The burden of digestive diseases in Asian countries and territories from 1990 to 2019: an analysis for the Global Burden of Disease 2019 study

Over the past 30 years, a declining trend in the ranking of DALYs and the age-standardized rates of DALYs due to digestive diseases were observed, while the absolute number of DALYs showed an increasing trend in Asia. Among all level 3 causes in GBD 2019, a decreasing trend in the ranking of DALYs was also found. Cirrhosis and other chronic liver diseases, which ranked 13th in 1990 and 17th in 2019, were the primary contributors to the burden. DALYs of digestive diseases were negatively related to SDI, with a few exceptions. Among the four risk factors in our study, alcohol use was most attributable. In addition to DALYs, there was an observed upward trend in the numbers of prevalence, incidence, and deaths. Demographic changes, population growth, as well as aging may be the primary factors driving and sustaining this trend, emphasizing the need for healthcare systems to provide essential treatment and care for the expanding demographic⁸.

The burden of digestive diseases in Asians varied by sex and age. The age group of 45–59 years had the most significant contribution to the burden of digestive diseases measured in DALYs. The high burden of digestive diseases among the working-age population caused enormous economic costs to societies, highlighting the imperative need for measures to reduce the prevalence and mortality from digestive diseases. Notably, there were higher deaths and DALYs burden observed in children aged 1–4 compared to those aged 5–20, which could be attributed to paralytic ileus and intestinal obstruction in children primarily. Compared with females, males bear a higher burden of digestive diseases. The Griswold’s study showed that alcohol use, associated with greater health loss in males compared to females, could be one of the driving factors⁹. It was reported that cirrhosis and other chronic liver diseases were higher in males. Moreover, male gender is an important risk factor of Hepatocellular Carcinoma among metabolic dysfunction-associated steatotic liver disease (MASLD) patients¹⁰. Chronic pancreatitis is also influenced by gender. Xiao’s study showed that although there was no gender disparity observed for acute pancreatitis or pancreatic cancer, the occurrence of chronic pancreatitis was twice as prevalent in males as in females¹¹. This could be attributed to the genotype in chronic pancreatitis partly¹².

The burden of digestive diseases in Asian also showed geographical variations, with a lower burden observed in countries with higher levels of SDI, except in middle-SDI countries. This trend could be attributed to differences in lifestyle and access to healthcare resources, emphasizing the importance of reducing healthcare disparities among ethnic and social groups^13,14.

Our data suggested that cirrhosis and other chronic liver diseases not only contribute to 52.25% of DALYs associated with digestive diseases but also account for more than half of deaths due to digestive diseases in Asia. As a significant contributor to mortality and morbidity among individuals with digestive diseases, the burden and epidemiology of cirrhosis and other chronic liver diseases are undergoing changes. The most common causes of cirrhosis and other chronic liver diseases worldwide are MASLD, alcohol-related liver disease, and hepatitis B virus and hepatitis C virus¹⁵. However, the etiologies of cirrhosis and other chronic liver diseases are transitioning from viral to non-viral risk factors^10,15,16,17. This could be attributed to heightened alcohol consumption, the increasing prevalence of obesity, and the pandemic of diabetes on the one hand, and advancements in the management of infections caused by hepatitis B virus and hepatitis C virus on the other hand¹⁶. In line with previous studies, chronic hepatitis B and C, including cirrhosis, showed a downward trend, particularly in China and India, both of which have played a significant role in reducing HBV incidence in Asia. China, as the first developing country to introduce a universal hepatitis B vaccination program for newborns and infants in 1992, achieved a reported three-dose hepatitis B (HepB3) coverage of 99.6% and a timely birth-dose coverage (HepB-TBD) of 95.6% by 2015, while India reported a HepB3 coverage of 91%, and this has significantly contributed to the reduction of HBV infection incidence in these regions^18,19. Noteworthy, MASLD has evolved into a significant public health issue globally, with Asia leading the rise in its prevalence. With the epidemic of obesity and type 2 diabetes (T2DM), It is anticipated that the incidence of MASLD, which is not only found in adults but also in children and adolescents, will keep rising, leading to an immense clinical and economic burden^10,20,21. Moreover, the increase in alcohol consumption, driven by economic growth, may have played a significant role in the escalating burden of alcohol-related liver disease, with the relative deficiency of aldehyde dehydrogenase 2 in Asian populations, compared to Western populations, potentially exacerbating liver damage induced by alcohol toxicity²².

Although the burden of cirrhosis and other chronic liver diseases has improved when adjusted for aging and population growth, the absolute number of DALYs has continued to rise. The increase in metabolic syndrome, alcohol abuse, and injection drug use in recent years could potentially exacerbate the future burden of cirrhosis. Patients with cirrhosis and other chronic liver diseases experienced higher healthcare expenses, lower employment rates, reduced income, elevated rates of comorbidities, more disability, and a lower quality of life²³. While treatment of decompensated forms of cirrhosis may not result in a significant improvement in survival, it is essential to prioritize greater efforts in promoting primary prevention, identifying and treating liver disease at an early stage, and enhancing access to healthcare. Inexpensive and cost-effective preventive measures, such as administering HBV vaccinations, conducting screenings, ensuring safe blood transfusions, maintaining hygienic health facilities, and providing general education, are crucial in this regard⁴.

Followed by cirrhosis and other chronic liver diseases, upper digestive system diseases were another primary contributor to digestive disease burden in Asia. Among upper digestive system diseases, peptic ulcer disease was observed a significant decrease, due to the reduced prevalence of Helicobacter pylori (H. pylori) infection and the extensive usage of potent anti-secretory drugs. However, the increasing use of non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin could take a heavy toll on the aged population, and ulcers not associated with H. pylori infection and NSAIDs were imposing great challenges to the diagnosis and therapy^24,25. Dumic’s study revealed that besides being linked to peptic ulcer disease, H. pylori infection may be associated with extra intestinal diseases (neurologic, dermatological, cardiovascular, and hematologic)²⁶. Another study conducted by Sbeit showed that both upper digestive system diseases and cardiovascular diseases were common and could affect each other through systemic inflammation, disturbed hemodynamics, interactions, and adverse effects of medications, as well as bacterial overgrowth²⁷. Taking into account the combined effects of multiple etiologies could be beneficial for optimizing patient management and improving patient prognosis.

Alcohol use, smoking, drug use, and high body-mass index were included in the GBD database as risk factors for digestive diseases, the deleterious impacts of which have been well established^9,28,29. In our study, alcohol consumption was observed to be the most attributable risk factor for digestive diseases in Asia. The harmful use of alcohol, recognized as a global issue, was estimated to be the world’s third-largest risk factor for disease and disability, with the liver considered the major victim³⁰. Meanwhile, the various risk factors do not only act independently. For example, as an independent risk factor for pancreatitis, smoking could synergize with alcohol-related risks³¹. In the past few decades, urbanized lifestyles and dietary changes in many Asian countries, characterized by increased consumption of added fats and reduced physical activity, led to a higher prevalence of obesity. This obesity epidemic may significantly impact the health trajectory of future generations^22,32. These four risk factors in our study were modifiable, and their impact on the burden of digestive diseases demonstrates the necessity of implementing ambitious prevention strategies in public health regulations and policies.

In recent years, increasing attention has been given to metabolic syndrome (MetS), which includes visceral obesity, dyslipidemia, diabetes mellitus, and hypertension, with MASLD emerging as the primary hepatic disorder in patients with this syndrome³³. MASLD, MetS, and atherosclerosis share overlapping risk factors and similar pathophysiological mechanisms. MASLD is considered an emerging risk enhancer for atherosclerotic cardiovascular diseases, and the relationship between MASLD and type 2 diabetes is bidirectional^34,35,36. Digestive diseases, cardiovascular diseases, and endocrinological disorders all significantly contribute to the global disease burden and escalating healthcare costs^13,37,38. These interconnected conditions underscore the need for integrated prevention and management strategies. Moreover, the global burden of cancer is substantial and growing, with digestive system cancers constituting a significant proportion of human cancers, and effectively managing digestive diseases could potentially contribute to the reduction of these cancers^39,40. Additionally, other generalized diseases, such as comorbid malnutrition, could worsen outcomes for patients with digestive diseases⁴¹. Therefore, it is essential to analyze these additional risk factors and comorbidities after their inclusion in the GBD database.

Our study investigated the burden of digestive diseases over the past 3 decades in Asian countries. However, there were some limitations in this study. Firstly, several digestive diseases, such as Barrett’s esophagus and eosinophilic esophagitis, may not be present in the GBD 2019 database. Secondly, The GBD 2019 contains only pre-COVID-19 pandemic data. Studies showed that, in addition to affecting the respiratory system, the novel coronavirus can also lead to a range of digestive system diseases. Lockdowns and restricted vaccine availability during this stage also had a negative impact on digestive diseases^42,43. Lastly, this study only concentrated on the impact of individual etiologies and did not include the combined effects of multiple causes, as well as the synergistic interactions among risk factors.