A socioeconomic perspective on the global burden of gastroesophageal reflux disease (1990–2021): findings from the GBD 2021

Abstract

Background

Gastroesophageal reflux disease (GERD) constitutes a global public health challenge, afflicting individuals across nearly all age groups over the long term. However, few systematic investigations have assessed the associated disease burden from a socioeconomic perspective.​

Methods

GERD data were extracted from the GBD 2021 database, encompassing data from the global level, 5 sociodemographic index (SDI) groups, and 24 GBD regions for the period of 1990–2021. Estimated annual percentage changes (EAPCs) were calculated to characterize temporal trends. Health inequality analysis, decomposition analysis and frontier analysis were employed to evaluate the disease burden.

Results

From 1990 to 2021, the global number of incident cases increased from 180 million to 324 million, the number of prevalent cases increased from 451 million to 826 million, and the number of disability-adjusted life years increased from 3.47 million to 6.34 million. Compared with men, women presented a greater disease burden. The SDI showed a weak negative correlation with the disease burden, and the burden remained concentrated among low-SDI populations over the 30-year period (CII= -0.04), with no improvement observed. Decomposition analysis revealed that population growth (64.58%‒68.46%) and aging (22.85%‒29.53%) were the primary drivers of the increased burden, whereas epidemiological changes in high-SDI regions had negative effects. Frontier analysis indicated that regions with an SDI > 0.75 had the greatest potential for reduction.​

Conclusion

The global disease burden of GERD has continued to increase, with significant disparities across geographical, socioeconomic, and demographic characteristics. This study provides a scientific basis for formulating targeted public health strategies and alleviating health inequalities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-025-04389-7.

Introduction

GERD is defined as the reflux of gastric and duodenal contents into the esophagus [1]. It has emerged as a significant global public health concern, with a prevalence that varies across geographic regions, ranging from approximately 5% to 25% globally [2]. GERD is associated with a spectrum of genetic and behavioral risk factors, including dietary habits, obesity, psychological stress, and the use of certain medications [3]. The disease not only manifests with recurrent symptoms, such as heartburn and regurgitation, but also progresses to serious complications, including esophagitis, esophageal stricture, and esophageal adenocarcinoma [4]. These manifestations significantly compromise patients’ quality of life and impose a substantial economic burden on global health care systems.​

The GBD database [5], a collaborative repository hosted by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington, compiles epidemiological data spanning nearly all countries and regions. This comprehensive resource encompasses key health metrics, including disease incidence, mortality rates, and DALYs, thereby facilitating multidimensional assessments of global health burdens [6]. Since its establishment in 1990, the GBD database has provided longitudinal datasets that support temporal trend analyses and cross-period comparisons [7]. By utilizing standardized methodologies that integrate epidemiological surveillance, statistical modeling, and computational algorithms [8], the GBD framework ensures robust data validity and cross-regional comparability [9]. Although prior investigations leveraging GBD datasets have documented a progressive increase in the burden of GERD—as evidenced by a 77.53% increase in global cases from 441.57 million (1990) to 783.95 million (2019)—critical knowledge gaps persist [10]. Notably, substantial geographic heterogeneity exists, with the highest age-standardized prevalence rates (ASPR >12,000 per 100,000 population) concentrated in Latin America, South Asia, North Africa, and the Middle East, whereas East Asian regions, including China, exhibit the lowest ASPR values (< 5%) [11]. Despite regular database updates, comprehensive analyses of GERD epidemiology incorporating the latest GBD 2021 release are lacking [12].

As a comprehensive indicator used to measure the level of social development, the SDI is a fundamental determinant of GERD burden, and it profoundly affects the distribution of GERD by influencing downstream risk factors, such as diet structure, obesity rate, and diagnosis and treatment opportunities. Furthermore, studies predominantly focus on the descriptive reporting of conventional epidemiological indicators, neglecting systematic investigations into socioeconomic determinants of the disease burden and failing to adopt dynamic longitudinal analytical frameworks [13].

This study innovatively integrated frontier analysis, decomposition analysis, and health inequality analysis to systematically investigate the association patterns between the global and regional burden of GERD and socioeconomic indicators from 1990 to 2021. The findings of this study are intended to provide a scientific basis for the development of global GERD prevention and control policies, contributing to the advancement of health equity.

Research methods

Data sources and study population

The GBD database covers the burden of 371 diseases and injuries and 88 risk factors across 204 countries and territories, providing comprehensive, up-to-date epidemiological insights with adjustments for missing data and confounding factors [14]. All the raw data used in this study were retrieved from the freely accessible GBD 2021 database (https://ghdx.healthdata.org/gbd-2021/sources).

GERD, categorized as an upper gastrointestinal tract disorder, constituted the focus of this study, with affected individuals serving as the study population [15]. GERD was defined by the following codes according to the 10th revision of the International Classification of Diseases (ICD-10): K21-K21.9, K22.7, and R12. In this study, estimates and their corresponding 95% uncertainty intervals (UI) for the prevalence, incidence, and DALYs associated with GERD were extracted from the GBD 2021 data. To comprehensively characterize the evolutionary trends of GERD, this study incorporated global data across all age groups and sexes to evaluate regional disease trends.

Ethical review and approval were not needed for the study of human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation or institutional requirements.

Overall time trend analysis of GERD​

We utilized the counts of incident cases, prevalent cases, deaths, and DALYs, along with age-standardized incidence rates (ASIRs), age-standardized prevalence rates (ASPRs), and age-standardized DALY rates (ASDRs), to characterize temporal variations in the disease burden. Disability-adjusted life years (DALYs) represent a composite metric that quantifies the healthy life expectancy loss attributed to disease, encompassing premature mortality and disability [16]. ASRs were computed using the formula , where a.i. denotes the specific rate for the i-th age group (e.g., incidence or mortality rate), and wi represents the weight of the i-th age group (proportion within the standard population) [17]. The EAPC is a percentage value used to measure the average annual increase or decrease in disease burden indicators, such as incidence. The EAPC was derived via the regression model 𝑦=𝛼+𝛽𝑥+𝜀, where 𝑦 denotes the natural logarithm of the ASR and 𝑥 corresponds to the calendar year. The EAPC calculation employed the formula . An EAPC with a 95% confidence interval (CI) exceeding 0 signified an increasing trend in disease burden, whereas an EAPC with a 95% CI below 0 indicated a decreasing trend [18].

Correlation analysis

The SDI functions as a composite indicator that is routinely employed to evaluate and compare health, economic, and social development across diverse countries and regions. The SDI ranges from 0 to 1, with a higher SDI indicating faster socioeconomic development. The SDI is associated with disease morbidity and mortality. For this study, the SDI was stratified into five categories (low, low-middle, middle, high-middle, and high) to investigate the relationship between the GERD burden and socioeconomic development [19].​

Pearson’s correlation coefficient [20] was used in this study to evaluate the associations between the SDI and ASRs, with the aim to clarify the influence of socioeconomic factors on the GERD burden. Correlation strength was defined as follows: very strong (absolute coefficient: 0.8–1.0), strong/moderate (0.5–0.8), fair/weak (0.2–0.5), and poor/very weak (< 0.2) [21]. The dplyr(version 1.1.4) and ggplot2(version 4.0.0) packages in R were employed for data manipulation and visualization.

Health inequality analysis

Methods from the GBD framework were adopted to conduct an in-depth analysis of health disparities, with a focus on variations in GERD incidence, mortality, and DALYs across 204 countries/regions to quantify unequal disease burden distributions. The concentration index (CII) quantifies the magnitude of the covariation between disease burden and socioeconomic status ranking (relative SDI rank), with values ranging from [−1, 1], to assess the relative distribution inequalities in the disease burden. The slope index of inequality (SII) is used to estimate the linear relationship between the SDI ranking and the disease burden through weighted least squares regression, characterizing the absolute burden disparities between the lowest and highest SDI strata [22]. The data were aggregated by geographical regions as defined by the GBD study, and maps were created using the ggplot2(version 4.0.0) and simple features (version 1.0–16) R packages to visualize the distribution of disease burden.

Frontier analysis

Frontier analysis was employed to establish GERD burden benchmarks by comparing each country/region with its top-performing counterparts. This methodology identifies leading countries/regions and thereby establishes benchmarks and targets for the remaining regions. An efficiency gap and relative efficiency index were calculated for each country/region to quantify current versus potential GERD burden discrepancies and identify priority improvement areas to inform targeted health intervention policy development [23].

Decomposition analysis

The decomposition method developed by Das Gupta [24] was applied to decompose GERD incidence, prevalence, and DALYs into contributions from aging, population growth, and epidemiological changes. This decomposition was designed to quantify the primary drivers of changes in the GERD burden from 1990 to 2021.

Statistics

All the statistical analyses and data visualizations were conducted using R software (version 4.4.2) and JD_GBDR (version 2.37; Jingding Medical Technology Co., Ltd.). Specifically, we employed the nonparaeff package (version 0.8–2.8) for the frontier analysis, the oaxaca package (version 0.1.5) for the decomposition analysis, and the diff package (version 2.0.2) to calculate the concentration index for assessing health inequalities. Final figure refinement was performed using Adobe Illustrator (version CS5). Statistical significance was defined as a two-tailed p value < 0.05.

Results

Global, regional, and national trends in the incidence, prevalence, and dalys of GERD​

Global and regional levels​

The global and regional incidence, prevalence, and DALY data for GERD are presented in Table 1, Table S1, and Table S2, respectively. From 1990 to 2021, the global number of incident GERD cases increased from 180 million to 324 million, the number of prevalent cases rose from 451 million to 826 million, and the number of DALYs increased from 3.47 million to 6.34 million. The ASIR increased from 3739.86 to 3881.86 per 100,000 population, with an EAPC of 0.10 (95% CI: 0.06 to 0.13). The ASPR increased from 9516.49 to 9838.60 per 100,000 population (EAPC = 0.08; 95% CI: 0.04 to 0.12), and the ASDR rose from 73.01 to 75.56 per 100,000 population (EAPC = 0.08; 95% CI: 0.04 to 0.12). These findings indicate that the global disease burden of GERD is increasing, with a progressive growth trend.

Table 1.

The incidence and prevalence of GERD cases and rates in 1990 and 2021 and trends from 1990 to 2021

location	Incidence
	1990		2021		1990-2021 EAPC (95% CI)
	Cases (95% Ul)	ASIR (95% Ul)	Cases (95% Ul)	ASIR (95% Ul)
global	180,018,233(158660995.15,199950073.37)	3739.86(3314.20,4142.33)	324,139,599(287693228.73,358912515.95)	3881.86(3445.56,4299.95)	0.10(0.06,0.13)
High SDI	34,136,779(29922480.92,38124823.62)	3418.57(2986.04,3815.08)	47,166,281(41524019.23,52774700.94)	3353.31(2926.72,3742.91)	−0.13(−0.21, −0.06)
High-middle SDI	35,652,655(31443953.74,39686082.38)	3293.70(2900.96,3661.82)	50,357,993(44527625.01,55976704.96)	3130.06(2771.29,3484.45)	−0.23(−0.30, −0.15)
Middle SDI	50,019,122(43995351.08,55575248.45)	3345.96(2974.03,3704.33)	98,388,206(87127604.58,108930034.37)	3660.46(3252.07,4047.06)	0.28(0.26,0.31)
Low-middle SDl	43,396,198(38366263.24,48127012.67)	4882.26(4352.48,5408.16)	88,397,917(78018085.72,98019118.90)	4894.02(4362.32,5416.81)	0.00(−0.00,0.01)
Low SDI	16,607,902(14551684.70,18469681.04)	4829.00(4287.06,5342.74)	39,536,249(34516600.96,44014348.38)	4809.96(4268.66,5318.34)	−0.01(−0.01, −0.00)
Region
Andean Latin America	1,856,763(1650176.58,2070989.00)	6101.73(5438.31,6737.72)	4,072,658(3613213.53,4506116.09)	6099.59(5437.15,6734.20)	−0.00(−0.00, −0.00)
Australasia	787,267(687934.36,883727.64)	3542.28(3088.20,3979.31)	1,346,856(1182680.16,1504797.01)	3542.46(3088.47,3978.80)	0.01(−0.08,0.12)
Caribbean	1,953,702(1738949.35,2170054.33)	6102.11(5438.55,6738.49)	3,106,455(2776439.49,3417854.66)	6100.63(5437.95,6736.16)	−0.00(−0.00, −0.00)
Central Asia	2,523,219(2213209.30,2814204.36)	4321.79(3813.97,4806.07)	4,133,539(3613385.38,4611899.13)	4317.35(3809.52,4802.35)	−0.00(−0.00, −0.00)
Central Europe	6,033,314(5312670.75,6702640.36)	4363.70(3842.38,4832.61)	6,664,589(5925379.49,7384056.31)	4392.32(3870.96,4864.31)	0.02(0.02,0.02)
Central Latin America	8,047,123(7150120.91,8954727.72)	6161.54(5503.87,6741.05)	16,350,513(14578247.13,17895434.39)	6162.98(5505.46,6740.47)	0.00(−0.00,0.00)
Central Sub-Saharan Africa	1,665,153(1454925.74,1868796.15)	4509.51(3952.88,5031.98)	4,396,283(3812333.81,4954038.85)	4508.19(3950.90,5033.91)	−0.00(−0.00, −0.00)
East Asia	4,396,283(3812333.81,4954038.85)	1856.21(1621.35,2093.92)	33,637,020(28943253.60,38112786.07)	1849.87(1609.66,2090.47)	−0.08(−0.20,0.05)
Eastern Europe	11,747,714(10345127.65,13074504.50)	4590.71(4043.55,5114.67)	12,175,725(10796381.67,13579954.01)	4580.24(4035.48,5100.44)	−0.15(−0.25, −0.06)
Eastern Sub-Saharan Africa	5,643,894(4932893.23,6306155.03)	4580.06(4025.35,5095.97)	13,906,525(12066920.90,15614112.53)	4583.75(4027.78,5100.72)	0.00(0.00,0.00)
High-income Asia Pacific	5,029,062(4403132.72,5630395.24)	2550.17(2231.67,2860.11)	6,777,190(5987675.54,7610830.24)	2580.33(2258.22,2887.89)	0.16(0.07,0.25)
High-income North America	12,982,928(11377720.82,14443654.61)	4111.10(3588.35,4566.76)	17,494,199(15416218.08,19443438.21)	3794.49(3313.53,4242.52)	−0.48(−0.65, −0.31)
North Africa and Middle East	12,433,731(10918819.08,13870452.16)	4819.92(4253.79,5357.61)	29,265,665(25678681.28,32620732.47)	4836.65(4293.67,5351.47)	0.01(−0.00,0.03)
Oceania	106,819(92868.34,121220.99)	2166.66(1896.97,2442.25)	251635.57(218734.17,285023.71)	2167.33(1897.19,2443.04)	−0.00(−0.00,0.00)
South Asia	45,304,673(39908976.11,50385397.14)	5323.55(4733.69,5897.15)	96,465,350(84966662.55,107155382.93)	5324.47(4735.23,5897.01)	−0.00(−0.01,0.00)
Southeast Asia	8,438,772(7357716.71,9560854.17)	2223.19(1956.69,2512.38)	16,344,889(14269226.13,18517056.73)	2222.39(1955.85,2511.31)	−0.00(−0.00, −0.00)
Southern Latin America	2,392,030(2121244.00,2651093.87)	4986.72(4419.15,5529.91)	3,816,332(3395847.19,4238885.12)	4985.60(4418.34,5528.66)	−0.08(−0.11, −0.05)
Southern Sub-Saharan Africa	1,854,646(1624068.29,2067573.02)	4660.05(4105.04,5187.63)	3,541,990(3089189.06,3975059.93)	4663.54(4108.83,5192.32)	0.00(0.00,0.00)
Tropical Latin America	8,310,404(7382342.68,9188869.79)	6270.12(5623.81,6884.86)	15,834,153(14081470.84,17386189.99)	6248.12(5567.61,6874.80)	−0.05(−0.06, −0.04)
Western Europe	15,173,305(13359262.53,16904747.62)	3297.99(2874.87,3680.35)	18,917,642(16679273.72,21114806.35)	3296.77(2878.87,3692.37)	0.01(0.00,0.02)
Western Sub-Saharan Africa	6,075,830(5311324.20,6771689.58)	4595.96(4043.06,5115.15)	15,640,391(13609464.02,17514451.47)	4601.02(4045.23,5122.30)	0.00(0.00,0.00)

In 2021, the low-middle-SDI region presented the highest ASIR, ASPR, and ASDR, at 4894.02, 12563.56, and 96.06 per 100,000 population, respectively. All the indicators in this region remained relatively stable, with EAPCs of 0.00 (95% CI: −0.00 to 0.01) for the ASIR, −0.00 (95% CI: −0.02 to 0.01) for the ASPR, and 0.01 (95% CI: −0.01 to 0.02) for the ASDR. In contrast, the high-SDI region showed a general downward trend across all indicators, with EAPCs of −0.13 (95% CI: −0.21 to −0.06) for the ASIR, −0.19 (95% CI: −0.28 to −0.10) for the ASPR, and − 0.19 (95% CI: −0.28 to −0.10) for the ASDR. The middle-SDI region, however, exhibited a significant upward trend, with EAPCs of 0.28 (95% CI: 0.26 to 0.31) for ASIR, 0.27 (95% CI: 0.24 to 0.30) for ASPR, and 0.28 (95% CI: 0.25 to 0.30) for ASDR.​

At the subregional level in 2021, Tropical Latin America exhibited the highest ASIR, ASPR, and ASDR, at 6248.12, 16681.34, and 127.65 per 100,000 population, respectively, with all the indicators showing a downward trend (EAPCs: −0.05 [95% CI: −0.06 to −0.04] for ASIR; −0.09 [95% CI: −0.12 to −0.06] for ASPR; −0.09 [95% CI: −0.12 to −0.06] for ASDR). East Asia exhibited the lowest burden, with ASIR, ASPR, and ASDR values of 1849.87, 4554.18, and 35.22 per 100,000 population, respectively. The most substantial reduction in disease burden was observed in high-income North America, with EAPCs of −0.48 (95% CI: −0.65 to −0.31) for ASIR, −0.63 (95% CI: −0.83 to −0.42) for ASPR, and − 0.64 (95% CI: −0.85 to −0.44) for ASDR.

Country-level analysis​

As shown in Fig. 1, Fig. S1, and Fig. S2, the countries with the highest incidence rates are concentrated in Latin America, with El Salvador (ASIR = 6109 per 100,000), Brazil (6249 per 100,000), and Paraguay (6177 per 100,000) ranking among the top. Extremely high prevalence rates are observed in Caribbean nations: the Dominican Republic (ASPR = 16,421 per 100,000), Bahamas (16,421 per 100,000), and Saint Lucia (16,400 per 100,000). In contrast, high-income European countries bear the lightest burden: Switzerland has the lowest incidence (ASIR = 2091 per 100,000), and Norway has the lowest prevalence (ASPR = 4330 per 100,000).​

Fig. 1.

Global disease burden of GERD in 2021. A ASIR; (B) EAPC of ASIR

The analysis of age-standardized EAPCs across 204 countries reveals significant geographical disparities and socioeconomic correlations in the dynamic changes in GERD burden. South Korea, Turkey, and Switzerland exhibit the fastest-growing burden, with ASDR EAPCs of 0.37 (95% CI: 0.10–0.64), 0.26 (95% CI: 0.20–0.32), and 0.15 (95% CI: 0.09–0.21), respectively. These countries also rank among the highest globally in EAPCs for the ASIR (South Korea: 0.26 [95% CI: 0.07–0.46]; Turkey: 0.16 [95% CI: 0.13–0.19]) and the ASPR (South Korea: 0.36 [95% CI: 0.09–0.63]; Turkey: 0.27 [95% CI: 0.21–0.33]).​

The most substantial decreases in disease burden are observed in the United States, Russia, and Argentina. The United States has the lowest ASDR EAPC at −0.69 (95% CI: −0.92–−0.47), with corresponding ASIR and ASPR EAPCs of −0.52 (95% CI: −0.71–−0.34) and − 0.68 (95% CI: −0.90–−0.45), respectively. Notably, high-income countries exhibit a polarized trend: Western European nations, such as Switzerland (ASIR EAPC = 0.12 [95% CI: 0.08–0.16]) and Sweden (ASDR EAPC = 0.13 [95% CI: 0.07–0.20]), along with East Asian countries, such as South Korea, show a continuous upward trend, whereas Anglo-American countries demonstrate significant declines. China, classified as a low-burden region for GERD, has an ASDR of 35.12 per 100,000, with EAPCs of −0.08 (95% CI: −0.21–0.05) for the ASIR and − 0.09 (95% CI: −0.23–0.05) for the ASPR.​

For more detailed information on national trends in GERD burden, refer to Table S3.​

Overall trends by sex and age structure​

We analyzed global disparities in GERD incidence, prevalence, and DALYs by sex and age group. Globally, the ASIR, ASPR, and ASDR of GERD tended to initially increase but then decrease with age. In 2021, the global numbers of incident cases (men: 16,463,111; women: 17,272,298), prevalent cases (men: 42,955,218; women: 45,317,937), and DALYs (men: 337,582; women: 351,061) peaked in the 35–39 age group.​.

The ASIR peak for men was observed in the 70–74 age group (Fig. 2A), at 6719.80 per 100,000 population (95% UI: 4741.15 to 8671.50), whereas for women, it was observed in the 60–64 age group, at 7267.47 per 100,000 population (95% UI: 5315.30 to 9290.81). The ASPR peak for men was observed in the 75–79 age group (Fig. 2B), at 18,574.83 per 100,000 population (95% UI: 13,802.80 to 24,297.59), whereas for women, it was observed in the 70–74 age group, at 19,895.49 per 100,000 population (95% UI: 15,113.73 to 25,078.96). With respect to the ASDR, both sexes reached their peaks in the 70–74 age group (Fig. 2C): 135.67 per 100,000 population for men (95% UI: 66.70 to 245.10) and 145.76 per 100,000 population for women (95% UI: 73.10 to 268.05).​.

Fig. 2.

Sex and age structure of the GERD disease burden in 2021. A Incidence number and ASIR; (B) prevalence number and ASPR; (C) DALY and ASDR

Overall, the sex-specific trends of GERD indicate that compared with men, women exhibit a greater disease burden. However, adolescents aged 10–20 years experience a relatively high disease burden.​.

Correlation analysis of the SDI

Additionally, we evaluated the correlation between the SDI and the ASRs of GERD across 21 regions and among 204 countries from 1990 to 2021 (Fig. 3). We observed a weak negative correlation between the SDI and the burden of GERD within the 21 regions and among the 204 countries. Moreover, the temporal trends linking the SDI with the ASIR, ASPR, and ASDR were similar. Overall, the global burden of GERD was lower than expected. When the SDI exceeded 0.6, the burden of GERD significantly decreased. Regions such as Latin America and South Asia had substantially higher burdens than expected, whereas regions such as East Asia and Oceania had substantially lower burdens. Among the 204 countries, nations such as Brazil, Mexico, the U.S. Virgin Islands, Cuba, and Pakistan had significantly higher disease burdens than expected, whereas areas such as Japan, China, Taiwan (Province of China), the Republic of Korea, and Norway had significantly lower burdens.

Fig. 3.

Trend and correlation analysis of the SDI for 1990 to 2021. A Changing trends and correlations of the ASIR and the SDI globally and in 21 regions; (B) Trends and correlations of the ASIR and the SDI across 204 countries; (C) Trends and correlations of the ASPR and the SDI in the world and 21 regions; (D) Trends and correlations of the ASPR and the SDI across 204 countries; (E) Trends and correlations of the ASDR and the SDI across the world and 21 regions; (F) Trends and correlations of the ASDR and the SDI across 204 countries

Cross-country inequality analysis

Low-SDI regions bear a disproportionately high burden. The CII clearly indicated a systematic skewing of disease distribution toward vulnerable populations: the CII was − 0.04 (95% CI: −0.06 to −0.02) in 1990 and remained − 0.04 (95% CI: −0.06 to −0.02) in 2021, with no significant change observed over three decades, which confirms the long-term entrenchment of health inequalities.

In terms of incidence, the SII was − 934.03 in 1990 and − 904.03 in 2021, with only a 3.2% reduction. In terms of prevalence, the SII was − 2424.44 in 1990 and − 2346.15 in 2021, reflecting a decrease of less than 3.3%. Notably, the absolute value of the SII for prevalence remained the highest among the three indicators, highlighting that prevalence is most sensitive to socioeconomic status. With respect to DALY rates, the SII was − 17.96 in 1990 and − 17.61 in 2021, with only a 1.9% reduction.

These results suggest that there has been virtually no improvement in CII and SII over the past three decades and indicates that the disease burden of GERD has remained persistently concentrated in populations with low socioeconomic status (Fig. 4).

Fig. 4.

Health inequality concentration curves and regression curves for the ASIR (A, B), ASPR (C, D), and ASDR (E, F) of GERD worldwide in 1990 and 2021

Frontier analysis

Using data from 1990 to 2021, we conducted a frontier analysis based on the ASRs and the SDI to explore the potential for reducing the disease burden of GERD while accounting for national and regional development levels (Fig. 5). Overall, as sociodemographic development progresses, efficiency disparities generally increase to a certain extent. When the SDI exceeds 0.75, the actual burden in all regions deviates from the frontier, particularly in North America, indicating that countries or regions with high SDI exhibit increased potential for burden reduction.

Fig. 5.

Frontier analysis exploring the relationships between the SDI and the ASIR (A), the ASPR (B), and the ASDR (C) of GERD across 204 countries and territories. The color gradient from light blue (1990) to dark blue (2021) represents the change in years. Each dot denotes a specific country or territory in 2021, with the frontier line shown in black. The top 15 countries and territories with the greatest discrepancies from the frontier are labeled in black. The direction of change in the ASR from 1990 to 2021 is indicated by the color of the dots: orange dots represent a decrease, and blue dots represent an increase

Taking the frontier analysis between the ASIR and the SDI as an example, the 15 countries and regions with the greatest gaps between the potential and the actual burden reduction include Brazil, Mexico, Paraguay, the United States Virgin Islands, Puerto Rico, Antigua and Barbuda, Barbados, Bermuda, Trinidad and Tobago, Cuba, Costa Rica, Grenada, Dominica, Jamaica, and the Bahamas.

Decomposition analysis

Over the period of 1990–2021, the core drivers of the increased GERD burden significantly differed globally. Of the increase of 144 million in global incident cases, 68.46% were attributed to population growth, and 22.85% were attributed to aging. The increase of 375 million in prevalent cases was predominantly due to population growth (64.58%), followed by aging (29.53%). Population growth accounted for 64.99% of the increase of 2.86 million in DALYs. Epidemiological change had a positive effect on incidence (+ 8.69%) but a significant negative effect on prevalence in high-SDI regions (e.g., −38.15% in North America), suggesting that medical interventions reduced disease severity.

A “population growth + epidemiological protection” pattern was generally observed. In high-income North America, epidemiological change contributed − 42.81% to DALY rates, whereas in Western Europe, this contribution reached − 58.91%, reflecting that advanced diagnostic and therapeutic technologies reduced disease-related disability. Aging contributed to 55.24% of the increase in incidence in low-SDI regions, with this percentage reaching 59.35% in West and Central Africa. Aging accounted for 55.14% of the increase in prevalence in low-SDI regions, but epidemiological change made a negligible contribution (−0.50%), highlighting the absence of effective medical interventions. Population growth dominated the increase in prevalence in East Asia (82.43%) and the increase in incidence in South Asia (51.80%) in middle-SDI regions (Fig. 6).

Fig. 6.

Decomposition analysis of GERD burden by SDI and 21 GBD regions, 1990 to 2021. A Incidence; (B) Prevalence; (C) DALYs. Black dots represent the total change attributed to the three components. The magnitude of positive values indicates a corresponding increase in GERD caused by that component, whereas the magnitude of negative values indicates a corresponding decrease in GERD caused by that component

Discussion

In this study, on the basis of the GBD 2021 database, the socioeconomic gradient and dynamic evolution of the global GERD burden from 1990 to 2021 were systematically analyzed using a combination of frontier analysis, decomposition analysis, and health inequality analysis. There is not yet consensus regarding the global prevalence rate of GERD. There are significant differences across countries and regions, and the risk factors are diverse as well. This poses a serious challenge to global health [2]. We found that the global number of incident cases, prevalent cases, and DALYs of GERD showed a continuous increasing trend, with significant geographical differentiation: low-middle-SDI regions bore the heaviest burden (e.g., Tropical Latin America had an ASIR of 6248.12 per 100,000 population), while high-SDI regions generally showed a decline (e.g., high-income North America had an annual decrease in ASIR of 0.48%). In terms of sex differences, the disease burden was slightly greater in women than in men. The age distribution revealed that the peak incidence occurred in the 35–39-year-old group, whereas the peak severity occurred in the 70–74-year-old group. The SDI was weakly negatively correlated with the GERD burden, and health inequalities persisted: the concentration index (CII = −0.04) and slope index of inequality (SII < −900) indicated that the aggregation of the disease in low-SDI populations did not improve over three decades. Decomposition analysis confirmed that population growth and aging were the core drivers of the increase in the global burden, whereas frontier analysis suggested that high-SDI regions had increased potential for improvement.

The strong negative correlation between the SDI and the ASIR and DALYs suggests that higher socioeconomic development confers protective effects, likely through improved access to preventive care, healthier diets and lower obesity prevalence. Compared with earlier GBD 2017 estimates [25], the 2021 data reveal a modest but statistically significant decline in the ASIR in high-income North America and a concurrent increase in high-income Asia-Pacific, highlighting that socioeconomic advancement alone does not guarantee burden reduction. Lifestyle transitions and urbanization may offset gains [26].

These results are consistent with and significantly extend previous findings from studies on the global burden of disease [27]. The steady increase in the ASIR, ASDR, and ASPR of GERD is consistent with the findings of the GBD 2019 study, which also revealed geographical disparities in the GERD burden, with the highest ASPR (>12,000 per 100,000 population) observed in Latin America, the Caribbean, South Asia, North Africa, and the Middle East. East Asia and China had the lowest ASPR, which is generally consistent with the updated GBD 2021 data. Compared with regional studies, our study revealed a high burden in Tropical Latin America (ASPR = 16,681.34 per 100,000 population), such as Brazil and Mexico, where refined carbohydrate intake accounts for >50% of total calories [28]. In contrast, the low burden in East Asia (ASDR = 35.22 per 100,000 population) may be associated with dietary habits, which provides cross-cultural evidence for dietary interventions. Additionally, the burden may be closely linked to lifestyle factors, obesity, alcohol consumption, smoking, ethnicity, and economic income levels [5, 29].

Notably, through SDI-stratified analysis combined with decomposition analysis, health inequality analysis, and frontier analysis, this study further quantified the impact of socioeconomic factors. The burden showed a significant downward trend when the SDI was >0.6, which indicates that the geographical differentiation of the global GERD burden is closely related to socioeconomic development. This may be associated with advanced medical technologies in developed regions, such as the popularization of gastroscopy, the accessibility of proton pump inhibitors (PPIs), and improved health education. The high burden in low-middle-SDI regions may stem from multiple factors. First, the transformation of dietary structures (e.g., increased intake of high-fat and high-sugar foods) and increasing obesity rates (adult obesity rates >30% in Latin America) synergistically exacerbate lower esophageal sphincter dysfunction, which is consistent with the findings of previous studies on the association between dietary patterns and GERD [30]. Second, insufficient access to medical resources leads to low coverage of standardized PPI use, resulting in persistent symptoms [31]. Third, a lack of health education leads to delayed medical consultation and an increased risk of complications [32]. In contrast, the declining burden in high-SDI regions may benefit from three advancements: the increased popularity of laparoscopic anti-reflux surgery [33], the application of new acid-suppressive drugs (e.g., vonoprazan) [34], and the implementation of public health interventions.

The lack of significant changes in CII over three decades reflects the entrenchment of health inequalities and is suggestive of structural flaws in current policies. More than 55% of the burden increase in low-SDI regions is attributed to aging and population expansion, whereas epidemiological interventions contribute minimally, which is directly related to the weakness of the primary health care systems in these regions [35]. Decomposition analysis revealed that epidemiological factors in high-SDI regions had a negative contribution to DALYs, which confirms the key role of standardized diagnosis and treatment in reducing disease severity and providing a replicable intervention pathway for low-SDI regions.

The notably high burden of GERD among children and adolescents aged 10–20 presents a distinct and growing public health concern [36]. Our study highlights the significant prevalence of this demographic condition, moving beyond the historical perception of GERD as primarily an adult condition [37]. The pathogenesis in this age group is multifactorial and strongly linked to the global rise in childhood obesity, which increases intra-abdominal pressure and disrupts esophageal motility [38]. Dietary shifts toward high-fat, acidic, and processed foods, coupled with increased sedentary behavior and psychosocial stress, further exacerbate the risk.

Addressing this burden requires a tailored, multilevel approach. First-line management must emphasize aggressive lifestyle interventions, including weight control and dietary modification, which are cornerstone therapies [39]. For health care systems, particularly in primary care settings, enhancing awareness and early diagnosis using validated pediatric tools is crucial for preventing long-term complications, such as esophagitis. Longitudinal studies should be prioritized in future research to elucidate the natural history of early-onset GERD and its progression into adulthood.

This study has several limitations. First, in some low- and middle-income countries, reliable epidemiological data are lacking, which may lead to an underestimation of the true burden in low-SDI regions. Second, the decomposition analysis did not separately quantify the contributions of specific socioeconomic factors (e.g., education level and medical insurance coverage), which requires verification in future studies using individual-level data. Finally, the results of the frontier analysis assumed a linear relationship between the SDI and the GERD burden, but a nonlinear threshold effect may exist, which requires further verification through segmented regression models.

In conclusion, this study provides empirical evidence from a socioeconomic perspective for GERD prevention and control. Future public health strategies should focus on stratified interventions. For policy-makers, GERD should be included in the national chronic disease prevention and control system to improve the priority given to the disease, which will help attract funds and attention and achieve comprehensive management [40]. Public education campaigns on typical GERD symptoms (heartburn, reflux), risk factors (obesity, poor diet), and the importance of lifestyle interventions should be provided [41].

For clinicians, lifestyle intervention is the primary cornerstone. For all GERD patients, detailed guidance should be given on managing weight, not smoking, limiting alcohol, elevating the head of the bed, avoiding eating 3 h before bedtime, and reducing the intake of high-fat/spicy/acidic foods [42]. Standardized and stepwise drug therapy should be implemented, and patient education and communication should be strengthened to promote compliance [43].

Conclusion

From 1990 to 2021, the global number of incident cases, prevalent cases, and DALYs of GERD increased continuously. The disease burden showed significant geographical and socioeconomic disparities. Low-middle-SDI regions had the highest GERD burden, whereas high-SDI regions generally exhibited a declining trend. Sex differences indicated that compared with men, women had a greater disease burden. However, the disease burden among adolescents aged 10–20 years should not be overlooked. The SDI was weakly negatively correlated with the disease burden, and health inequalities persisted over the long term. Population growth and aging were the primary drivers of the increase in the global burden, whereas epidemiological changes made a negative contribution in high-SDI regions. Specifically, low-middle-SDI regions require increased investment in basic medical resources, high-SDI regions should optimize interventions to unlock improvement potential, and attention should be given to addressing health inequalities to promote fairness and efficiency in global GERD prevention and control.

Abbreviations

EAPC

Estimated annual percentage change

GERD

Gastroesophageal reflux disease

SDI

Sociodemographic index

GBD

Global burden of disease

ASR

Age-standardized rate

ASIR

Age-standardized incidence rate

ASPR

Age-standardized prevalence rate

ASDR

Age-standardized DALY rate

UI

Uncertainty interval

CI

Confidence interval

DALYs

Disability-adjusted life years

Authors’ contributions

Lw X: Conceptualization, Methodology, Software, Data curation, Writing- Original draft preparation. T X: Supervision, Writing- Reviewing and Editing.All authors approved the manuscript for publication.

Funding

None.

Data availability

The original contributions presented in the study are included in the article, and further inquiries can be directed to the corresponding authors.

Declarations

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.