DESK REVIEWS | 01.02.01. Prevalence and burden of significant non-communicable diseases (NCDs) or conditions

DESK REVIEW | 01.02.01. Prevalence and burden of significant non-communicable diseases (NCDs) or conditions

Risk behaviours

In 2017, around 10.1% of the adult population (≥18 years old) smoked tobacco, of which 2.6% were classified as heavy smokers (≥20 cigarettes/per day) and 6.7% were passive smokers in the work environment. Around 54% of people were classified as being overweight (IMC≥35) and 18.9% were obese (≥30). About 14.6% consumed sugary drinks five or more days per week and 19.1% regularly consumed alcohol to excess. Around 13.9% of both men and women (≥18 years old) were physically inactive. There was a greater difference among sex in the age group between 18 and 24 years where 21% of the women and 9% of men were physically inactive. Besides, physical inactivity was increased among people with fewer years of schooling (Brazilian Ministry of Health, 2017b).

Diabetes

The prevalence rate of diabetes in Brazil varied from 8 to 9%, and 8.1% when adjusted by age, according to the Brazilian Society of diabetes in 2017 (Brazilian Society of Diabetes, 2017). Between 2006 and 2016, the number of people with diabetes grew by 61.8%, amounting to 8.9% of the population (9.9% in women and 7.8% in men) (Ministry of Health, 2017). In 2017, estimates from the Brazilian Ministry of Health based on data from 27 large cities (people aged 18+) showed that the prevalence of diabetes in the urban population was 7.6% for both genders. However, this rate tended to increase with age and was higher among those with lower education levels (up to eight years of education) (Brazilian Ministry of Health, 2017b). Estimates from the National Health Research 2013 revealed that the prevalence of diabetes was 4.6% in people aged 18 years and over in the rural population of Brazil (Brazilian Institute of Geography and Statistics, 2020).

High Blood Pressure

The prevalence of high blood pressure in the population aged 18 and over is about 24.3%, being higher in women (26.4%) than in men (21.7%). In both genders, prevalence rate tended to increase with age and was higher in those with low levels of education (up to 8 years of education) (Brazilian Ministry of Health, 2017b).

Obesity

The prevalence of being overweight is about 54%, being higher in men (57.3%) than in women (51.2%). Women who were older were more likely to be overweight, while those who were more educated were less likely to be overweight. No specific pattern was observed for men. The prevalence of obesity was 18.9% for men and women. The frequency of obesity was lower among more educated women, but no particular pattern was observed among men (Brazilian Ministry of Health, 2017b).

Mental disorders

Between 1999 and 2016, Alzheimer’s disease was one of the ten leading causes of age-standardised years of life lost (YLL) rate in Brazil. This condition was also among the main causes of years of life lived with disability (YLD) in 2016 together with depressive, bipolar and anxiety disorders (GBD 2016, 2018). According to a WHO report, the prevalence of depressive disorders in Brazil was 5.8% and of anxiety disorders was 9.3% in 2017 (World Health Organization, 2017). We could not find any report document ‘mental disorders’ more generally.

References:

Brazilian Institute of Geography and Statistics. (2020). Tabela 4492: Pessoas de 18 anos ou mais de idade que referem diagnóstico médico de diabetes, total, percentual e coeficiente de variação, por condição em relação à força de trabalho na semana de referência e situação do domicilio. SIDRA. https://sidra.ibge.gov.br/tabela/4492

Brazilian Ministry of Health. (2017b). Ministry of Health Report on Surveillance of Risk Factors.

Brazilian Society of Diabetes. (2017). Atlas da diabetes no Brasil.

GBD 2016. (2018). Burden of disease in Brazil, 1990-2016: A systematic subnational analysis for the Global Burden of Disease Study 2016. The Lancet Neurology, 392. http://dx.doi.org/10.1016/S0140-6736(18)31221-2

Ministry of Health. (2017). Ministry of Health Report on Surveillance of Risk Factors.

World Health Organization. (2017). Depression and Other Common Mental Disorders: Global Health Estimates. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf;jsessionid=F9B8AE77F2B1D3698E01577B2AFCBC03?sequence=1

There has been an increase in the burden of non-communicable (NCD) diseases over the past two decades, with NCD burden rising from 30% of total disease burden in 1990 to 55% of total disease burden in 2016 (Indian Council of Medical Research, Public Health Foundation of India and Institute of Health Metrics and Evaluation [ICMR, PHFI and IHME], 2017). The most considerable DALY rate increase (from 1990-2016) was observed for diabetes and ischemic heart disease (IHD) (ICMR, PHFI and IHME, 2017). In addition, there has also been a rise in NCD neurological disorders in India, with their contribution to total DALYs increasing from 4% in 1990 to 8.2% in 2019 (India State-Level Disease Burden Initiative Neurological Disorders Collaborators, 2021). Stroke, headache disorders, and epilepsy contributing most significantly to total neurological disorder DALYs in 2019 (India State-Level Disease Burden Initiative Neurological Disorders Collaborators, 2021).

Moreover, NCDs which typically present over the age of 55 in developed countries are presenting almost a decade earlier (≥45 years of age) in the Indian population (Arokiasamy, 2018). In addition, considering that communicable diseases are also highly prevalent in the country as they contribute to 27.5% of all deaths (Mohan et al., 2019), the Indian public health system faces significant challenges with this double burden of disease (Arokiasamy, 2018).

State wise variations in NCDs:

As per GBD 2019 data, the prevalence of NCDs varies across different across states. In 2019, the lowest prevalence rate was in Arunachal Pradesh, which had a prevalence rate of 91,599.98 prevalent cases per 100,000 people (90,577.05 – 92,577.86) (ICMR, PHFI and IHME, 2019). Whereas, the highest prevalence was in Kerala, with 94,140.27 prevalent cases per 100,000 people (93,473.85 – 94,765.24) (ICMR, PHFI and IHME, 2019). With respect to NCD burden, the number of deaths and Disability Adjusted Life Year’s (DALY’s) are also described. The least number of deaths was in the state of Arunachal Pradesh with 262.98 deaths per 100,000 people (214.73 – 318.26) and the highest number of deaths was in the state of Kerala – 596.35 deaths per 100,000 people (503.58 – 697.71) (ICMR, PHFI and IHME, 2019). In terms of DALY’s – the state of Arunachal Pradesh again had the lowest number of 14,675.94 per 100,000 people (12,212.71 – 17,202.98) and Tamil Nadu had the highest number of DALY’s with 23.406.3 per 100,000 people (19,820.32 – 27,314.47) (ICMR,PHFI and IHME, 2019).

References:

Arokiasamy, P. (2018). India’s escalating burden of non-communicable diseases. The Lancet Global Health, 6, e1262–e1263. https://doi.org/10.1016/S2214-109X(18)30448-0

India State-Level Disease Burden Initiative Neurological Disorders Collaborators (2021). The burden of neurological disorders across the states of India: The Global Burden of Disease Study 1990-2019. The Lancet. Global health, 9(8), e1129–e1144.

Indian Council of Medical Research, Public Health Foundation of India and Institute for Health Metrics and Evaluation (ICMR, PHFI, and IHME). (2017). India: Health of the Nation’s States-The India State-level Disease Burden Initiative, New Delhi: ICMR, PHFI and IHME. Available from: https://www.healthdata.org/sites/default/files/files/policy_report/2017/India_Health_of_the_Nation%27s_States_Report_2017.pdf

Indian Council of Medical Research, Public Health Foundation of India, and Institute for Health Metrics and Evaluation (ICMR, PHFI, and IHME). (2019). GBD India Compare Data Visualization. Available from: https://vizhub.healthdata.org/gbd-compare/

Mohan, P., Mohan, S. B., & Dutta, M. (2019). Communicable or noncommunicable diseases? Building strong primary health care systems to address double burden of disease in India. Journal of family medicine and primary care8(2), 326–329. https://doi.org/10.4103/jfmpc.jfmpc_67_19

According to the WHO (2014) non-communicable diseases are now the leading causes of mortality in Indonesia, accounting for an estimated ‘71% of total deaths’ (WHO Noncommunicable Diseases Country Profiles, 2014). NCDs, including cardiovascular diseases (35%), maternal, perinatal and nutritional conditions (21%), cancers (12%), chronic respiratory diseases (6%), injuries (6%), and diabetes (6%) account for a considerable share of mortality (WHO, 2018). Mortality due to diabetes was found to have increased by 63 per cent between 2005 and 2016. This represents the largest increase in mortality among NCDs in Indonesia. Furthermore, ‘hypertension and diabetes are primary risk factors for stroke’. The prevalence of strokes between 2007 and 2013 has increased from 8.3 strokes to 12.3 strokes per 1000 population. In 2014, approximately 15 per cent of mortality was related to strokes, which is ‘among the highest proportion’ worldwide (Agustina et al., 2019, p.82).

The cost of care for people with diabetes and stroke are expected to cause substantial burden on the Indonesian health care system. Agustina and colleagues citing data from a 2014 report by the National Institute of Health Research Development report that the cost burden for diabetes (56%), stroke (57%), hypertension (46%), and heart disease (34%) are expected to increase substantially by 2020. The financial implications have been estimated to amount to $5.80 billion for the health care system as well as increasing out-of-pocket costs (Agustina et al., 2019, p.82)

Furthermore, over the last decade, illnesses such as depression and anxiety disorders have been found to increase by 22 per cent and 18 per cent, respectively (Agustina et al., 2019, p.80). This made depressive disorders the ‘seventh largest contributor to years lived with disability in 2016’. It is reported that in 2013 approximately 400,000 people aged 15 and older lived with severe mental disorders. Despite the banning of restraints in 1977, an estimated 57,200 (14.3%) people were subject to this practice (Agustina et al., 2019, p.83; based on National Institute of Health Research and Development. Basic health research 2013).

Overview of significant NCDs

Most data on NCDs are available from the Riset Kesehatan Dasar (Riskesdas)/Basic Health Survey, conducted every five years by the Ministry of Health. Since 2018, in line with Indonesia’s One Data Policy, Riskesdas was integrated into the Survei Sosial Ekonomi Nasional (Susenas)/National Socioeconomic Survey, which is a household survey managed by Statistics Indonesia (Kementrian PPN/BAPPENAS, 2018).

Diabetes Mellitus

The prevalence of diabetes in people aged 15 or above based on previous diagnosis from healthcare professionals increased from 1.1% in 2007 to 2.1% in 2013 and decreased slightly to 2.0% in 2018 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013; Kementrian Kesehatan Republik Indonesia, 2018). The highest prevalence can be found in the four provinces DKI Jakarta (3.4%), DI Yogyakarta (3.1%), East Kalimantan (3.1%), and North Sulawesi (3.0%) (Kementrian Kesehatan Republik Indonesia, 2018). This is likely linked to stark increase in obesity (10% in 2007 to 21.8% in 2018 and other NCDs) (Agustina et al., 2019, p.75; Kementrian Kesehatan Republik Indonesia, 2018). According to the latest Riskesdas survey, a measurement based of blood glucose level in line with the American Diabetes Association (ADA) and PERKENI 2015 criteria was added to the survey (Kementrian Kesehatan Republik Indonesia, 2018). The national prevalence is much higher (10.9%) when the diagnosis of diabetes is based on this, although this cannot be compared to previous data.

 Hypertension

In 2018, the prevalence of hypertension was 34.11% among the population aged 18 or over (based on blood pressure measurement). This marks as a significant increase from 2013, when prevalence was recorded at 25.8%. However, there had been a 5.9% decrease between the years 2010 to 2013 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013).

Heart disease

In 2018, the prevalence of all types of heart disease was 1.5%. The four provinces with the highest prevalence of heart disease are North Kalimantan (2.2%), DI Yogyakarta (2.0%), Gorontalo (2.0%), and DKI Jakarta (1.9%) (Kementrian Kesehatan Republik Indonesia, 2018). Previous data in 2013 only reported coronary heart disease (1.5%) and heart failure (0.3%) prevalence in the population (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013)

Stroke

In 2018, the prevalence of stroke in Indonesia confirmed by diagnosis was 10.9 per 1,000 people, which presents a decrease from 12.1 per 1,000 people in 2013 (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013; Kementrian Kesehatan Republik Indonesia, 2018). To aid interpretation of this data, it is important to point out that stroke is reported as the leading cause of death in Indonesia (CDC, 2020; IHME, 2019), (thus prevalence reported here might indicate the number of survivors). However, prevalence of stroke may be underreported as some patients may not have been able to access appropriate healthcare services or were not aware of their diagnosis. Estimates based on diagnosis and interview of symptoms suggest a prevalence rate of 1.21% in 2013  (Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI, 2013), but results using this method were not reported for 2018 data.

References:

Agustina, R., Dartanto, T., Sitompul, R., Susiloretni, K. A., Suparmi, Achadi, E. L., Taher, A., Wirawan, F., Sungkar, S., Sudarmono, P., Shankar, A. H., Thabrany, H., Susiloretni, K. A., Soewondo, P., Ahmad, S. A., Kurniawan, M., Hidayat, B., Pardede, D., Mundiharno, … Khusun, H. (2019). Universal health coverage in Indonesia: concept, progress, and challenges. The Lancet, 393(10166), 75–102. https://doi.org/10.1016/S0140-6736(18)31647-7

Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI. (2013). Riset Kesehatan Dasar 2013 (Vol. 6). https://doi.org/1 Desember 2013

CDC. (2020). CDC in Indonesia (Issue Cdc).

IHME. (2019). Indonesia. http://www.healthdata.org/indonesia

Kementrian Kesehatan Republik Indonesia. (2018). Riset Kesehatan Dasar 2018. https://doi.org/1 Desember 2013

Kementrian PPN/BAPPENAS. (2018). Revolusi Kebijakan One Data, Riskesdas 2018 Tampil Beda. Berita Pembangunan. https://www.bappenas.go.id/id/berita-dan-siaran-pers/revolusi-kebijakan-one-data-riskesdas-2018-tampil-beda/

National Institute of Health Research and Development. (2013). Basic health research 2013. Report: Ministry of Health Republic of Indonesia, Jakarta, 2013.

WHO. (2014). Noncommunicable Diseases Country Profiles, 2014. https://apps.who.int/iris/bitstream/handle/10665/128038/9789241507509_eng.pdf;jsessionid=26014D4B19896037A6A9EE830F4A33C4?sequence=1

WHO. (2018). NCDs Country Profiles 2018 WHO. 224. https://www.who.int/nmh/publications/ncd-profiles-2018/en/

Non-communicable diseases (NCDs) account for more than 50 to 70% of hospital admissions and 55% of hospital deaths in Kenya (MoH-Kenya, KNBS, & WHO, 2015). The greatest burden on the healthcare system is attributable to four major NCDs: cardiovascular diseases, diabetes mellitus, cancer, and chronic respiratory illnesses. According to the 2015 NCDs surveillance using the STEPS (STEPwise approach to surveillance), a standardized protocol involving three levels of gathering data on demographics and risk factors from nationally representative populations, articles revealed the following rates (Wamai, Kengne, & Levitt, 2018):

Hypertension: The age-standardized prevalence for hypertension in Kenya was 24.5% with 15.6% of them being aware of their elevated blood pressure of which 26.9% were on treatment and only half were able to achieve their blood pressure control.

Diabetes: The age-standardized prevalence for pre-diabetes and diabetes mellitus was 3.1% and 2.4% respectively, with 43.7% being aware of having pre-diabetes or diabetes of whom 20% were on treatment and only 7% were able to achieve glycaemic control.

Cervical cancer: Out of 1180 women who were interviewed, 16.4% had screened for cervical cancer despite high awareness.

NCDs common risk factors: Three-quarters of individuals who had participated in the STEPS study had four to six risk factors for NCDs while 10% were exposed to more than six risk factors. The most universal risk factor was inadequate fruit intake (99.8%), and majority had high dietary salt consumption (89.5%) and insufficient physical activity (80.3%). Other modifiable risk factors associated with these four NCDs are tobacco use, excessive alcohol consumption, air pollution, environmental degradation, climate change and psychological stress. Additional significant contributors to the burden of disease are violence, injuries, haemoglobinopathies, mental disorders, oral, eye and dental diseases.

 

References:

MoH-Kenya, KNBS, & WHO. (2015). Kenya STEPwise Survey for Non Communicable Diseases Risk Factors 2015 Report. MoH-Kenya. https://www.health.go.ke/wp-content/uploads/2016/04/Executive-summary-6-2.pdf

Wamai, R. G., Kengne, A. P., & Levitt, N. (2018). Non-communicable diseases surveillance: Overview of magnitude and determinants in Kenya from STEPwise approach survey of 2015. BMC Public Health, 18(Suppl 3), 1–8. http://doi.org/10.1186/s12889-018-6051-z

Diabetes

The main non-communicable diseases in Mexico are diabetes, hypertension, and obesity. The prevalence of diabetes reached very high levels at the beginning of this century and has been steadily increasing. In 2000, 6.5% of the population aged 20 or over was diagnosed as diabetic, rising to 7.5% in 2006 and to 9.4% in 2016 (Rojas-Martínez et al., 2017).

In an actualisation of the GBD reported in 2016, in Mexico diabetes was the first cause of YLDs, similar to other countries in Latin America like Barbados, Jamaica, Puerto Rico, Saint Vincent and the Grenadines, Trinidad and Tobago, and the Virgin Islands (Vos et al., 2016). This emphasises the necessity of intensive long-term management to prevent fatal and disabling complications in those countries.

The National Health and Nutrition Survey (ENSANUT), a national probabilistic survey, reported in 2016 that 9.4% of the adults interviewed (10.3% of women and 8.4% of men), reported a diagnosis of diabetes by a physician or other health professionals (Table 4), a slight increase from ENSANUT 2012’s reported prevalence of 9.2%, and 7.25% in ENSANUT 2006. The majority (87.8%) reported receiving medical treatment to control their illness. Most people with a previous medical diagnosis of diabetes were between 60 and 70 years of age (INSP & Secretaría de Salud, 2016).

Table 4. Percentage of adults who reported having received a prior medical diagnosis of diabetes

  Men   Women   Total  
Age group Number (Thousands) % Number (Thousands) % Number (Thousands) %
20-29 23.2 0.3 153.1 1.6 176.3 1.0
30-39 70.0 0.9 275.6 3.1 345.6 2.1
40-49 543.6 9.4 582.6 8.2 1126.2 8.7
50-59 743.9 17.7 872.1 17.2 1616 17.4
60-69 951.8 27.7 1,228.4 32.7 2,180.2 30.3
70-79 280.1 19.3 500.5 29.8 780.5 24.9
80 and more 80.6 12.5 159.3 21.8 239.9 17.5
Total 2,693.2 8.4 3,771.6 10.3 6,464.8 9.4

(Source: ENSANUT MC, 2016)

The report of diabetes by previous medical diagnosis was higher among women than among men, both nationally (10.3% vs 8.4%), in urban (10.5% vs 8.2%) or rural (9.5% vs 8.9%) localities (INSP & Secretaría de Salud, 2016).

Hypertension

According to ENSANUT 2016 (Campos-nonato et al., 2018), current prevalence of hypertension[1] is 25.5%, although 40.0% of these did not know they had hypertension before the survey. Of the total adults 20 years and older with a previous diagnosis of hypertension who were receiving treatment, only 45.6% had controlled or normal hypertension (SBP≤140mmHg; DBP≤90mmHg) when measured at the time of the survey. By sex, 26.1% of men and 24.9% of women reported having hypertension. The prevalence was highest among people aged 70 to 79 years. In ENSANUT 2016, no statistically significant differences were observed in the prevalence of arterial hypertension between geographic regions, nor between rural and urban localities (INSP & Secretaría de Salud, 2016).

Table 5. Prevalence of hypertension, by sex and age group. Mexico 2015

Hypertension Detected at survey Previous diagnosis
% (CI 95%) n % (CI 95%) n % (CI 95%) n
Total 25.5 23.3-27.8 2204 10.2 8.9-11.7 839 15.3 13.4-17.5 1365
Women 26.1 23.5-28.9 1426 7.7 6.5-9.1 447 18.4 16.0-21.2 979
Men 24.9 21.6-28.5 778 12.8 10.9-15.0 392 12.1 9.4-15.5 386
Age Group
20-29 8.3 6.1-11.2 96 5.4 3.6-8.0 54 2.9 1.8-4.7 42
30-39 13.1 8.8-19.2 198 5.6 3.8-8.1 104 7.6 3.8-14.6 94
40-49 24.2 20.9-27.9 388 10.6 8.3-13.6 164 13.6 11.3-16.2 224
50-59 39.8 35.3-44.5 489 13.3 10.4-16.9 157 26.5 22.1-31.4 332
60-69 56.0 50.6-61.2 529 19.6 14.4-26.2 178 36.3 30.2-43.0 351
70-79 66.3 60.0-72.1 367 23.9 17.9-31.2 129 42.4 36.0-49.1 238
≥80 59.4 49.1-69.0 137 22.1 14.7-31.9 53 37.3 27.5-48.3 84

Source: (Campos-nonato et al., 2018)

Obesity

In Mexico it is considered that there is an epidemic of being overweight and obesity, which began in the 90’s and has presented a growing trend, especially in children under 20 (Secretaría de Salud, 2015b). By sex, the prevalence of obesity (BMI ≥30 kg/m2) is higher in females (38.6%, 95% CI 36.1, 41.2) than males (27.7%, 95% CI 23.7, 32.1) (Secretaría de Salud, 2015b).

The prevalence of abdominal obesity (defined as having a waist circumference in men ≥90 cm and in women ≥80 cm) in adults 20 years of age or older is 76.6%. Prevalence is higher for women than for men and increases with age, except for the very old (INSP & Secretaría de Salud, 2016).

Table 6. Prevalence of abdominal obesity* in adults 20 years of age or older, categorised by sex and age groups

Age Group Waist Perimeter Abdominal obesity
  Men Women Men Women
20-29 49.0 24.7 51.0 75.3
30-39 32.2 10.2 67.8 89.8
40-49 29.8 8.4 70.2 91.6
50-59 27.8 5.3 72.2 94.7
60-69 25.9 6.1 74.1 93.9
70-79 20.0 13.7 80.0 86.3
≥80 33.2 14.7 66.8 85.3
Total 34.6 12.3 65.4 87.7

Source: (Secretaría de Salud, 2015b)

According to national data, the combined prevalence of being overweight and obese in the school-age population in 2016 was 33.2%. The prevalence of being overweight was 17.9% and obesity 15.3%. In contrast with the adult population, a higher prevalence of obesity was observed in boys 18.3%, compared to girls 12.2% (INSP & Secretaría de Salud, 2016).

[1] Hypertension is classified as those who reported have been previously given a diagnosis of hypertension by a health professional or that presented, when interviewed, measures of systolic blood pressure (SBP) ≥140mmHg and diastolic blood pressure ≥90mmHg.

References:

Campos-nonato, I., Hernández-Barrera, L., Pedroza-Tobías, A., Medina, C., & Barquera, S. (2018). Hipertensión arterial en adultos mexicanos: prevalencia, diagnóstico y tipo de tratamiento. Ensanut MC 2016. Salud Publica de Mexico, 60(3), 233–243. https://doi.org/10.21149/8813

INSP, & Secretaría de Salud. (2016). Encuesta Nacional de Salud y Nutrición de Medio Camino, 2016 (Vol. 2016). https://doi.org/10.1111/acem.12546

Rojas-Martínez, R., Basto-Abreu, A., Aguilar-Salinas, C. A., Zárate-Rojas, E., Villalpando, S., & Barrientos-Gutiérrez, T. (2017). Prevalencia de diabetes por diagnóstico médico previo en México. Salud Pública de México, 60(3). https://doi.org/10.21149/8566

Secretaría de Salud. (2015b). Prontuario de la Salud. Informe sobre la salud de los Mexicanos 2015.

Vos, T., Allen, C., Arora, M., Barber, R. M., Brown, A., Carter, A., Casey, D. C., Charlson, F. J., Chen, A. Z., Coggeshall, M., Cornaby, L., Dandona, L., Dicker, D. J., Dilegge, T., Erskine, H. E., Ferrari, A. J., Fitzmaurice, C., Fleming, T., Forouzanfar, M. H., … Zuhlke, L. J. (2016). Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. The Lancet, 388(10053), 1545–1602. https://doi.org/10.1016/S0140-6736(16)31678-6