The Economic Costs of Cardiovascular Disease, Diabetes Mellitus, and Associated Complications in South Asia: A Systematic Review

This article explores the burden of the major non-communicable diseases in South Asia and the extent to which obstacles hinder prevention and management of these diseases

BackgroundThis study examines the incidence, prevalence, deaths, and disability-adjusted life years (DALYs) related to non-communicable diseases (NCDs) in South Asia, exploring the environmental, metabolic, and behavioural risk factors, and exploring changes in deaths and DALYs driven by population growth, aging, and mortality rates.MethodsUsing data from the Global Burden of Disease (GBD) study 2021, we estimated age-standardized incidence, prevalence, deaths, and DALYs for four major NCDs: cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases from 2010 to 2021. Gender and age-specific estimations were conducted across all NCDs, with 95% uncertainty intervals and a decomposition analysis was employed to estimate change in death and DALYs attributable to NCDs.FindingsThe burden of NCDs in South Asia increased by 3.00% in incidence from 2010 to 2021, while overall prevalence decreased by 1.00%, yet the age-standardized prevalence rate remains above the global rate (91,570 per 100,000 population). Incidences of cardiovascular and respiratory diseases declined by 3.00% and 13.00%, respectively, whereas diabetes and cancer rose by 21.00% and 13.00% in South Asia. Nepal faced the highest environmental impact (23.4% of DALYs), Bangladesh the greatest metabolic impact (25.62%), and India the highest from behavioural factors (23.95%). Population growth and aging were primary drivers of changes in deaths and DALYs across the region.ConclusionThis finding emphasizes the need for targeted public health interventions addressing environmental, metabolic, and behavioral risks for NCDs in South Asia, alongside strategies to support healthy aging and effective disease management across diverse demographic groups.

The burgeoning non-communicable diseases (NCDs) in South Asia in recent decades has changed the morbidity and mortality trends. Among other NCDs, one-third of population in South Asia develops cardiovascular diseases during their lifetime. The rise in NCDs is predicated on multitude of factors such as life-style related behaviours and the increasing urbanization. In recent years, South Asia has seen booming economy, unprecedented amount of rural to urban migration, fast growing urban cities together with decreasing urban green spaces (UGS). Among manifold benefits of UGS such as reducing temperature, noise and improving the air quality, UGS also provides an enabling environment for physical activities, which has been established to reduce the burden of NCDs. In South Asia, although urbanization has apparently improved regional economy, the encroachment and destruction of urban greenspace has put a huge threat to ecological ambience for healthy living which can contribute to rising burden of NCDs and consequently lead to huge economic loss. We draw on literature and our regional perspective to advocate the need for sustainable urban green cities by exploring the impact of urban green space on NCDs.

Non-communicable diseases (NCDs) such as metabolic, cardiovascular, cancers, injuries and mental health disorders are increasingly contributing to the disease burden in South Asia, in light of demographic and epidemiologic transitions in the region. Home to one-quarter of the world's population, the region is also an important priority area for meeting global health targets. In this review, we describe the current burden of and trends in four common NCDs (cardiovascular disease, diabetes, cancer and chronic obstructive pulmonary disease) in South Asia. The 2010 Global Burden of Disease Study supplemented with the peer-reviewed literature and reports by international agencies and national governments. The burden of NCDs in South Asia is rising at a rate that exceeds global increases in these conditions. Shifts in leading risk factors-particularly dietary habits, tobacco use and high blood pressure-are thought to underlie the mounting burden of death and disability due to NCDs. Improvements in life expectancy, increasing socioeconomic development and urbanization in South Asia are expected to lead to further escalation of NCDs. Although NCD burdens are currently largest among affluent groups in South Asia, many adverse risk factors are concentrated among the poor, portending a future increase in disease burden among lower income individuals. There continues to be a notable lack of national surveillance data to document the distribution and trends in NCDs in the region. Similarly, economic studies and policy initiatives addressing NCD burdens are still in their infancy. Opportunities for innovative structural and behavioral interventions that promote maintenance of healthy lifestyles-such as moderate caloric intake, adequate physical activity and avoidance of tobacco-in the context of socioeconomic development are abundant. Testing of health care infrastructure and systems that best provide low-cost and effective detection and treatment of NCDs is a priority for policy researchers.

Non-communicable diseases (NCDs) such as cardiovascular diseases, diabetes mellitus, cancer, and chronic respiratory diseases are on the rise in South East Asia Region (SEAR). NCDs account for nearly 54% of the deaths, significant amount of disabilities and huge socioeconomic losses in countries of SEAR. NCDs are caused by a set of behavioural risk factors, such as tobacco and alcohol consumption, physical activity and unhealthy diet (high in salt, sugar and fat and low in fruits and vegetables) and biological risk factors like raised blood pressure, raised blood sugar and impaired cholesterol levels and others.South Asia is experiencing urbanization, with widening incme and social inequities. The impact of noncommunicable diseases on the rich and the poor are likely to be different, in terms of both the principal causes and manifestations. As the rich are likely to reconnise their risk earlier and seek medical attention, they will develop chronic but manageable disease; as the poor are likely to be less aware of their risk and less able to access medical care, they will develop rapidly progressive disease with early and sudden fatal outcomes To challenge to public health is to anticipate and avert an epidemic of non-communicable diseases.NCDs risk factors can be reduced with existing knowledge through cost- effective policies and programmes, Establishment of surveillance systems for non-communicable diseases and their risk factors is essential for developing prevention strategies and monitoring the impact of control programmes.Key Words: Non-communicable diseases; South Asia; Risk factors; BurdenDOI: 10.3329/uhj.v6i2.7255University Heart Journal Vol. 6, No. 2, July 2010 pp.97-102

Current guideline statements for primary and secondary prevention of cardiovascular disease (CVD) rely on estimates of absolute risk of coronary events. For example, the American Heart Association guidelines on primary prevention state that persons with ≥10% risk over 10 years of myocardial infarction (MI) or coronary death should be considered for antiplatelet therapy with aspirin.1 Similarly, the National Cholesterol Education Program Adult Treatment Panel III (ATP III) guidelines2 state that target low-density lipoprotein level should be based on projected absolute risk of future coronary events rather than on presence or absence of specific risk factors. These guidelines state that patients at high risk of MI and coronary death, defined as an absolute 10-year risk of ≥20%, should have a target low-density lipoprotein level <100 mg/dL and should receive statin therapy if needed to achieve this goal. Stroke, however, is not included as one of the outcomes contributing to these absolute risk levels. Included in the group of patients with elevated risk, moreover, are those who already have ischemic heart disease, as well as patients deemed to be “coronary heart disease (CHD) risk equivalents,” indicating those at the same elevated risk as patients with ischemic heart disease. CHD risk equivalents include patients with diabetes mellitus, those with multiple risk factors that put them at elevated risk based on calculation of their Framingham Score, and patients with “other forms of symptomatic atherosclerotic disease.” The latter group is further defined to include those with peripheral arterial disease (PAD), abdominal aortic aneurysm (AAA), and carotid artery disease. The category of “risk equivalents” in the ATP III guidelines, however, does not include the vast majority (≈80%3) of ischemic stroke patients without carotid artery disease as cause of their stroke. Ischemic stroke is therefore notably excluded from the list of outcomes contributing to …

The burden of noncommunicable diseases (NCDs) is increasing with the rapid urbanization, modernization and the lifestyle changes that are taking place in Asia, leading to the double burden of disease. Lowand middle-income countries currently account for 80% of all NCDs related mortality and exceeding those due to communicable diseases, maternal, neonatal, and injury-related deaths combined.1 The sociobehavioral risk factors of NCDs are common characteristics of Asian countries facing the economic transition and the changing lifestyles, and this is affecting the achievement of the Millennium Development Goals focusing on health and the social determinants. Cardiovascular disease (CVD) was the leading cause of NCD deaths in 2012 and was responsible for 17.5 million deaths.1 Four major NCDs (cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes) are responsible for 82% of NCD deaths. Of the 17.5 million deaths due to CVDs in 2012, an estimated 7.4 million were due to heart attacks and 6.7 million were due to strokes.2 More than 80% of cardiovascular deaths occur in lowand middle-income countries. In 2012, heart disease and stroke were among the top 3 causes of years of life lost due to premature mortality globally.3 Metabolic syndrome is a significant predictor of CVDs and it was shown that better knowledge and health practices were associated with decrease in CVD risk-markers in Sri Lankan urban adults with metabolic syndrome.4 In Asia, the risen prevalence of diabetes is a cause of public health concern. The global prevalence of diabetes in 2014 was estimated to be 9%.1 Diabetes was responsible for 4% and other NCDs were responsible for approximately 24% of NCD deaths in those younger than 70 years.1 Diabetic complications are escalating and the understanding of patient’s help-seeking behavior in terms of health promotion is warranted. It has been shown that social influences play a significant role in help-seeking process and depends not only on the capacity of the individual but also on the social networks within the health system.5 Raised blood pressure is estimated to have caused 9.4 million deaths and 7% of disease burden, as measured in disability-adjusted life years (DALYs) in 2010.1 In 2014, the global prevalence of raised blood pressure in adults aged 18 years and older was around 22% and higher in lowand middle-income countries.1 Psychosocial determinants of hypertension have also been linked to the pathogenesis of hypertension. Among others, stress related to work is one of them. The risk of hypertension was found to increase with high levels of overcommitment and the prevalence of effort-reward imbalances among managerial and administrative officers.6 In another study, there were significant sociodemographic correlates with prehypertension, such as upper socioeconomic status, obese individuals, male gender, those who smoked and consumed alcohol, and had low physical activity.7

Cardiovascular diseases (CVD) are major contributors to mortality and morbidity in South Asia. Chronic exposure to air pollution is an important risk factor for cardiovascular diseases, although the majority of studies to date have been conducted in developed countries. Both indoor and outdoor air pollution are growing problems in developing countries in South Asia yet the impact on rising rates of CVD in these regions has largely been ignored. We aimed to assess the evidence available regarding air pollution effects on CVD and CVD risk factors in lower income countries in South Asia. A literature search was conducted in PubMed and Web of Science. Our inclusion criteria included peer-reviewed, original, empirical articles published in English between the years 1990 and 2012, conducted in the World Bank South Asia region (Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka). This resulted in 30 articles. Nine articles met our inclusion criteria and were assessed for this systematic review. Most of the studies were cross-sectional and examined measured particulate matter effects on CVD outcomes and indicators. We observed a bias as nearly all of the studies were from India. Hypertension and CVD deaths were positively associated with higher particulate matter levels. Biomarkers of oxidative stress such as increased levels of P-selection expressing platelets, depleted superoxide dismutase and reactive oxygen species generation as well as elevated levels of inflammatory-related C-reactive protein, interleukin-6 and interleukin-8 were also positively associated with biomass use or elevated particulate matter levels. An important outcome of this investigation was the evidence suggesting important air pollution effects regarding CVD risk in South Asia. However, too few studies have been conducted. There is as an urgent need for longer term investigations using robust measures of air pollution with different population groups that include a wider range of air pollutants and outcomes, including early indicators of CVD. These regions are facing burdens from increasing urbanization, air pollution and populations, generally weaker health infrastructure, aging populations and increased incidence of non-communicable diseases, included CVD. The extent to which the problem of air pollution and CVD will impact these countries will depend largely on the information available to inform policy and programs, which are still lacking, political will as well as social and economic development.

ABSTRACTNonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the West, and is also increasing alarmingly in South Asia, reaching an epidemic proportion of 30% because of epidemic of obesity and metabolic syndrome (MS) in younger South Asians in the last two decades. Prevalence of MS and fatty liver is escalating in geometric progression in South Asian countries, such as India, Pakistan, Sri Lanka, Bangladesh, Nepal, Bhutan, Burma, and Maldives because of sedentary lifestyle, poor health awareness, socioeconomic growth, affluence, urbanization, and dietary westernization. Almost 20% of world’s population resides in South Asia, making it the most populous and most densely populated geographic region in the world, thereby having most of MS and NAFLD cases within its territory. The risk factors and course of NAFLD do not differ between South Asians and other ethnic populations, but the obesity epidemic is more recent in South Asia than elsewhere in the world. Nonalcoholic fatty liver disease may progress through stages of simple bland steatosis, nonalcoholic steatohepatitis (NASH), hepatic fibrosis, cirrhosis, and finally hepatocellular carcinoma (HCC). It is frequently associated with obesity, MS, dyslipidemia, insulin resistance (IR), and type-2 diabetes mellitus (DM). Nonalcoholic fatty liver disease is frequently diagnosed with abdominal ultrasonography (US) study. Despite its high prevalence in the community till now, no definitive pharmacotherapy is available for NAFLD. However, modification of risk factors, such as dyslipidemia, control of diabetes, and weight reduction do help to some extent. The nonobese South Asians are also at increased risk of having NAFLD and NASH as, despite of absence of frank obesity in South Asians, they are metabolically more obese compared to other ethnic population and more prone to develop NAFLD-related complications. Therefore, the cost-effective US abdomen should be included in the list of tests for persons undergoing preemployment or master health checkups for early diagnosis of NAFLD in this resource-constraint South Asian region, so that early necessary measures can be undertaken to reduce NAFLD associated morbidity and mortality in the community.How to cite this articlePati GK, Singh SP. Nonalcoholic Fatty Liver Disease in South Asia. Euroasian J Hepato-Gastroenterol 2016;6(2):154-162.

This article provides an overview of the relationship between abdominal obesity (AO) and Non-Communicable Diseases (NCDs) in South Asia. A literature review has been conducted using key words: Abdominal obesity, Non-Communicable Diseases, Adipokines and South Asia, searching Scopus, Pubmed, Google scholar and Medline databases. South Asians suffer from abdominal obesity that results in systematic inflammation giving rise to excess production of harmful adipokines that eventually leads to the occurrence of NCDs. The incidence of NCDs related mortality ranges between 44 per cent - 84 per cent. Impaired developments during pregnancy may also have a linkage with AO and NCDs. Adipokines and fat derivatives produced in abundance by the abdominal fat tissues have a crucial implication in the progression of NCDs. South Asians have unhealthy metabolic profile leading to several forms of NCDs. Further research needs to be done in the population groups suffering from abdominal obesity to derive interventional strategies to prevent as well as manage NCDs in clinical settings.

The chapter introduces the book that highlights various challenges and opportunities for water management and cooperation in South Asia. Taking into consideration the increasing urbanization and development in the region and related pressure on water resources, the various chapters investigate water conflictual and cooperative attitudes and gestures between countries and regions, analyse management trade-offs between nature, agriculture and urban uses, and look into water sustainable management and related policies. The chapter highlights the increasing importance of South Asia, alerts for the constraining impacts of water scarcity, and indicates challenges for improved sustainable water management. The chapter concludes with synopses of each part of the book and of the chapters that compose them.

In general it has been observed that the Preparedness levels against the corona virus disease 2019 (COVID-19) pandemic were relatively poor in South Asian countries. However, South Asian countries have lower mortality levels compared with other world countries. COVID-19 has revealed the vulnerabilities of the health system as a whole. In addition, the high burden of non-communicable diseases in South Asia multiplies the complexities in combating present and future health crises. The advantage offered by the younger population demographics in South Asia may not be sustained with the rising burden of noncommunicable diseases and lack of priority setting for improving health systems. Thus the COVID-19 pandemic has provided a window for introspection, scaling up preparedness for future pandemics, and improving the health of the population overall. The COVID pandemic arrived in South Asia at a much later stage compared with other countries. As such, the South Asian countries may have been able to learn from countries that had early peaks, and therefore achieved better preparation in terms of the public health response. For example, this could have resulted in a lower viral load due to more people wearing masks. South Asian countries lift lockdowns despite rising case numbers. Healthcare facilities and hospitals are stretched due to the increase in the number of cases. It has been reported that testing levels in Pakistan and Bangladesh have fallen dramatically. Social distance is much prevalent in sangha members of Buddhism and caste system in Hindu and its associated communities. That help much to such communities during COVID-19 pandemic. Further requires strong leadership and great political will to allocate substantial resources to prepare for future pandemics. The region needs to scale up the existing social ‘safety nets’ rapidly, such as cash transfers for food. South Asian countries have also resorted to the use of online portals, social media, working from home, online learning, direct benefit transfers, delivery of health services through ‘virtual doctors’, deploying facial recognition, and use of thermal scanners for identification of infected people. Delayed vaccine campaigns in Japan, South Korea, and Taiwan have brought more negative attention to their governments as other developed countries surge ahead. Since a huge extent of PM 2.5 can be credited to traffic vehicle’s gas and mechanical consuming of fills, this over all decrease of AQI information by implication shows an impact of lockdown in these nations. Urgent advanced training of both mental and physical health by way of yoga and meditation require

Future of Kerala depends on its willingness to learn from pastEditor-The Kerala model in health, cited by Bhutta et al in the theme issue on health in South Asia as...

Pandemic preparedness and response to COVID-19 in South Asian countries

BackgroundAtherosclerotic cardiovascular disease (ASCVD) disproportionately impacts low-middle income countries, such as those in South Asia and understanding future ASCVD rates can inform public policy.ObjectivesThis study aimed to project the burden of ASCVD in South Asia till 2040.MethodsYearly ischemic heart disease (IHD), stroke, and peripheral artery disease (PAD) counts for South Asia (Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) and mid-year population were obtained from Global Burden of Disease (1990-2021) in 5-year age brackets (40-79 years) and estimated mid-year national population (2022-2040) was collected. Age-adjusted prevalence (aaPR) and mortality rate (per 100,000) were projected with Bayesian age-period-cohort models in South Asia (overall, males, and females); trends were reported as the estimated annual percent change (EAPC).ResultsBetween 2021 and 2040, the IHD aaPR in South Asia was projected to increase (2021: 9434.6 [95% CI: 9,432.1-9,437.1], 2040: 9,846.6 [95% CI: 8,800.0-10,893.3], EAPC: 0.23% [95% CI: 0.08%-0.37%]) because of increased rates among females (EAPC: 1.16%; 95% CI: 1%-1.32%). The overall IHD age-adjusted mortality rate will reduce (2021: 254.7 [95% CI: 254.3-255.1), 2040: 224.0 [95% CI: 166.5-281.6), EAPC: −0.67% [95% CI: −1.61% to 0.27%]) but may increase in females (EAPC: 1.16%; 95% CI: 1%-1.32%). Stoke aaPR in South Asia is projected to increase slightly (2021: 1,065.5 [95% CI: 1,064.7-1,066.4], 2040: 1,074.6 [95% CI: 953.7-1,195.5]). The PAD aaPR is projected to increase (2021: 1809.5 [95% CI: 1,808.5-1,810.6], 2040: 1,879.5 [95% CI: 1,684.9-2,074.0], EAPC: 0.26% [95% CI: 0.04%-0.47%]) because of increased rates in females (EAPC: 0.29%; 95% CI: −0.01% to 0.59%).ConclusionsIHD and PAD prevalence rates are projected to increase in South Asia with a disproportionate increase among females.