India latest health scorecard: More heart disease, a surge in diabetes and a rising suicide rate

Heart disease, lung disease and diabetes have been rising in India in recent decades. A new series of studies now that quantifies the trend shows an alarming increase in these non-communicable diseases, as well as in the rate of suicide among Indians.

Between the years 1990 and 2016, Indians recorded an 50% increase in ischemic heart disease and stroke. The number of people with diabetes has increased 2.5 times from 26 million in 1990 to 65 million in 2016. The number of chronic obstructive lung disease cases in India has almost doubled from 28 million to 55 million in the same period. Meanwhile, the contribution of cancers to total health loss in India has doubled between 1990 to 2016.

One of the most worrying findings relates to mental health. One study shows that suicide is presently the leading cause of death in people between the ages of 15 and 39 in India. Of all the suicides in the world, 37% are those of women in India.

The analysis based on disease data since 1990 as part of the Global Disease burden study was was conducted by the India State-level Disease Burden Initiative, which is a joint initiative of the Indian Council of Medical Research, the Public Health Foundation of India, the Institute for Health Metrics and Evaluation in collaboration with the Ministry of Health and Family Welfare. The findings were reported in a series of five research papers published in publications of The Lancet.

The disease burden has been calculated both in terms of number of deaths and in terms of Disability-Adjusted Life Years or DALYs. (DALYs are a measure of the gap between current health status and an ideal health situation where the entire population lives to an advanced age, free of disease and disability. They are calculated as the sum of the Years of Life Lost due to premature mortality in the population and the Years Lost due to Disability for people living with the health condition or its consequences.)

Here is a look at what the studies show.

Twice as much heart disease

• In 2016, cardiovascular diseases contributed to 28% of all deaths in India compared to 15% in 1990. They also made up 14% of DALYs in 2016 as opposed to about 7% in 1990.
• The number of cases of cardiovascular diseases increased in India from 25·7 million in 1990 to 54·5 million in 2016, which is roughly twice the prevalence in the last 25 years.
• Among all cardiovascular diseases, ischaemic heart disease – that is, narrowing of the arteries so that less blood and oxygen reaches the heart muscle – was predominant,  contributing to 18% of all deaths and 9% of DALYs in 2016. A much larger proportion of men that women suffered ischemic heart disease.
• Stroke  was another major cardiovascular disease contributing to 7% of deaths and about 4% of DALYs.
• The highest prevalence of cardiovascular disease occurred in Kerala, Punjab, and Tamil Nadu, which are more developed states in an advanced state of epidemiological transition – that is, with better development and healthcare the pattern of mortality and disease changes from is transformed from infections and epidemics and deaths among children to one of degenerative and lifestyle diseases affecting mostly the elderly. The next highest prevalence of cardiovascular diseases is seen in followed by Andhra Pradesh, Himachal Pradesh, Maharashtra, Goa, and West Bengal.
• However, the increase in the prevalence of ischaemic heart disease since 1990 was higher in the many less developed states that are home to 55% of India’s population.
• A key takeaway is that more than half of the total cardiovascular disease deaths in India in 2016 were in people younger than 70 years. The largest proportion of these deaths occurred in states less developed states. This throws up a major challenge health systems in these states as they will have to find ways to reduce premature deaths from cardiovascular diseases in the economically productive age groups.
• The researchers call the increasing prevalence of various lifestyle risk factors and environmental risks contributing to cardiovascular diseases across India “ominous”. They find that risk factors for heart disease like high systolic blood pressure, ambient air pollution, high total cholesterol, high fasting plasma glucose, and high body mass index have increased across India since 1990.

Diabetes is the fastest rising non-communicable disease

• The prevalence of diabetes in adults 20 years or older in India increased from 5·5% in 1990 to 7·7% – or 65 million people – in 2016. The disease contributed to 3.1% of all deaths in India.
• Diabetes, which did not feature in the top 30 causes of DALYs in India in 1990, was the thirteenth leading cause of disease in 2016, making it the disease causing the highest increase in DALYs since 1990 in India among major non-communicable diseases.
• This prevalence was highest in the more developed states such as Tamil Nadu, Kerala and Delhi but the prevalence has increased in every state across the country, with some of the greatest increases occurring in less developed states.
• The researchers point out that the increase in both diabetes prevalence and death rates points to possible shortfalls in the management of diabetes – delayed diagnosis, suboptimal glycaemic control and failure to screen for early-stage complications that leaves people more prone to the development of late-stage complications.

Disproportionately high burden of respiratory disease

• India has 32% of global DALYs due to chronic respiratory diseases in 2016. The contribution of chronic respiratory diseases to the total DALYs in India increased from 4·5% in 1990 to 6·4% in 2016.
• Chronic obstructive pulmonary disease was the major respiratory disease causing 76% of all DALYS. In numbers, COPD cases in India increased from 28·1 million in 1990 to 55·3 million in 2016, which is a 3% increase in prevalence, with 37·9 million cases of registered in 2016.
• Asthma contributed another 20% to DALYs due to respiratory disease.  
• Less developed states lie Rajasthan and Uttar Pradesh have a greater prevalence of both COPD and asthma.
• Of the DALYs due to COPD, 54% were attributable to air pollution, 25% to tobacco use, and about 17% to occupational risks, making these the leading risk factors for COPD.

Double the number of cancer cases

• The incidence of cancer as well as mortality and DALYs due to cancer in India has increased substantially in the last 26 years, with the number of new cases and deaths due to cancer doubling in India from 1990 to 2016.
• Cancer caused more than 8% of all deaths and 5% of all DALYs in India in 2016.
• There are several factors for the observed cancer trends. For example, the substantial decrease in incidence rate of stomach cancer might be due to lifestyle changes like reduced consumption of salt-preserved foods, better availability of refrigeration, and increasing fruit consumption. The substantial decrease in the age-standardised incidence rate of oesophageal cancer might be partly due to the decrease in smoking prevalence and use of smokeless tobacco over the past 26 years. Meanwhile, the increase in breast cancer incidence may be associated with women giving birth to children at later ages, and increase in overweight and obesity.
• Types of cancer incidence varies greatly across the country corresponding to a variety of different risk factors. States in the north-east generally have high tobacco use as well as a high incidence of lung, oesophageal, nasopharynx and other pharynx cancers associated with such tobacco use. The prevalence of the human papillomavirus or HPV and cervical cancer, which the virus causes, are both high in Dindigul in Tamil Nadu. Consumption of smoked or preserved meats and stomach cancer are high in Mizoram. Delayed childbearing and is common in Kerala, a state that also has a high rate of breast cancer.

High and increasing suicide rate

• India recorded 2,30,314 suicide deaths in 2016.
• In 1990, suicide among women in India were 25% of all the suicide deaths in the world. This number has shot up to almost 37% in 2016 or 2.1 times the global average. The study notes that married women account for the highest proportion of suicide deaths among women in India, with contributing factors including arranged and early marriage, young motherhood, low social status, domestic violence, and economic dependence.
• Among men, suicides have gone up from 18·7% of the number of suicides globally in 1990 to 24·3% in 2016.
• Suicide was the leading cause of death in India in 2016 for those between 15 and 39 years.
• The highest age-specific suicide death rates among women in 2016 occurred in for ages 15-29 years and 75 years or older, and among men for ages 75 years or older.
• If these trends continue, the probability of India achieving the it sustainable development goal of having zero suicides by 2030 is low. The study quantifies this as the majority of states with 81% of India’s population have less than 10% probability. Three states have a probability of between 10% and 15% and six states have a change of between 25% and 37% of eliminating suicide.