,285,117 (95% UI 1,892,297–2,792,790) in 1990. For CKD-DM, total DALYs were 568,351 (95% UI 490,064–653,946) in 2015 and 234,194 (95% UI: 201,911–272,837) in 1990. In 2015, the proportion of YLLs to DALYs was 45% for diabetes mellitus and 73% for CKD-DM.
Rates of disability-adjusted life years of diabetes mellitus per 100,000 population in the World Health Organization regions. AFR African region, EMR Eastern Mediterranean region, EUR European region, AMR Region of Americas, SEAR Southeast Asia region, WPR Western Pacific region. (Global Burden of Disease 2015 study, World Health Organization regions, 2015)
Rates of disability-adjusted life years of chronic kidney disease due to diabetes mellitus per 100,000 population in the World Health Organization regions. AFR African region, EMR Eastern Mediterranean region, EUR European region, AMR Region of Americas, SEAR Southeast Asia region, WPR Western Pacific region. (Global Burden of Disease 2015 study, World Health Organization regions, 2015)
Disability-adjusted life years (DALYs) of diabetes mellitus and chronic kidney disease due to diabetes mellitus in the Eastern Mediterranean Region countries, 2015
Location | Chronic kidney disease due to diabetes mellitus | Diabetes mellitus | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
Male | Female | Male | Female | |||||||||
Rate | 95% UI | Rate | 95% UI | Rate | 95% UI | Rate | 95% UI | |||||
Afghanistan | 137 | 73 | 222 | 204 | 124 | 322 | 735 | 550 | 970 | 1201 | 874 | 1645 |
Bahrain | 51 | 41 | 64 | 47 | 37 | 56 | 1569 | 1210 | 1988 | 1529 | 1188 | 1926 |
Djibouti | 111 | 61 | 215 | 82 | 52 | 146 | 1359 | 713 | 2691 | 856 | 483 | 1642 |
Egypt | 35 | 27 | 44 | 34 | 26 | 41 | 1265 | 1016 | 1570 | 1294 | 1029 | 1595 |
Iran | 75 | 56 | 97 | 66 | 51 | 83 | 908 | 685 | 1155 | 925 | 684 | 1191 |
Iraq | 25 | 19 | 32 | 28 | 21 | 35 | 1287 | 990 | 1613 | 1494 | 1157 | 1926 |
Jordan | 130 | 104 | 157 | 113 | 94 | 135 | 1052 | 810 | 1343 | 956 | 715 | 1242 |
Kuwait | 49 | 39 | 61 | 51 | 40 | 62 | 663 | 475 | 889 | 629 | 453 | 839 |
Lebanon | 70 | 47 | 101 | 86 | 60 | 117 | 1232 | 923 | 1585 | 1280 | 932 | 1627 |
Libya | 117 | 79 | 166 | 115 | 84 | 154 | 865 | 655 | 1112 | 1032 | 772 | 1334 |
Morocco | 122 | 85 | 174 | 124 | 87 | 168 | 1663 | 1265 | 2118 | 2061 | 1548 | 2611 |
Oman | 70 | 54 | 86 | 80 | 66 | 95 | 1203 | 916 | 1525 | 1168 | 888 | 1483 |
Pakistan | 114 | 86 | 141 | 67 | 54 | 81 | 895 | 699 | 1109 | 1091 | 847 | 1371 |
Palestine | 51 | 39 | 65 | 42 | 34 | 52 | 572 | 432 | 733 | 547 | 414 | 707 |
Qatar | 41 | 31 | 52 | 41 | 31 | 52 | 1015 | 748 | 1325 | 1077 | 801 | 1407 |
Saudi Arabia | 226 | 164 | 266 | 159 | 140 | 181 | 655 | 472 | 876 | 514 | 371 | 686 |
Somalia | 79 | 43 | 154 | 75 | 41 | 142 | 657 | 328 | 1303 | 527 | 265 | 1021 |
Sudan | 89 | 53 | 150 | 85 | 52 | 131 | 689 | 515 | 909 | 787 | 590 | 1013 |
Syria | 24 | 17 | 33 | 22 | 16 | 29 | 510 | 381 | 672 | 578 | 423 | 764 |
Tunisia | 264 | 196 | 354 | 183 | 137 | 238 | 1783 | 1396 | 2210 | 1527 | 1170 | 1920 |
UAE | 119 | 72 | 186 | 65 | 46 | 91 | 1231 | 890 | 1630 | 916 | 667 | 1196 |
Yemen | 86 | 50 | 143 | 107 | 62 | 184 | 536 | 386 | 719 | 792 | 571 | 1102 |
Discussion
Our study showed that the burden of diabetes has increased considerably during the last 25 years in the EMR. This burden is higher than expected based on the demographic and social status of the countries in the region. Clearly, the region’s health systems have not performed at the expected level, given their socio-demographic status, to control and prevent diabetes and CKD. This is in contrast to the European region and Western Pacific region, where observed levels are lower than expected levels. There are several potential reasons for such differenced: people in the EMR have lower perceived risk, and access to and quality of health care are lesser in this region (Mokdad et al. 2014; Moradi-Lakeh et al. 2016b) Our results call for urgent efforts to address the burden of diabetes in the region.
Several interventions have been suggested for prevention and control of diabetes. Although the effectiveness and cost-effectiveness of all interventions are not promising, there is evidence of several successful experiences around the world (Davies et al. 2017; Sun et al. 2017). For example, the National Diabetes Prevention Program showed successful changes in determinants of diabetes (Ely et al. 2017). Indeed, a multi-sectorial approach is needed to control and prevent diabetes in the region. WHO suggests the Package of Essential Non-communicable (PEN) Disease Interventions to be used in primary health care in low-resource settings. PEN is a prioritized set of cost-effective interventions, tools, and aids to deliver an acceptable quality of care in the primary health care setting. Such interventions are feasible for adoption by most counties in the region (Zhang et al. 2016). For instance, Iran launched an adopted version, called IraPEN, with specific targets for prevention and control of non-communicable diseases. On the other hand, “Screen and Treat” strategies are unlikely to have a substantial impact to reduce the diabetes epidemic. Therefore, they should be complemented by population-wide approaches for effective diabetes prevention (Barry et al. 2017).
EMR countries are at different stages of prevention and control of diabetes; all high-income countries except Oman (Bahrain, Kuwait, Qatar, Saudi Arabia, and United Arab Emirates), some of the middle-income EMR countries (Iran, Jordan, Lebanon, and Tunisia), and none of the low-income EMR countries have an operational policy, strategy, or plan of action for diabetes (WHO 2017).
CKD mortality increased in recent years in the region, underscoring the need for better treatment and management of blood pressure and diabetes. Diagnosis and control of diabetes and blood pressure are not optimal in the region. Early detection through screening of high-risk individuals is crucial to control blood pressure and diabetes and reduce diabetes and CKD burden and mortality. Although evidence is not strong enough to conclude that early diagnosis of diabetes will increase survival, treatment of impaired glucose tolerance or impaired fasting glucose, as well as lifestyle interventions, is associated with delayed progression to diabetes (Selph et al. 2015a, b). There is a need for more aggressive programs to control blood pressure and diabetes that include medical and preventive care approaches.
Access to and quality of medical care has a major impact on mortality from diabetes and CKD (Alegre-Diaz et al. 2016). Several studies have suggested that proper treatment might reduce complications and improve outcomes. Both diabetes and CKD require patients to adhere to long-term management of the condition (Brunton and Polonsky 2017). Unfortunately, not all the region’s residents have equal access to quality medical care. It is possible that proper management of these conditions varies by county and has led to the observed increases in mortality.
Several studies have shown that obesity has rapidly increased in the region during the time period of this study (Mokdad et al. 2014, 2016). The studies have shown that inadequate physical activity and high body mass index are common in the region (El Bcheraoui et al. 2016). Moreover, dietary factors are among the major risk factors for diabetes and CKD (Moradi-Lakeh et al. 2016b; Yakoob et al. 2016). For example, low intake of whole grains, nuts and seeds, and fruit, and the consumption of processed food and red meats are known risk factor for diabetes; and high sodium intake is an important risk factor for CKD (Afshin et al. 2015; Moradi-Lakeh et al. 2016b). Diet has not improved much in the region during the study period (Afshin et al. 2015; Melaku et al. 2016; Otto et al. 2016). Moreover, there is only limited local information on dietary habits in the region (Afshin et al. 2015; Moradi-Lakeh et al. 2017). There is a need for programs to improve diet and physical activity and to control weight gain in the region to reduce the burden of diabetes as well as many other conditions. Only a few EMR countries have an operational policy, strategy, or plan of action to reduce obesity and physical inactivity (WHO 2017). The countries need to target different age groups, especially youth, to initiate sustainable changes in lifestyle. High intake of processed meat, sugar-sweetened beverages, and salt, and low intake of fruits and vegetables and whole grains need to be specifically addressed with regard to obesity, diabetes, and CKD-DM (Mokdad et al. 2016; Moradi-Lakeh et al. 2016a, 2017a; Ng et al. 2014).
Our study has a few limitations. For many countries with sparse data, estimates were driven by covariates in statistical modeling. The attributable effect of high body mass index (BMI) on ischemic heart disease, stroke, and diabetes was derived from prospective observational studies and meta-analyses. Our study does not account for variation within countries. We also do not have adequate data on access to and quality of health care in the region. More details on these limitations have been published elsewhere (Moradi-Lakeh et al. 2016b). On the other hand, we used new data for some countries, such as Saudi Arabia, which changed our estimates compared to GBD 2013 (El Bcheraoui et al. 2014; Moradi-Lakeh et al. 2016b).
Conclusion
Our study showed a large and increasing burden of diabetes in the region. This burden will increase with aging and growth of the population unless effective programs for control and prevention are put in place. Diabetes is a costly disease and most countries in the region spend a large percentage of their health resources on the disease. The region’s financial and manpower resources are already stretched. Hence, there is an urgency to deal with diabetes and its consequences, and these efforts should be at the forefront of disease prevention and health promotion.
Notes
GBD 2015 Eastern Mediterranean Region Diabetes and CKD Collaborators:
Maziar Moradi-Lakeh, MD, Department of Community Medicine, Preventive Medicine and Public Health Research Center, Gastrointestinal and Liver Disease Research Center (GILDRC), Iran University of Medical Sciences, Tehran, Iran. Charbel El Bcheraoui, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Ibrahim Khalil, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Raghid Charara, MD, American University of Beirut, Beirut, Lebanon. Ashkan Afshin, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Haidong Wang, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Michael Collison, BS, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Kristopher J. Krohn, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Adrienne Chew, ND, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Farah Daoud, BA/BS, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Christopher D. Blosser, MD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Leslie Cornaby, BS, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Kyle J. Foreman, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA; Imperial College London, London, UK. Nicholas J. Kassebaum, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA; Department of Anesthesiology & Pain Medicine, Seattle Children’s Hospital, Seattle, Washington, USA. Laura Kemmer, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Michael Kutz, BS, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Patrick Liu, BA, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Ben Zipkin, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Johan Ärnlöv, PhD, Department of Neurobiology, Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden; School of Health and Social Studies, Dalarna University, Falun, Sweden. Kalkidan Hassen Abate, MS, Jimma University, Jimma, Ethiopia. Alireza Ahmadi, PhD, Kermanshah University of Medical Sciences, Kermanshah, Iran. Hamid Ahmadieh, MD, Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran; Department of Ophthalmology, Labbafinejad Medical Center, Tehran, Iran. Muktar Beshir Ahmed, MPH, College of Health Sciences, Department of Epidemiology, ICT and e-Learning Coordinator, Jimma University, Jimma, Ethiopia. Ziyad Al-Aly, MD, Washington University in St. Louis, St. Louis, MO, USA. Khurshid Alam, PhD, Murdoch Childrens Research Institute, The University of Melbourne, Parkville, Victoria, Australia; The University of Melbourne, Melbourne, VIC, Austraila; The University of Sydney, Sydney, NSW, Austraila. Deena Alasfoor, MSc, Ministry of Health, Al Khuwair, Oman. Raghib Ali, MSc, University of Oxford, Oxford, UK. Reza Alizadeh-Navaei, PhD, Gastrointestinal Cancer Research Center, Mazandaran University of Medical Sciences, Sari, Mazandaran, Iran. Juma M. Alkaabi, MD, College of Medicine and Health Sciences, United Arab Emirates University, Al-Ain City, United Arab Emirates. Ala'a Alkerwi, PhD, Luxembourg Institute of Health (LIH), Strassen, Luxembourg. Rajaa Al-Raddadi, PhD, Joint Program of Family and Community Medicine, Jeddah, Saudi Arabia. Khalid A. Altirkawi, MD, King Saud University, Riyadh, Saudi Arabia. Nelson Alvis-Guzman, PhD, Universidad de Cartagena, Cartagena de Indias, Colombia. Erfan Amini, MD, Uro-Oncology Research Center, Tehran University of Medical Sciences, Tehran, Iran; Non-communicable Diseases Research Center, Endocrinology and Metabolism Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Nahla Anber, PhD, Mansoura University, Mansoura, Egypt. Palwasha Anwari, MD, Self-employed, Kabul, Afghanistan. Solomon Weldegebreal Asgedom, PhD, Mekelle University, Mekelle, Ethiopia. Tesfay Mehari Atey, MS, Mekelle University, Mekelle, Ethiopia. Leticia Avila-Burgos, PhD, National Institute of Public Health, Cuernavaca, Mexico. Ashish Awasthi, PhD, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. Peter Azzopardi, PhD, Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia; Murdoch Childrens Research Institute, Melbourne, VIC, Australia; Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia; Centre for International Health, Burnet Institute, Melbourne, VIC, Australia. Till Bärnighausen, MD, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA; Africa Health Research Institute, Mtubatuba, KwaZulu-Natal, South Africa; Institute of Public Health, Heidelberg University, Heidelberg, Germany. Umar Bacha, PhD, School of Health Sciences, University of Management and Technology, Lahore, Pakistan. Aleksandra Barac, PhD, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. Shahrzad Bazargan-Hejazi, PhD, College of Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA; David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA. Neeraj Bedi, MD, College of Public Health and Tropical Medicine, Jazan, Saudi Arabia. Derbew Fikadu Berhe, MS, School of Pharmacy, Mekelle University, Mekelle, Ethiopia. Addisu Shunu Beyene, MPH, College of Health and Medical Science, Haramaya University, Harar, Ethiopia. Zulfiqar A. Bhutta, PhD, Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON, Canada. Boris Bikbov, PhD, Centre of Excellence in Women and Child Health, Haramaya University, Harar, Ethiopia. Mulugeta M. Birhanu, MS, University of Groningen, Groningen, Netherlands; Mekelle University, Mekelle, Ethiopia. Zahid A. Butt, PhD, Al Shifa Trust Eye Hospital, Rawalpindi, Pakistan. Lucero Cahuana-Hurtado, PhD, National Institute of Public Health, Cuernavaca, Mexico. David O. Carpenter, MD, University at Albany, Rensselaer, New York, USA. Juan Jesus Carrero, PhD, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden. Jee-Young Jasmine Choi, PhD, Seoul National University Hospital, Seoul, South Korea; Seoul National University Medical Library, Seoul, South Korea. Hadi Danawi, PhD, Walden University, Minneapolis, Minnesota, USA. Samath D. Dharmaratne, MD, Department of Community Medicine, Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka. Eric L. Ding, ScD, Harvard T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA. Shirin Djalalinia, PhD, Undersecretary for Research & Technology, Ministry of Health & Medical Education, Tehran, Iran. Kerrie E. Doyle, PhD, RMIT University, Bundoora, VIC, Australia; Australian National University, Canberra, ACT, Australia. Hedyeh Ebrahimi, Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran; Liver and Pancreaticobiliary Diseases Research Center, Digestive Disease Research Institute, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran. Aman Yesuf Endries, MPH, Arba Minch University, Arba Minch, Ethiopia. Alireza Esteghamati, MD, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran. Maryam S. Farvid, PhD, Department of Nutrition, Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA; Harvard/MGH Center on Genomics, Vulnerable Populations, and Health Disparities, Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, MA, USA. Seyed-Mohammad Fereshtehnejad, PhD, Department of Neurobiology, Care Sciences and Society (NVS), Karolinska Institutet, Stockholm, Sweden. Tesfaye Regassa Feyissa, MPH, Wollega University, Nekemte, Ethiopia. Florian Fischer, PhD, School of Public Health, Bielefeld University, Bielefeld, Germany. Tsegaye Tewelde Gebrehiwot, MPH, Jimma University, Jimma, Ethiopia. Philimon N. Gona, PhD, University of Massachusetts Boston, Boston, Massachusetts, USA. Sameer Vali Gopalani, MPH, Department of Health and Social Affairs, Government of the Federated States of Micronesia, Palikir, Federated States of Micronesia. Bishal Gyawali, MPH, Aarhus University, Aarhus, Denmark; Kathmandu, Nepal. Nima Hafezi-Nejad, MD, Endocrinology and Metabolism Research Center, Tehran University of Medical Sciences, Tehran, Iran. Randah Ribhi Hamadeh, DPhil, Arabian Gulf University, Manama, Bahrain. Samer Hamidi, DrPH, Hamdan Bin Mohammed Smart University, Dubai, United Arab Emirates. Masako Horino, MPH, Bureau of Child, Family & Community Wellness, Nevada Division of Public and Behavioral Health, Carson City, NV, USA. Mohamed Hsairi, MD, Department of Epidemiology, Salah Azaiz Institute, Tunis, Tunisia. Mihajlo B. Jakovljevic, PhD, Faculty of Medical Sciences, University of Kragujevac Kragujevac, Central Serbia-Sumadija, Serbia, The Center for Health Trends and Forecasts, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Aida Jimenez-Corona, PhD, Department of Ocular Epidemiology and Visual Health, Institute of Ophthalmology Condede Valencia, Mexico City, Mexico; General Directorate of Epidemiology, Ministry of Health, Mexico City, Mexico. Denny John, MPH, International Center for Research on Women, New Delhi, India. Jost B. Jonas, MD, Department of Ophthalmology, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany. Amir Kasaeian, PhD, Hematology-Oncology and Stem Cell Transplantation Research Center, Tehran University of Medical Sciences, Tehran, Iran; Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran. Andre Pascal Kengne, PhD, South African Medical Research Council, Cape Town, South Africa, University of Cape Town, Cape Town, South Africa. Ezra Belay Ketema, MS, Mekelle University, Mekelle, Ethiopia. Yousef Saleh Khader, ScD, Department of Community Medicine, Public Health and Family Medicine, Jordan University of Science and Technology, Irbid, Jordan. Ejaz Ahmad Khan, MD, Health Services Academy, Islamabad, Pakistan. Daniel Kim, DrPH, Department of Health Sciences, Northeastern University, Boston, Massachusetts, USA. Yun Jin Kim, PhD, Faculty of Chinese Medicine, Southern University College, Skudai, Malaysia. Yohannes Kinfu, PhD, Centre for Research and Action in Public Health, University of Canberra, Canberra, Australian Capital Territory, Australia. Katarzyna A. Kissimova-Skarbek, PhD, Jagiellonian University Medical College, Kraków, Poland. Ai Koyanagi, MD, Research and Development Unit, Parc Sanitari Sant Joan de Deu (CIBERSAM), Barcelona, Spain. Heidi J. Larson, PhD, Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK; Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Anders Larsson, PhD, Department of Medical Sciences, Uppsala University, Uppsala, Sweden. Yongmei Li, PhD, San Francisco VA Medical Center, San Francisco, California, USA. Paulo A. Lotufo, DrPH, University of São Paulo, São Paulo, Brazil. Raimundas Lunevicius, PhD, Aintree University Hospital National Health Service Foundation Trust, Liverpool, UK; School of Medicine, University of Liverpool, Liverpool, UK. Azeem Majeed, MD, Department of Primary Care & Public Health, Imperial College London, London, UK. Reza Malekzadeh, MD, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran; Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Deborah Carvalho Malta, PhD, Universidade Federalde Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Mohsen Mazidi, PhD, Key State Laboratory of Molecular Developmental Biology, Institute of Genetics and Developmental Biology, Chinese Academy of Sciences, Beijing, China. Ziad A. Memish, MD, Saudi Ministry of Health, Riyadh, Saudi Arabia, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia. Walter Mendoza, MD, United Nations Population Fund, Lima, Peru. Mubarek Abera Mengistie, MS, Jimma University, Jimma, Ethiopia. Haftay Berhane Mezgebe, MS, Mekelle University, Mekelle, Ethiopia. Ted R. Miller, PhD, Pacific Institute for Research & Evaluation, Calverton, MD, USA; Centre for Population Health, Curtin University, Perth, WA, Australia. Muktar Sano Kedir Mohammed, MS, Mizan Tepi University, Mizan Teferi, Ethiopia. Shafiu Mohammed, PhD, Health Systems and Policy Research Unit, Ahmadu Bello University, Zaria, Nigeria; Institute of Public Health, Heidelberg University, Heidelberg, Germany. Ulrich O. Mueller, PhD, Federal Institute for Population Research, Wiesbaden, Germany. Gabriele Nagel, PhD, Ulm University, Ulm, Germany. Cuong Tat Nguyen, MSc, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam. Quyen Le Nguyen, MD, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam. Vuong Minh Nong, MSc, Institute for Global Health Innovations, Duy Tan University, Da Nang, Vietnam. Jean Jacques N. Noubiap, MD, University of Cape Town, Cape Town, South Africa, Medical Diagnostic Centre, Yaounde, Cameroon. Felix Akpojene Ogbo, MPH, Centre for Health Research, Western Sydney University, Sydney, New South Wales, Australia. Alberto Ortiz, PhD, IIS-Fundacion Jimenez Diaz-UAM, Madrid, Spain. Erika Ota, PhD, St. Luke's International University, Tokyo, Japan. Tejas Patel, MD, Mount Sinai Health System, New York, NY, USA. Jonathan Pearson-Stuttard, MD, Imperial College London, London, UK; Liverpool, UK. Norberto Perico, MD, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy. Max Petzold, PhD, Health Metrics Unit, University of Gothenburg, Gothenburg, Sweden; University of the Witwatersrand, Johannesburg, South Africa. Farhad Pishgar, Non-communicable Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran; Uro-Oncology Research Center, Tehran University of Medical Sciences, Tehran, Iran. Farshad Pourmalek, PhD, University of British Columbia, Vancouver, British Columbia, Canada. Mostafa Qorbani, PhD, Non-communicable Diseases Research Center, Alborz University of Medical Sciences, Karaj, Iran. Vafa Rahimi-Movaghar, MD, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. Rajesh Kumar Rai, MPH, Society for Health and Demographic Surveillance, Suri, India. Saleem M. Rana, PhD, Contech School of Public Health, Lahore, Pakistan; Contech International Health Consultants, Lahore, Pakistan. David Laith Rawaf, MD, WHO Collaborating Centre, Imperial College London, London, UK, North Hampshire Hospitals, Basingstroke, UK, University College London Hospitals, London, UK. Salman Rawaf, MD, Imperial College London, London, UK. Giuseppe Remuzzi, MD, IRCCS-Istituto di Ricerche Farmacologiche Mario Negri, Bergamo, Italy; Azienda Socio-Sanitaria Territoriale, Papa GiovanniXXIII, Bergamo, Italy; Department of Biomedical and Clinical Sciences "L. Sacco", University of Milan, Milan, Italy. Andre M. N. Renzaho, PhD, Western Sydney University, Penrith, NSW, Australia. Satar Rezaei, PhD, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran. Gholamreza Roshandel, PhD, Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran; Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Dietrich Rothenbacher, MD, Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany. Mahdi Safdarian, MD, Sina Trauma & Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. Sare Safi, MS, Ophthalmic Epidemiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Saeid Safiri, PhD, Managerial Epidemiology Research Center, Department of Public Health, School of Nursing and Midwifery, Maragheh University of Medical Sciences, Maragheh, Iran. Mohammad Ali Sahraian, MD, MS Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Payman Salamati, MD, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran. Abdallah M. Samy, PhD, Ain Shams University, Cairo, Egypt. Juan Ramon Sanabria, MD, J Edwards School of Medicine, Marshall Univeristy, Huntington, WV, USA; Case Western Reserve University, Cleveland, OH, USA. Maria Dolores Sanchez-Niño, PhD, IIS-Fundacion Jimenez Diaz, Madrid, Spain. Milena M. Santric Milicevic, PhD, Institute of Social Medicine, Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Centre School of Public Health and Health Management, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. Benn Sartorius, PhD, Public Health Medicine, School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa; UKZN Gastrointestinal Cancer Research Centre, South African Medical Research Council (SAMRC), Durban, South Africa. Sadaf G. Sepanlou, PhD, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran. Masood Ali Shaikh, MD, Independent Consultant, Karachi, Pakistan. Diego Augusto Santos Silva, PhD, Federal University of Santa Catarina, Florianopolis, SC-Santacatarina, Brazil. Dayane Gabriele Alves Silveira, MD, Brasília University, Brasília, DF, Brazil. Badr H. A. Sobaih, MD, King Saud University, Riyadh, Saudi Arabia. Rizwan Suliankatchi Abdulkader, MD, Ministry of Health, Kingdom of Saudi Arabia, Riyadh, Saudi Arabia. Rafael Tabarés-Seisdedos, PhD, Department of Medicine, University of Valencia, Incliva Health Research Institute and CIBERSAM, Valencia, Spain. Arash Tehrani-Banihashemi, PhD, Preventive Medicine and Public Health Research Center, Iran University of Medical Sciences, Tehran, Iran. Mohamad-Hani Temsah, MD, King Saud University, Riyadh, Saudi Arabia. Roman Topor-Madry, PhD, Institute of Public Health, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland. Bach Xuan Tran, PhD, Johns Hopkins University, Baltimore, Maryland, USA; Hanoi Medical University, Hanoi, Vietnam. Kingsley Nnanna Ukwaja, MD, Department of Internal Medicine, Federal Teaching Hospital, Abakaliki, Nigeria. Olalekan A. Uthman, PhD, Warwick Medical School, University of Warwick, Coventry, UK. Job F. M. van Boven, PhD, University of Groningen, Groningen, Netherlands. Tolassa Wakayo, MS, Jimma University, Jimma, Ethiopia. Andrea Werdecker, PhD, Competence Center Mortality-Follow-Up of the German National Cohort, Federal Institute for Population Research, Wiesbaden, Germany. Abdulhalik Workicho, MPH, Jimma University, Jimma, Ethiopia; Ghent University, Ghent, Belgium. Mohsen Yaghoubi, MSc, School of Public Health, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Yuichiro Yano, MD, Department of Preventive Medicine, Northwestern University, Chicago, Illinois, USA. Mehdi Yaseri, PhD, Tehran University of Medical Sciences, Tehran, Iran; Ophthalmic Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Naohiro Yonemoto, MPH, Department of Biostatistics, School of Public Health, Kyoto University, Kyoto, Japan. Mustafa Z. Younis, DrPH, Jackson State University, Jackson, MS, USA. Bassel Zein, MS, Department of Neuroscience, Georgetown University, Washington, DC, USA. Anthony Lin Zhang, PhD, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia. Aisha O. Jumaan, PhD, Independent Consultant, Seattle, Washington, USA. Theo Vos, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Simon I. Hay, DSc, Oxford Big Data Institute, LiKa Shing Centre for Health Information and Discovery, University of Oxford, Oxford, UK; Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Mohsen Naghavi, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Christopher J. L. Murray, DPhil, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA. Ali H. Mokdad, PhD, Institute for Health Metrics and Evaluation, University of Washington, Seattle, Washington, USA.
Compliance with ethical standards
Ethical statements
The authors of this paper have complied with all ethical standards and do not have any conflicts of interest to disclose at the time of submission. The funding source played no role in the design of the study, the analysis and interpretation of data, and the writing of the paper.
Human participants and animals
The study did not involve human participants and/or animals; therefore, no informed consent was needed.
Funding
This research was funded by the Bill & Melinda Gates Foundation.
Conflict of interest
The authors declare that they have no conflicts of interest at this time.
Supplementary material
References
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