Abstract
Background:
Evaluating the impact of digestive system diseases is vital for devising effective prevention strategies. However, comprehensive reports on the burden of digestive system diseases in China are lacking. Our study aimed to provide an overview of the burden and trends of digestive system diseases from 1990 to 2019 in China and its provinces.
Methods:
This cross-sectional study utilized the Global Disease Burden Study 2019 to estimate the incidence, mortality rate, disability-adjusted life years (DALYs), years of life disability, years of life lost, and changes in the burden of digestive diseases across Chinese provinces from 1990 to 2019. The analysis of disease burden primarily examines the characteristics of sub-disease distribution, time trends, age distribution, and sex distribution. Additionally, we compared provincial age-standardized DALYs for digestive diseases with the expected rates based on the socio-demographic index (SDI).
Results:
In 2019, there were 499.2 million cases of digestive system diseases in China, resulting in 1,557,310 deaths. Stomach cancer, colon and rectal cancer, and esophageal cancer are the top three diseases associated with mortality and DALY related to digestive system diseases. Meanwhile, cirrhosis and other chronic liver diseases, gastroesophageal reflux disease, and gallbladder and biliary diseases are the top three kinds of diseases with the highest prevalence among digestive system diseases. The risk of gastric cancer sharply increases among men after the age of 40 years, leading to a significant disparity in burden between men and women. As the SDI increased, the DALYs associated with digestive system diseases in China and its provinces showed a downward trend.
Conclusion:
Our study highlights the inverse correlation between DALYs associated with digestive system diseases and the SDI.
Keywords: Chronic liver diseases, Colon and rectal cancer, Digestive disease, Epidemiology, Esophageal cancer, Gastrointestinal diseases, Health expenditures, Liver cancer, Stomach cancer
Introduction
Digestive system diseases include non-neoplastic digestive diseases and digestive system neoplasms. Digestive system neoplasms can further be categorized into malignant neoplasms, and benign and in situ neoplasms.[1] Globally, digestive system diseases are prevalent and significantly increase socioeconomic and individual burdens.[2,3,4] The incidence of digestive cancer is increasing worldwide, with gastric, liver, and colorectal cancers being prominent contributors to cancer-related mortality.[4] While non-neoplastic digestive diseases also attract an increasing attention. Apart from directly leading to mortality, chronic diseases such as chronic hepatitis, peptic ulcer, and reflux esophagitis significantly impact the quality of life and productivity of patients.[3] Therefore, it is crucial to pay adequate attention to the prevalence and burden of digestive system diseases.
As medical resource demand increases, there is a growing emphasis on the monitoring and measurement of the cumulative effects of digestive system diseases. Various countries and regions, including the US and European Union, have conducted comprehensive surveys on gastrointestinal health and reported significant economic burden associated with digestive system diseases, highlighting the need to improve gastroenterology services.[2,5,6,7] China initiated the Gastrointestinal Health Index project to enhance prevention and control efforts for digestive system diseases and improve the monitoring ability.[8] However, the lack of a systematic burden survey for digestive system diseases, along with a lack of autonomous surveillance system in China limits the development of effective preventive and treatment strategies.
Our study aimed to provide an overview of the burden and trends of digestive system diseases from 1990 to 2019 in China and its provinces. The findings are intended to complement previous reports concerning the burden of various digestive system diseases.[9,10,11,12]
Methods
The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 provides estimates of the incidence, prevalence, mortality, years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life years (DALYs) of 369 diseases and injuries. The definitions of digestive system diseases, digestive system neoplasms, non-neoplastic digestive diseases, malignant neoplasms, benign and in situ neoplasms are derived from the GBD database and a synthesis of resources from PubMed Central. These estimates are stratified by sex, age group, and geographic region, covering 204 countries and territories from 1990. The burden estimation methods have been explained in previously published literature.[13] Here, we summarized the methodology employed to estimate the burden of digestive system diseases in China and its provinces between 1990 and 2019.
We utilized different estimation methods applied in the GBD 2019 to assess the disease burden and evaluate the state of population health at the provincial level in China. Our analysis encompassed 33 provincial level administrative units, excluding the Xinjiang Production and Construction Corps, and Taiwan. These units comprise 22 provinces, 5 autonomous regions, 2 special administrative regions, and 4 municipalities, all herein referred to as provinces.
We focused on six malignant neoplasms, benign and in situ neoplasms, eleven non-neoplastic digestive diseases, and other digestive diseases. The corresponding International Classification of Diseases (ICD) codes are shown in the Supplementary File, http://links.lww.com/CM9/C124. The burden of digestive system diseases was assessed by considering prevalence, mortality, DALYs, YLLs, and YLDs, which were calculated collectively and individually for each disorder. The institutional review board at Changhai Hospital in Shanghai, China, waived ethical approval because data used in the study are publicly available.
DALYs, YLLs, and YLDs
DALYs, the sum of YLLs and YLDs, were utilized to compare both fatal and non-fatal outcomes across different diseases. YLLs were calculated by multiplying the number of deaths by the standard life expectancy at the time of death. The standard life expectancy value was derived from the lowest observed age-specific mortality rate among populations worldwide (>5 million). Conversely, YLDs were computed by multiplying the prevalence of individual sequelae associated with each disease by a disability weight. This weight quantifies the severity of a particular sequelae on a scale ranging from 0 (perfect health) to 1 (death).
Mortality rate estimation
All-cause mortality rates were estimated based on the vital registration data of countries with complete coverage. In countries without complete coverage, the probabilities of death before the age of 5 years and those between the ages of 15 years and 60 years were estimated using verbal autopsies. These probabilities were converted into age-specific death rates by sex, year, and location using model life tables. Cause of death was classified using subsequent versions of the ICD (or the Bespoke classification in some countries). In cases where the coded data provided limited information or when a specific diagnosis was unavailable, cause of death was redistributed to more precise codes. Each death was attributed to a single underlying cause, and the mortality attributable to each cause was determined by multiplying the attributable fraction with the mortality. Cause of death was analyzed using the cause-of-death ensemble model.[13] The sum of all-cause-specific mortality rates was adjusted to match the all-cause mortality rates in each category, defined by age, sex, location, and year to ensure consistency.
Socio-demographic index
Data were stratified by the socio-demographic index (SDI), an indicator of socio-demographic development. It reflects the geometric mean of normalized values of a location’s income per capita, the average number of years of education in the population aged ≥15 years, and the total fertility rate. A higher SDI value indicates a higher level of socioeconomic development.[14] Countries and territories were grouped into five quintiles based on their 2019 SDI values: high, high-middle, middle, low-middle, and low.
DALYs were calculated using GBD 2019 global data, and subgroup analysis was performed based on age, sex, and year. Furthermore, the correlation between SDI and DALYs in various Chinese provinces from 1990 to 2019 was examined. The findings are presented in trend charts and heat maps.
Estimated annual percentage change (EAPC)
In the GBD study, the EAPC is also known as “age-standardized predicted annual change.” These metrics are used to gauge the health status or disease trends within a given population. EAPC values were computed using age-normalized odds regression analysis over time.
Standardization and uncertainty measures
All the rates were age-standardized using the GBD 2019 standard unless stated otherwise. The uncertainty of all estimates was considered by generating 1000 values for each burden estimate and aggregating them across causes and locations. This process was applied to all intermediate steps in the calculation. The lower and upper bounds of the 95% uncertainty intervals were the 25th and 975th values of the ordered 1000 values. Significance of differences was established if 975 or more of the ordered 1000 values of difference were on either side of zero. The ICD codes, imputation procedures, and modeling strategies for digestive system diseases are described in the Supplementary File, http://links.lww.com/CM9/C124.
Results
Mortality, prevalence, YLD, YLL, and DALY rates for digestive system diseases in 1990–2019, globally and in China
In 2019, there were 2.3 billion cases of digestive system diseases worldwide, resulting in 6.3 million deaths. Digestive system diseases accounted for 11.0% of total fatalities and 10.5% of all-cause DALYs. Of these, 3.7 million people died from malignant neoplasms, while 2.6 million died from non-neoplastic digestive diseases [Supplementary Table 1, http://links.lww.com/CM9/C124]. The current global age-standardized mortality rates (ASMRs) and age-standardized disability-adjusted life year rates (ASDRs) of digestive system diseases were 78.5 cases per 100,000 population (with a change rate of −26.3% from 1990 to 2019) and 2135.4 DALYs per 100,000 population (with a change rate of −28.8% from 1990 to 2019), respectively [Supplementary Table 2, http://links.lww.com/CM9/C124].
In 2019, China reported 499.2 million cases of digestive system diseases, resulting in 1,557,310 deaths. Compared with 1990, this marked an increase of 42.1% and 34.7% in cases and deaths, respectively [Supplementary Table 3, http://links.lww.com/CM9/C124]. Most deaths (82.2%) were attributed to malignant neoplasms, while the rise in prevalence rates was primarily driven by non-neoplastic digestive diseases (98.5%). The most prevalent disease was cirrhosis and other chronic liver diseases, totaling 427.9 million cases. The leading causes of deaths were stomach cancer, colon and rectal cancers, and esophageal cancer, with increases in the prevalence of 38.0%, 230.0%, and 45.7%, respectively, compared with the corresponding values reported in 1990. In 2019, the ASMR, age-standardized prevalence rate (ASPR), and ASDR for digestive system diseases were 81.4, 27, 587.6, and 2056.5 per 100,000 people, respectively [Table 1]. Between 1990 and 2019, there was a decrease of 42.4%, 12.0%, and 47.0% in the ASMR, ASPR, and ASDR of digestive system diseases, respectively. During the same period, the ASPR of benign and in situ neoplasms and non-neoplastic digestive diseases decreased by 6.7% and 12.5%, respectively, while the ASPR of malignant neoplasms increased by 77.0%. Pancreatic cancer showed an increase in both ASMR (79.5% change) and ASDR (67.6% change), as did colon and rectum cancer (36.2% and 30.5% changes in ASMR and ASDR, respectively), and gallbladder and biliary tract cancer (12.6% and 7.2% changes in ASMR and ASDR, respectively) since 1990. Other digestive diseases displayed a downward or flat trend.
Table 1.
Age-standardized mortality, prevalence, YLLs, YLDs, and DALYs of digestive system diseases in China and percentage change.
| Diseases | Mortality | Prevalence | DALYs | YLDs | YLLs | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | |
| Digestive system diseases | 81.4 (79.4–83.4) | –42.4 | 27,587.6 (27,585.6–27,589.6) | –12.0 | 2056.5 (2054.5–2058.5) | –47.0 | 210.5 (208.5–212.5) | –16.5 | 1846 (1844.0–1848.0) | –49.1 |
| Benign and in situ neoplasms | NA | NA | 82.6 (63.5–106) | –6.7 | 0 | 0 | 0 (0–0) | 0 | – | – |
| Malignant neoplasms | 66 (64.0–68.0) | –34.7 | 283.1 (281.1–285.0) | 77.0 | 1517.8 (1515.9–1519.8) | –40.3 | 31.8 (29.9–33.8) | 22.7 | 1486.0 (1484.0–1487.9) | –41.0 |
| Colon and rectal cancer | 13.9 (11.9–16) | 36.2 | 167.7 (143.7–194.5) | 243.8 | 320.6 (275.4–370.7) | 30.5 | 15.4 (10.9–20.8) | 187.1 | 305.2 (260.5–355.5) | 27.0 |
| Esophageal cancer | 13.1 (10.3–15.7) | –40.5 | 24.1 (18.2–28.8) | –16.7 | 277.5 (221.7–335.9) | –45.3 | 3.7 (2.6–5.1) | –28.3 | 273.8 (217.9–332.1) | –45.4 |
| Gallbladder and biliary tract cancer | 1.8 (1.3–2.2) | 12.6 | 2.4 (1.7–2.9) | 46.5 | 37.7 (27.9–45.3) | 7.2 | 0.5 (0.3–0.7) | 29.2 | 37.2 (27.4–44.8) | 7.0 |
| Liver cancer | 9.4 (8.0–11.1) | –63.8 | 14.4 (11.9–17.2) | –48.9 | 264.3 (220.7–315.1) | –65.6 | 2.5 (1.7–3.4) | –55.8 | 261.8 (218.1–312.7) | –65.7 |
| Pancreatic cancer | 6 (5.1–6.9) | 79.5 | 4.5 (3.8–5.2) | 85.4 | 136.6 (115.6–158.9) | 67.6 | 1.2 (0.8–1.6) | 77.1 | 135.4 (114.5–157.7) | 67.5 |
| Stomach cancer | 21.7 (18.3–25.3) | –42.4 | 70.1 (58.2–83.8) | 40.1 | 481.1 (403.2–567.4) | –46.9 | 8.6 (6.0–11.5) | –1.7 | 472.6 (394.6–558.6) | –47.3 |
| Non-neoplastic digestive diseases | 15.4 (13.3–17.8) | –61.8 | 27,222.0 (25,712.0–28,849.4) | –12.5 | 538.7 (463.3–615.6) | –59.6 | 178.7 (125.5–246.3) | –21.0 | 360 (308–419.4) | –67.5 |
| Appendicitis | 0.1 (0.1–0.1) | –81.3 | 6.7 (5.3–8.4) | 8.6 | 4.3 (3.4–5.3) | –74.1 | 2.2 (1.4–3.1) | 9.3 | 2.1 (1.7–2.6) | –85.3 |
| Cirrhosis and other chronic liver diseases | 7.8 (6.6–9.2) | –58.7 | 23,561.2 (21,807.8–25,635.2) | –12.1 | 217.8 (183.4–256.9) | –61.8 | 6.3 (4.3–9.1) | –34.0 | 211.5 (177.1–251.2) | –62.3 |
| Gallbladder and biliary diseases | 1.0 (0.9–1.3) | –65.2 | 3436.8 (2899.9–4138.4) | –24.9 | 42.2 (32.7–53.3) | –53.8 | 1.2 (0.8–1.7) | –19.7 | 41.1 (31.3–52.1) | –54.3 |
| Gastritis and duodenitis | 1.1 (0.8–1.3) | –54.1 | 624.8 (512.5–748.5) | –34.6 | 61.7 (49.1–75.6) | –71.7 | 1.7 (1.1–2.5) | –50.7 | 60 (47.5–73.9) | –72.1 |
| Gastroesophageal reflux disease | NA | NA | 4509.3 (3899.1–5133.2) | –0.5 | 65.5 (52.7–79.3) | –54.3 | 1.5 (1.0–2.2) | –22.0 | 64 (51.5–77.7) | –54.8 |
| Inflammatory bowel disease | 0.3 (0.2–0.3) | –65.3 | 47.1 (40.1–55.0) | 106.0 | 18 (12.6–24.5) | –52.2 | 0.5 (0.3–0.8) | –23.8 | 17.5 (12.1–23.9) | –52.8 |
| Inguinal, femoral, and abdominal hernia | 0.1 (0.1–0.1) | –69.5 | 251.1 (204.1–306.2) | –11.9 | 30.3 (23.1–39.5) | –61.9 | 1.5 (0.9–2.2) | –30.2 | 28.9 (21.6–38.0) | –62.7 |
| Pancreatitis | 0.6 (0.5–0.7) | –45.3 | 15.1 (13.1–17.0) | –9.1 | 87.9 (61.1–122.9) | –42.0 | 72.9 (46.3–107.5) | –24.3 | 15.1 (12.4–20.2) | –72.7 |
| Paralytic ileus and intestinal obstruction | 1.1 (0.9–1.2) | –60.9 | 8.2 (7.7–8.7) | 14.3 | 44.3 (33.6–57.1) | –52.1 | 25.6 (15.9–38.8) | –40.5 | 18.6 (13.3–22.2) | –62.3 |
| Peptic ulcer disease | 2.3 (2.0–2.7) | –69.0 | 74.5 (61.5–89.8) | –46.1 | 34.9 (17.7–63) | –0.3 | 34.9 (17.7–63) | –0.3 | NA | NA |
| Vascular intestinal disorders | 0.4 (0.3–0.4) | –19.3 | 0.7 (0.6–0.8) | –1.0 | 13.1 (10.3–16.3) | –46.5 | 7.1 (4.6–9.9) | 102.6 | 6 (4.8–7.0) | –71.3 |
| Other digestive diseases | 0.6 (0.5–0.7) | –76.8 | 0 | 0 | 17.2 (14.1–20.5) | –78.4 | 4.6 (3.1–6.3) | –23.4 | 12.6 (10.1–15.5) | –82.9 |
Data in parentheses are 95% uncertainty intervals; ASR: Age-standardized rate; DALYs: Disability-adjusted life years; NA: Not applicable; YLD: Years lived with disability; YLL: Years of life lost.
Mortality, prevalence, YLDs, YLLs, and DALY rates for digestive system diseases in China and its provinces in 2019 and percentage change from 1990 to 2019
Global data, including data from each SDI region, showed an inverse relationship between SDI and DALYs for digestive system diseases [Supplementary Tables 4 and 5, http://links.lww.com/CM9/C124]. The provincial DALYs were lower in regions with more developed economies and superior environments (e.g., the south-eastern coast), while regions with complex environments and less developed economies (e.g., the west) had higher DALYs. Among these provinces, Qinghai Province bore the heaviest burden [Table 2]. Similar patterns were observed when analyzing subgroups of digestive system diseases, such as malignant neoplasms and non-neoplastic digestive diseases [Supplementary Tables 6 and 7; Supplementary Figures 1–3, http://links.lww.com/CM9/C124]. Among the main contributing diseases to DALYs, stomach cancer was the primary contributor in the economically developed south-eastern coastal areas, whereas non-neoplastic digestive diseases were the main contributors in the less developed areas [Supplementary Figures 4, http://links.lww.com/CM9/C124].
Table 2.
Age-standardized mortality, prevalence, DALYs, YLDs, and YLLs of digestive system diseases in China and its provinces and % change.
| Region | Mortality | Prevalence | DALYs | YLDs | YLLs | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | 2019 ASR per 100,000 | Percentage change in ASR, 1990–2019 (%) | |
| China | 81.4 | –42.4 | 27,587.6 | –12.0 | 2056.5 | –47.0 | 210.5 | –16.5 | 1846.0 | –49.1 |
| Anhui | 89.2 | –46.5 | 27,026.9 | –11.6 | 2171.4 | –51.4 | 199.5 | –13.9 | 1971.9 | –53.4 |
| Beijing | 52.2 | –48.6 | 27,515.2 | –4.5 | 1353.0 | –49.6 | 253.9 | –20.8 | 1099.1 | –53.5 |
| Chongqing | 93.5 | –37.7 | 28,019.5 | –10.5 | 2351.4 | –46.4 | 226.8 | –13.3 | 2124.6 | –48.5 |
| Fujian | 88.7 | –47.4 | 25,304.9 | –10.4 | 2160.6 | –51.7 | 178.4 | –15.6 | 1982.2 | –53.5 |
| Gansu | 92.7 | –39.8 | 30,815.2 | –11.8 | 2422.5 | –45.5 | 334.5 | –16.7 | 2088.1 | –48.3 |
| Guangdong | 60.1 | –56.3 | 26,889.0 | –16.7 | 1633.6 | –56.6 | 204.8 | –15.1 | 1428.8 | –59.4 |
| Guangxi | 86.4 | –37.2 | 28,869.2 | –16.5 | 2403.1 | –38.1 | 199.1 | –18.2 | 2204.0 | –39.4 |
| Guizhou | 98.7 | –35.4 | 28,132.4 | –12.7 | 2459.4 | –46.1 | 238.3 | –22.6 | 2221.2 | –47.8 |
| Hainan | 81.0 | –26.8 | 27,200.5 | –13.2 | 2090.0 | –31.7 | 182.8 | –16.4 | 1907.2 | –32.8 |
| Hebei | 80.7 | –41.0 | 26,381.7 | –4.1 | 2023.2 | –42.1 | 166.6 | –13.7 | 1856.5 | –43.7 |
| Heilongjiang | 83.7 | –34.7 | 28,492.4 | –10.1 | 2172.4 | –38.1 | 193.3 | –18.0 | 1979.1 | –39.6 |
| Henan | 81.6 | –45.2 | 27,943.1 | –10.8 | 1948.3 | –49.6 | 177.6 | –9.7 | 1770.7 | –51.8 |
| Hong Kong | 59.1 | –39.3 | 24,505.8 | –7.8 | 1414.2 | –43.7 | 168.9 | –13.6 | 1245.4 | –46.2 |
| Hubei | 76.1 | –37.4 | 28,044.8 | –14.7 | 1961.0 | –42.2 | 224.0 | –16.3 | 1737.1 | –44.4 |
| Hunan | 71.3 | –37.4 | 29,789.1 | –16.2 | 1963.6 | –42.2 | 222.6 | –16.9 | 1741.0 | –44.4 |
| Inner Mongolia | 80.3 | –40.1 | 28,073.8 | –7.6 | 2055.4 | –46.2 | 229.9 | –21.1 | 1825.5 | –48.3 |
| Jiangsu | 85.4 | –44.1 | 27,481.1 | –9.8 | 2053.1 | –47.8 | 211.6 | –18.3 | 1841.6 | –49.9 |
| Jiangxi | 73.1 | –53.9 | 26,460.0 | –15.5 | 1887.2 | –59.8 | 185.4 | –24.4 | 1701.9 | –61.8 |
| Jilin | 72.0 | –56.0 | 28,082.4 | –14.8 | 1885.1 | –59.0 | 184.4 | –19.2 | 1700.7 | –61.1 |
| Liaoning | 79.1 | –30.0 | 28,426.5 | –8.4 | 2031.6 | –29.5 | 223.7 | –10.2 | 1807.9 | –31.3 |
| Macao | 51.6 | –40.9 | 24,975.8 | –4.8 | 1388.3 | –41.9 | 173.3 | –10.7 | 1215.0 | –44.7 |
| Ningxia | 100.3 | –34.4 | 26,570.7 | –9.2 | 2406.6 | –42.2 | 197.1 | –8.0 | 2209.5 | –44.1 |
| Qinghai | 143.0 | –29.1 | 28,641.4 | –9.8 | 3596.9 | –38.6 | 218.6 | –15.5 | 3378.2 | –39.7 |
| Shaanxi | 81.1 | –48.4 | 29,323.9 | –9.6 | 1999.9 | –54.6 | 199.9 | –19.2 | 1800.1 | –56.7 |
| Shandong | 74.2 | –42.0 | 26,013.4 | –12.2 | 1819.8 | –45.4 | 165.5 | –12.6 | 1654.2 | –47.3 |
| Shanghai | 71.1 | –48.5 | 28,770.5 | –15.9 | 1712.3 | –50.6 | 300.3 | –28.9 | 1412.0 | –53.6 |
| Shanxi | 94.1 | –38.4 | 26,109.5 | –6.1 | 2191.6 | –44.6 | 170.2 | –16.3 | 2021.4 | –46.1 |
| Sichuan | 108.3 | –31.7 | 28,780.0 | –11.7 | 2778.0 | –39.5 | 285.6 | –12.1 | 2492.5 | –41.6 |
| Tianjin | 53.8 | –42.1 | 27,032.0 | –0.5 | 1371.3 | –41.1 | 179.7 | –13.3 | 1191.6 | –43.8 |
| Xizang | 116.5 | –37.2 | 27,832.8 | –14.8 | 3248.7 | –44.2 | 173.3 | –17.5 | 3075.3 | –45.2 |
| Xinjiang | 98.3 | –27.8 | 28,513.3 | –4.1 | 2447.6 | –37.3 | 176.0 | –13.6 | 2271.6 | –38.7 |
| Yunnan | 90.0 | –35.8 | 28,494.7 | –11.5 | 2343.9 | –44.5 | 250.4 | –20.8 | 2093.5 | –46.4 |
| Zhejiang | 71.3 | –43.2 | 25,181.8 | –12.1 | 1768.1 | –45.2 | 228.3 | –8.3 | 1539.7 | –48.3 |
ASR: Age-standardized rate; DALYs: Disability-adjusted life years; YLD: Years lived with disability; YLL: Years of life lost.
Mortality, prevalence, YLD, YLL, and DALY rates for digestive system diseases by sex and age in China in 2019
The mortality rate among individuals with digestive system diseases of both sexes gradually increased from birth until the age of 40 years. Thereafter, it experienced a significant rise and peaked after the age of 95 years [Figure 1]. Conversely, the DALY rate for both sexes with digestive system diseases peaked before the age of one year, subsequently decreased and then started rising again after the age of 30 years. Typically, the peak in the DALY rate occurred between 85 years and 89 years of age, followed by a rapid decline. When considering the DALY rate, both sexes exhibited similar trends, while female individuals displayed a distinct pattern. Specifically, the female DALY rate was significantly increased between the ages of 30 years and 75 years; thereafter, it reached a plateau without any notable decrease. The increase in DALYs in men appeared earlier than that in women, which may have been related to the earlier appearance of stomach cancer in men as the main contributor of DALYs [Figure 2 and Supplementary Figure 5, http://links.lww.com/CM9/C124]. The burden of stomach cancer among older adults in China was a major contributor to the burden of digestive system diseases, regardless of sex.
Figure 1.
Mortality, prevalence, YLDs, YLLs, and DALYs of digestive system diseases by sex and age in China (2019). Early neonatal: Age 0–6 days; Late neonatal: Age 7–28 days; Post neonatal: Age 29–364 days; DALYs: Disability-adjusted life years; YLD: Years lived with disability; YLL: Years of life lost.
Figure 2.
Digestive system disease with the highest DALY rate among different age groups in China (2019). The leading causes of DALYs among digestive system diseases are highlighted in different colors. DALYs: Disability-adjusted life years.
Mortality, prevalence, YLD, YLL, and DALY rates of non-neoplastic digestive diseases, malignant neoplasms, and benign and in situ neoplasms by age in China in 2019
The mortality rate of malignant neoplasms exhibited a gradual increase before 40 years of age, followed by a rapid rise, peaking between 85 years and 89 years of age [Supplementary Figures 6 and 7, http://links.lww.com/CM9/C124]. Conversely, the mortality rate of non-neoplastic digestive diseases was gradually increased before 60 years of age but significantly accelerated thereafter. Furthermore, the DALYs of non-neoplastic digestive diseases decreased to a minimum point before one year of age and then gradually increased after 30 years of age. However, the DALYs of malignant neoplasms remained consistently low before 30 years of age and experienced a rapid increase, reaching its peak between 75 years and 79 years of age. Subsequently, it remained high between 70 years and 89 years of age before undergoing a steep decline at 90 years of age. After 50 years of age, stomach cancer had the highest mortality and DALY rate among digestive system diseases [Supplementary Figures 5 and 6, http://links.lww.com/CM9/C124]. From 1990 to 2019, the ASDR of all age groups showed a decreasing trend over time, including malignant neoplasms and non-neoplastic digestive diseases [Supplementary Figures 8 and 9, http://links.lww.com/CM9/C124].
Age-standardized DALYs for digestive system diseases by province and SDI
In China and its provinces, DALYs decreased as the SDI increased. The eastern and coastal provinces have been positioned close to the lower-right quadrant in Figure 3, while the central and western provinces have been in the upper-left quadrant. This trend was also observed for malignant neoplasms and non-neoplastic digestive diseases [Supplementary Figures 10 and 11, http://links.lww.com/CM9/C124].
Figure 3.
Age-standardized DALYs of digestive system diseases by regions and SDI values. The scatter trend chart displaying DALYs and SDI for digestive system diseases from 1990 to 2019. ASR: Age-standardized rate; DALYs: Disability-adjusted life years; SDI: Socio-demographic index.
Discussion
This study offers a comprehensive analysis of the Chinese burden of digestive system diseases using epidemiological methods and GBD 2019 data. Furthermore, we examined trends in burden over the past three decades and found a significant increase from 1990 in mortality, prevalence, and DALYs associated with digestive system diseases. In 2019, the top three kinds of causes of deaths were cirrhosis and other chronic liver diseases, colon and rectal cancers, and stomach cancer. Since 1990, the prevalence of these diseases has increased by 45.3%, 109.6%, and 21.4%, respectively. Despite the rise in deaths, the ASMR and ASDR of digestive system diseases have been declining, while the prevalence of the disease remains unchanged. This suggests that, although progress has been made in the prevention and control of digestive system diseases, the disease burden remains substantial owing to changes in population demographics and increased life expectancy.[15]
Despite the overall decrease in ASMR and ASPR, digestive system diseases remain a significant public health concern in China. Over the past 30 years, China has witnessed a rise in cases and deaths related to digestive system diseases, while the ASMR and ASPR have shown significant decreases. The reduction in the ASPR of non-neoplastic digestive diseases and benign and in situ neoplasms has contributed to an improvement in mortality of digestive system diseases, offsetting the increase in malignant neoplasms prevalence. The increased prevalence of malignant neoplasms can be attributed to population growth, aging, advances in medical technology, increased awareness of early cancer detection, and changes in lifestyle and environment. Since 2006, the Chinese government implemented cancer screening programs in high-risk populations, which may have helped to reduce the mortality rates of malignant neoplasms.[16] Chinese researchers have made advancements in screening technology and have introduced artificial intelligence-assisted screening to enhance the cost-effectiveness of gastrointestinal cancer screening.[17,18] Recently, digestive endoscopy has seen significant improvements in China, both in terms of its usage and quality.[19] During the past three decades, the ASMR and ASDR of almost all digestive system diseases in China have decreased to varying degrees. However, consistent with data from the National Cancer Center of China, the mortality rates of colon and rectal cancer, gallbladder and biliary tract cancer, and pancreatic cancer have increased, which may be linked to lifestyle changes resulting from economic and social development.[20] Colorectal and pancreatic cancers are more prevalent in developed than in developing countries.[21]
The ASMR and ASDR of digestive system diseases in Qinghai were 2.8-fold and 2.6-fold higher, respectively, compared with those in Macao and Beijing. This indicates a considerable difference in disease burden across the provinces in China. Higher-income and eastern coastal provinces typically exhibit better overall health than their western counterparts. Differences in economic development, geographical environment, dietary habits, and local customs could account for the disparities observed in health outcomes.[22,23] For example, the western region of China has a more diverse and geographically dispersed population than the eastern region,[24] which limits healthcare access and delivery. These disparities highlight the importance of addressing structural barriers to healthcare access in China’s provinces.
Age is a significant risk factor for digestive system diseases, with a sharp increase in prevalence of digestive system diseases after the age of 40 years in the Chinese population. Therefore, it is important to prioritize screening and enhance health education for the elderly population, promote reasonable dietary practices, and strengthen the prevention and treatment of digestive system diseases. Additionally, non-neoplastic digestive diseases imposes a significant burden during infancy, with a higher proportion of cases attributed to intestinal obstruction and liver cirrhosis. Owing to the incomplete development of physiological functions in infants, digestive system diseases can hinder digestion, absorption, metabolism, and detoxification. This can result in malnutrition and the accumulation of toxins, negatively affecting infant growth and development and even leading to disability and deformities. Therefore, it is crucial to raise awareness on the prevention and treatment of digestive system diseases in infants and young children, and establish a robust healthcare service system for these conditions.[25] After the age of 30 years, ASMR and ASDR tend to be higher in men compared to women. This could be attributed to the fact that gastric cancer emerges as a significant factor contributing to the disease burden in men between the ages of 30 years and 50 years, occurring earlier in men compared with women. The higher DALYs for non-neoplastic digestive diseases in adolescents aged <25 years may be attributed to the low incidence of malignant neoplasms in this age group. However, chronic liver diseases, such as cirrhosis, paralytic ileus, and intestinal obstruction, were the main causes of disease burden in adolescents.
We examined the correlation between the DALYs of digestive system diseases and the SDI in various Chinese provinces. Although there were variations in ethnic composition, environment, and healthcare resources across provinces, the results consistently demonstrated a correlation. Furthermore, significant differences persisted in the disease burden among Chinese provinces, underscoring the ongoing challenge of achieving health equity. The Chinese government has recognized this issue and prioritized it in the “Healthy China 2030” initiative.[26]
This study acknowledges the limitations of all GBD studies.[13,14] While GBD estimates have been obtained to improve the reliability and comparability of vital registration data (e.g., the redistribution of garbage codes), systematic biases may still exist. This study also had unique limitations. First, we specifically analyzed only six most common malignant neoplasms and did not include cancers associated with other systems (e.g., peritoneal mesothelioma). Consequently, the burden of malignant neoplasms may have been underestimated. Second, the GBD 2019 offers sufficient mortality, fertility, and population data for each province. However, the disease surveillance point system covers only a limited number of counties and districts in remote and underprivileged provinces. Based on the 2022 estimates from the National Cancer Center of China, it is noted that while this article reports similar prevalence trends and population distribution characteristics, the absolute values of tumor prevalence and deaths are actually overestimated.[20,27] The lack of reliable data from these regions negatively affected the accuracy of our estimates. Third, we did not investigate the correlation between the burden of digestive system diseases and risk factors, highlighting the need for further in-depth research to analyze this relationship.
In conclusion, we systematically analyzed the differences in the prevalence of digestive system diseases in China and its provinces. The findings revealed significant differences in terms of geography, age, and sex and suggested that some provinces should improve their prevention and control strategies to address the preventable and treatable burdens of digestive system diseases. The finding of a negative correlation between the DALYs of digestive system diseases and SDI can provide public health personnel with supporting information for the estimation of the burden in the region. Furthermore, this correlation can serve as a prediction reference for provinces and countries.
Funding
This research was supported by the First Affiliated Hospital of Naval Medical University (2019YXK006) and the Science and Technology Commission of Shanghai Municipality (21Y31900100).
Conflicts of interest
None.
Supplementary Material
Footnotes
Zhiyuan Cheng, Tinglu Wang, Yunfei Jiao, and Jinlei Qi contributed equally to this work.
How to cite this article: Cheng ZY, Wang TL, Jiao YF, Qi JL, Zhang X, Zhou SW, Xin L, Wan R, Zhou MG, Li ZS, Wang LW. Burden of digestive system diseases in China and its provinces during 1990–2019: Results of the 2019 Global Disease Burden Study. Chin Med J 2024;137:2182–2189. doi: 10.1097/CM9.0000000000003277
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