Non-communicable disease burden in China, 1990–2023: Evidence from the Global Burden of Disease Study 2023

Abstract

Background:

Non-communicable diseases (NCDs) are the leading cause of disease burden worldwide. Amid rapid population aging, China faces a substantial NCD burden. This study aimed to assess the NCD burden in China in 2023 using data from the Global Burden of Disease Study 2023.

Methods:

This study used data from the Global Burden of Disease Study 2023, which covers 31 provinces in Chinese mainland and the Hong Kong and Macao Special Administrative Regions. Age-standardized and all-age mortality and disability-adjusted life year (DALY) rates for NCDs were estimated and compared between 1990 and 2023. Analyses were conducted according to sex, age group, and region. Level 3 NCD causes were ranked according to mortality and DALY rates.

Results:

NCDs were the major contributor to China’s disease burden in 2023. Cardiovascular diseases (316.08/100,000), neoplasms (180.02/100,000), and chronic respiratory diseases (73.15/100,000) were the leading causes of NCD-related mortality rates. Cardiovascular diseases (6262.68/100,000) and neoplasms (4456.46/100,000) were the top contributors to DALY rates. Age-standardized mortality and DALY rates for major NCDs have declined since 1990; however, the absolute numbers continue to rise because of population aging. Notable increases in disease burden were observed. Compared to 1990, the mortality rate increased by 239.14% and the DALY rate by 77.04% for neurological disorders. For mental disorders, mortality increased by 382.34% and the DALY rate by 25.82%. For musculoskeletal disorders, the DALY rate increased by 48.17%. Geographic disparities persisted, with higher NCD burdens concentrated in the western and northeastern provinces, whereas the more developed eastern regions showed relatively lower rates.

Conclusions:

NCDs remain the leading cause of disease burden in China and vary significantly by disease type, sex, age, and region. Strengthening prevention, improving the management of high-risk populations, and enhancing data accuracy are essential for more effective and equitable NCD control.

Introduction

Population aging and growth have resulted in an increasingly significant impact of non-communicable diseases (NCDs) on disability and mortality. According to estimates from the Global Burden of Disease, Injury, and Risk Factors Study (GBD) in 2021, NCDs were the leading cause of disease burden globally among all primary causes.^[1,2] In 2021, 7.3 trillion cases of chronic diseases were reported worldwide, resulting in 43.8 million deaths and 1.73 billion disability-adjusted life years (DALYs).^[3] Furthermore, the disease burden caused by NCDs has increased continuously over the past decade.^[4]

China is the world’s most populous middle-income country and is currently undergoing rapid aging and urbanization, which further exacerbates the overall burden of NCDs.^[5] However, China’s provinces differ significantly in terms of population structure, socioeconomic development levels, access to healthcare resources, and exposure to disease risks, leading to marked regional disparities in the NCD burden and related health outcomes.^[6,7] In this context, assessing the NCD burden at the provincial level is crucial for developing targeted public health strategies, optimizing resource allocation, and reducing health inequalities. The GBD provides comparable data across regions, periods, and disease types, making it highly suitable for evaluating regional disparities and guiding targeted NCD prevention and control strategies.

This study used data from the GBD 2023 to analyze the NCD burden in China, focusing on Level 2 and 3 causes. The disease burden in 2023 was compared to that in 1990 to examine temporal trends and assess provincial- and geographic-level disparities in the NCD burden nationwide.

Methods

The data used in this study were obtained from the GBD 2023. The GBD 2023 systematically estimated the burden of diseases and injuries in 204 countries and territories worldwide, covering 31 provinces of Chinese mainland as well as the Hong Kong and Macao Special Administrative Regions (SARs). For China, the GBD 2023 integrated multiple national and subnational data sources to estimate mortality and DALY rates. Mortality data were primarily derived from the China Disease Surveillance Points system, National Maternal and Child Surveillance System, China Cancer Registry, national censuses and household surveys, cause-of-death reporting system managed by the Chinese Center for Disease Control and Prevention, death registration data from the Hong Kong and Macao SARs, and several published studies and reports. Non-fatal outcomes were estimated using data from the China Cancer Registry, national health surveys, hospital inpatient databases, and other epidemiological studies. All estimates were age-standardized to the GBD standard population to ensure comparability across regions and over time. The GBD 2023 employed a unified analytical framework and standardized modeling tools. Mortality estimation was primarily based on the Cause of Death Ensemble Model, whereas non-fatal outcomes were modeled using the Disease Model-Bayesian Meta-regression. Detailed descriptions of the GBD data sources, modeling procedures, and validation processes have been published elsewhere.^[5]

This study evaluated multiple metrics of disease burden, including all-age mortality and DALYs per 100,000 population, as well as age-standardized mortality and DALY rates. All estimates were reported with 95% uncertainty intervals (UIs), defined as the 2.5th and 97.5th percentiles of 1000 posterior draws. Temporal trends were assessed by comparing estimates from 1990 and 2023. Age- and sex-specific analyses were conducted for three age groups: 15–49, 50–69, and ≥70 years. Geographic variation was examined by comparing age-standardized rates across seven major regions (Northeast, North, East, Central, South, Northwest, and Southwest China) and assessing the provincial rankings of Level 2 NCD causes.

The analysis included all three Level 1 cause groups defined in the GBD framework: communicable, maternal, neonatal, and nutritional diseases; NCDs; and injuries. Particular focus was placed on 12 Level 2 NCD categories: neoplasms, cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), digestive diseases, neurological disorders, mental disorders, substance use disorders, diabetes and kidney diseases, skin and subcutaneous diseases, sense organ diseases, musculoskeletal disorders, and other NCDs (congenital birth defects, gynecological diseases, oral disorders, endocrine/metabolic/blood/immune disorders, hemoglobinopathies and hemolytic anemias, urinary diseases and male infertility, and sudden infant death syndrome). Level 2 NCDs were ranked according to mortality and DALY rates. Changes in the rankings of the top 25 Level 3 NCD causes between 1990 and 2023 were also analyzed using age-standardized mortality and DALY rates.

Results

In 2023, NCDs were the leading contributor to the disease burden among all Level 1 causes in China. NCDs accounted for 9.55 (95%UI: 8.83–10.41) million deaths and 325.89 (95% UI: 285.70–368.77) million DALYs. The mortality and age-standardized mortality rates attributable to NCDs were 667.33 (95%UI: 616.94–727.41) and 440.77 (95%UI: 408.58–478.47) per 100,000 population, respectively. The DALY and age-standardized DALY rates were 22,779.54 (95%UI: 19,970.10–25,776.75) and 16,484.48 (95%UI: 14,382.94–18,851.93) per 100,000 population, respectively. Although the number of deaths, DALYs, and crude mortality from NCDs have fluctuated in recent years, the overall long-term trend continues to increase. In contrast, the increase in DALY rate has been relatively modest. Despite a slight increase after 2020, both age-standardized mortality and age-standardized DALY rates attributable to NCDs have continued to decline [Figure 1 and Supplementary Table 1, http://links.lww.com/CM9/C689].

Figure 1.

Trends for changes in death and DALYs for NCDs in China from 1990 to 2023. (A) number, crude rate, and age-standardized rate of deaths; (B) number, crude rate, and age-standardized rate of DALYs. Shaded regions are 95% UIs. DALYs: Disability-adjusted life years; NCDs: Non-communicable diseases; UIs: Uncertainty intervals.

Among Level 2 NCDs, CVDs were the leading cause of death in 2023, with a mortality rate of 316.08 (95% UI: 269.78–352.35) per 100,000 population. Neoplasms ranked second, with a mortality rate of 180.02 (95% UI: 156.32–201.99) per 100,000 population, representing a 23.82% (95% UI: 5.57–50.14%) increase since 1990. CRDs were the third leading cause of NCD-related deaths, with a mortality rate of 73.15 (95% UI: 56.91–105.01) per 100,000 population. Neurological disorders ranked fourth, with a mortality rate of 50.56 (95% UI: 19.08–105.67) per 100,000 population, marking a 239.14% (95% UI: 154.84–303.51%) increase since 1990. Collectively, these four causes accounted for over 80% of all NCD-related deaths. Mortality rates from Level 2 NCDs were generally higher among men than among women. However, for neurological disorders, the female mortality rate (62.93 [95% UI: 22.81–136.59] per 100,000) was notably higher than the male rate (38.77 [95% UI: 16.64–77.12] per 100,000). The female mortality rates were also higher for diabetes and kidney diseases, as well as musculoskeletal disorders. Across nearly all Level 2 NCDs, except for substance use disorders, the mortality rate was substantially higher among individuals aged 70 years and older than in younger age groups [Table 1]. The male and female mortality rate rankings for Level 2 NCD causes were generally similar to those of the overall population, as were the rankings for those aged ≥70 years. In contrast, for the 15–49 and 50–69 years age groups, neoplasms had the highest mortality rate, followed by CVDs. Diabetes and kidney diseases, as well as digestive diseases, had higher mortality rates in these two age groups than in the older groups, whereas digestive diseases and substance use disorders had higher mortality rates in the 15–49 years age group [Supplementary Figure 1A, http://links.lww.com/CM9/C689]. Rankings based on age-standardized mortality rates remained largely consistent in 2023. Compared with 1990, age-standardized mortality rates declined for several major causes, including CVDs, neoplasms, CRDs, diabetes and kidney diseases, digestive diseases, other NCDs, substance use disorders, and skin and subcutaneous diseases. In contrast, the age-standardized mortality rate for mental disorders increased sharply by 508.38% (95% UI: 74.43–3168.22%) [Supplementary Table 2, http://links.lww.com/CM9/C689].

Table 1.

Mortality rates (per 100,000) from NCD Level 2 causes in China in 2023 by sex, age, and percentage changes from 1990 to 2023.

Level 2 causes	All age groups and sexes	Percentage change, 1990–2023 (%)	Sex		Age group (years)
			Male	Female	15–49	50–69	70+
CVDs	316.08 (269.78, 352.35)	12.80 (–6.38, 36.14)	339.42 (289.52, 387.34)	291.61 (227.96, 346.46)	21.52 (17.81, 25.59)	244.81 (211.63, 279.84)	2465.49 (2016.07, 2831.33)
Neoplasms	180.02 (156.32, 201.99)	23.82 (5.57, 50.14)	227.5 (198.96, 261.3)	130.24 (108.18, 153.27)	28.59 (24.73, 32.47)	276.87 (238.36, 318)	928.95 (763.68, 1093.14)
CRDs	73.15 (56.91, 105.01)	22.63 (–20.68, 117.18)	77.09 (62.09, 99.7)	69.03 (44.53, 117.09)	1.53 (1.17, 2.09)	34.92 (26.75, 50.24)	648.57 (492.94, 955.13)
Neurological disorders	50.56 (19.08, 105.67)	239.14 (159.40, 312.24)	38.77 (16.64, 77.12)	62.93 (22.81, 136.59)	1.28 (1.03, 1.56)	17.47 (7.91, 37.14)	465.20 (168.91, 991.15)
Diabetes and CKD	23.34 (19.70, 27.10)	34.88 (2.59, 74.16)	23.16 (19.1, 28.45)	23.54 (17.72, 29.14)	2.68 (2.25, 3.16)	26.23 (21.85, 31.79)	153.47 (124.41, 183.67)
Digestive diseases	16.59 (14.09, 19.36)	–34.27 (–53.56, –6.00)	20.74 (17.18, 25.55)	12.24 (9.78, 15.54)	3.94 (3.15, 4.88)	20.25 (16.53, 24.59)	94.33 (76.90, 111.36)
Other NCDs	4.29 (3.76, 4.82)	–75.37 (–80.67, –67.45)	4.61 (3.90, 5.28)	3.96 (3.34, 4.68)	1.29 (1.08, 1.5)	3.26 (2.66, 3.82)	18.01 (14.17, 21.23)
Substance use	1.66 (1.34, 2.11)	–57.00 (–69.84, –40.20)	2.87 (2.25, 3.72)	0.39 (0.27, 0.56)	1.67 (1.29, 2.12)	2.51 (1.95, 3.21)	2.25 (1.66, 3.04)
Musculoskeletal disorders	1.27 (0.91, 1.69)	25.90 (–14.66, 79.49)	0.72 (0.36, 1.07)	1.84 (1.27, 2.80)	0.39 (0.27, 0.55)	1.32 (0.96, 1.80)	7.37 (4.76, 10.03)
Skin diseases	0.36 (0.25, 0.49)	51.65 (–11.38, 179.00)	0.34 (0.23, 0.50)	0.38 (0.25, 0.57)	0.04 (0.02, 0.05)	0.20 (0.13, 0.27)	2.95 (2.05, 4.13)
Mental disorders	0.002 (0.001, 0.004)	382.34 (36.99, 2481.30)	0.001 (0.000, 0.003)	0.003 (0.001, 0.007)	0.004 (0.002, 0.007)	–	–

Data are shown as rates (95% uncertainty interval). CKD: Chronic kidney disease; CRDs: Chronic respiratory diseases; CVDs: Cardiovascular diseases; NCDs: Non-communicable diseases; –: Not available.

DALY patterns showed some differences compared to mortality rates. CVDs and neoplasms remained the top two contributors to DALYs among Level 2 NCDs, with DALY rates of 6262.68 (95% UI: 5516.52–6847.36) and 4456.46 (95% UI: 3965.64–4967.01) per 100,000 population, respectively. Together, these two causes accounted for the largest share of total NCD-related DALYs in 2023. Musculoskeletal disorders ranked third, with a DALY rate of 2092.70 (95% UI: 1518.82–2914.46) per 100,000 population, representing a 48.17% (95% UI: 39.57–59.11%) increase compared to 1990. Mental and neurological disorders ranked fourth and fifth, with DALY rates of 1842.06 (95% UI: 1392.34–2429.67) and 1618.75 (95% UI: 1080.91–2408.44) per 100,000 population, respectively. Compared with 1990, the DALYs rate from mental disorders increased by 25.82% (95% UI: 13.53–41.58%), and that from neurological disorders increased by 77.04% (95% UI: 52.39–109.71%). Sex differences were observed in most causes of NCDs. Male DALY rates were higher for CVDs (7299.70 vs. 5175.24 per 100,000), neoplasms (5691.15 vs. 3161.73 per 100,000), CRDs, diabetes and kidney diseases, digestive diseases, and substance use disorders. In contrast, female DALY rates per 100,000 were higher for musculoskeletal disorders (2526.15 vs. 1679.35), mental disorders (1963.90 vs. 1725.87), neurological disorders (2027.39 vs. 1229.05), sense organ diseases, skin and subcutaneous diseases, and other NCDs [Table 2]. Age patterns also varied across conditions. Most Level 2 NCDs had the highest DALY rates in the 50–69 and ≥70 years age groups. However, mental disorders showed relatively even DALY rates across all three age categories, and substance use was more concentrated in the younger age groups. Compared to the overall population, male DALY rate rankings were higher for mental disorders and CRDs, whereas female rates ranked higher for neurological disorders and other NCDs. In the 15–49 years age group, mental disorders ranked first in DALY rates, followed by musculoskeletal disorders, with neoplasms and CVDs ranking third and fourth, respectively. Among those aged ≥70 years, CRDs, neurological disorders, and sense organ diseases ranked higher than musculoskeletal and mental disorders [Supplementary Figure 1B, http://links.lww.com/CM9/C689]. From 1990 to 2023, age-standardized DALY rates decreased substantially for most Level 2 NCDs, with notable declines for CVDs (−59.54%, 95% UI: −65.74% to −50.84%), neoplasms (−47.93%, 95% UI: −55.24% to −38.26%), and CRDs (−56.62%, 95% UI: −70.04% to −31.82%). In contrast, some causes showed little change (e.g., neurological disorders: 0.30% [95% UI: −11.44% to 7.69%]), whereas mental disorders demonstrated an increase of 18.36% (95% UI: 5.26%–36.89%) in the age-standardized DALY rate [Supplementary Table 2, http://links.lww.com/CM9/C689].

Table 2.

DALY rates (per 100,000) from NCD Level 2 causes in China in 2023 by sex, age group, and percentage changes from 1990 to 2023.

Level 2 causes	All age groups and sexes	Percentage change, 1990–2023 (%)	Sex		Age group (years)
			Male	Female	15–49	50–69	70+
CVDs	6262.68 (5516.52, 6847.36)	–9.34 (–24.11, 10.48)	7299.70 (6428.02, 8097.27)	5175.24 (4277.67, 5985.64)	1238.81 (1050.59, 1446.62)	8123.15 (7060.26, 9150.60)	35617.79 (29982.65, 40377.58)
Neoplasms	4456.46 (3965.64, 4967.01)	–3.15 (–17.05, 15.02)	5691.15 (5085.92, 6428.86)	3161.73 (2734.06, 3673.63)	1436.87 (1255.83, 1619.43)	8431.68 (7283.02, 9643.45)	14587.19 (12023.31, 17069.12)
Musculoskeletal disorders	2092.70 (1518.82, 2914.46)	48.17 (39.57, 59.11)	1679.35 (1209.61, 2336.36)	2526.15 (1842.63, 3519.56)	1466.01 (1047.49, 1926.19)	3622.26 (2599.09, 5333.9)	4296.70 (3046.48, 6196.12)
Mental disorders	1842.06 (1392.34, 2429.67)	25.82 (13.53, 41.58)	1725.87 (1305.06, 2245.29)	1963.9 (1476.27, 2627.41)	1941.34 (1446.06, 2553.2)	2046.26 (1479.81, 2644.94)	1793.12 (1317.77, 2339.38)
Neurological disorders	1618.75 (1080.91, 2408.44)	77.04 (52.39, 109.71)	1229.05 (839.62, 1855.97)	2027.39 (1348.63, 3023.83)	727.83 (514.99, 993.42)	1494.16 (1066.13, 2152.9)	8643.28 (4881.89, 15233.34)
Sense organ diseases	1440.45 (1015.28, 1985.6)	79.89 (70.60 89.88)	1369.51 (958.3, 1892.9)	1514.84 (1074.75, 2080.98)	511.06 (344.11, 716.18)	2374.61 (1585.60, 3415.36)	5498.07 (3993.57, 7182.48)
CRDs	1420.28 (1189.43, 1904.82)	0.10 (–30.95, 61.29)	1550.25 (1295.6, 1918.13)	1284.00 (947.43, 2053.79)	215.50 (165.67, 272.35)	1368.23 (1111.73, 1828.6)	9466.12 (7507.78, 13,426.64)
Diabetes and CKD	1141.64 (930.51, 1362.05)	35.67 (17.08, 56.54)	1185.98 (954.5, 1423.7)	1095.14 (853.9, 1331.92)	496.14 (376.97, 637.32)	1958.44 (1564.37, 2373.84)	3864.26 (3265.34, 4556.69)
Other NCDs	1139.78 (835.86, 1502.63)	–49.64 (–59.74, –37.79)	772.91 (575.91, 1034.85)	1524.48 (1098.56, 2033.93)	1063.25 (746.74, 1460.90)	1204.80 (841.45, 1681.19)	1923.29 (1363.47, 2545.36)
Digestive diseases	620.53 (537.49, 712.83)	–40.13 (–54.79, –21.53)	749.93 (644.45, 875.27)	484.84 (399.04, 587.30)	348.31 (295.84, 419.79)	983.60 (837.49, 1175.9)	1818.21 (1557.61, 2113.55)
Skin diseases	450.71 (297.32, 663.2)	–8.63 (–12.58, –3.79)	428.71 (279.22, 632.88)	473.78 (312.55, 695.52)	358.63 (240.09, 508.51)	353.23 (244.72, 502.12)	442.63 (314.1, 623.79)
Substance use	293.50 (222.07, 374.78)	–41.78 (–50.55, –33.67)	442.29 (338.13, 561.08)	137.48 (101.86, 174.05)	446.69 (337.31, 569.15)	280.59 (215.34, 360.75)	145.41 (111.43, 187.73)

Data are shown as rates (95% uncertainty interval). CKD: Chronic kidney disease; CRDs: Chronic respiratory diseases; CVDs: Cardiovascular diseases; NCDs: Non-communicable diseases.

Between 1990 and 2023, stroke, ischemic heart disease, and chronic obstructive pulmonary disease (COPD) consistently remained the top three Level 3 causes of age-standardized mortality attributable to NCDs. Compared with 1990, the age-standardized mortality rates for stroke and COPD decreased by 69.2% (95% UI: 61.4–75.6%) and 58.7% (95% UI: 26.6–73.2%), respectively, whereas the mortality rate for ischemic heart disease increased by 125.6% (95% UI: 82.6–189.7%). The rankings of several cancers, including lung, colorectal, liver, pancreatic, breast, brain, bladder, and prostate cancers and lymphoma, showed notable increases since 1990. Among non-cancer conditions, Alzheimer’s disease rose from 12th to fifth place, diabetes moved from 17th to tenth place, and Parkinson disease advanced from 25th to 15th place. In contrast, the rankings for stomach, esophageal, and cervical cancers declined. Rheumatic heart disease decreased significantly from eighth to 19th place, and congenital birth defects decreased from 10th to 37th place [Figure 2A].

Figure 2.

Ranking of NCD Level 3 causes by mortality rate (A) and DALY rate (B) in China from 1990 to 2023. COPD: Chronic obstructive pulmonary disease; DALYs: Disability-adjusted life years; NCDs: Non-communicable diseases; Std: Standardized.

Stroke and ischemic heart disease remained the top two Level 3 causes of NCD-related DALY rates from 1990 to 2023. COPD, which ranked third in 1990, dropped to fourth in 2023, with a 61.1% (95% UI: 34.6–73.8%) decline in the age-standardized DALY rate. Lung cancer rose from sixth to third place, with the DALY rate increasing by 67.1% (95% UI: 32.7–105.5%) compared to that in 1990, although the age-standardized DALY rate also declined by 20.4% (95% UI: 1.0–36.8%). The largest rank increase was observed for Alzheimer’s disease, which increased from 27th in 1990 to sixth in 2023, with a 243.3% (95% UI: 178.4–300.7%) increase in the DALY rate. Other causes that increased in the top 25 DALY rankings included age-related hearing loss, diabetes, depressive disorders, other musculoskeletal disorders, headache disorders, anxiety disorders, colorectal cancer, blindness and vision loss, osteoarthritis, gynecological diseases, neck pain, oral disorders, and liver cancer. Conversely, several conditions showed notable declines in DALY rankings, including lower back pain, stomach cancer, esophageal cancer, chronic kidney disease, hypertensive heart disease, cirrhosis, and dermatitis [Figure 2B].

The NCD burden varied across geographic regions in 2023. Both age-standardized mortality and DALY rates were highest in Northeast China, followed by North, Northwest, Southwest, Central, East, and South China [Supplementary Figure 2, http://links.lww.com/CM9/C689]. In most provinces, CVDs were the leading cause of death, followed by neoplasms. However, in the Hong Kong and Macao SARs, neoplasms ranked first, followed by CVDs. CRDs were the second leading cause of death in Yunnan. In all provinces except Beijing, Hebei, Henan, Hong Kong SAR, Jilin, Liaoning, and Tianjin, the top three causes of NCD-related deaths were CVDs, neoplasms, and CRDs. Among these exceptions, neurological disorders, rather than CRDs, ranked third. Digestive diseases ranked fourth in Xizang, a position notably higher than that in other provinces [Figure 3A]. CVDs and neoplasms were the top two causes of DALYs in most provinces. In Chongqing, Fujian, Jiangsu, Macao SAR, Shanghai, and Zhejiang, neoplasms ranked first, followed by CVDs in second place. Mental, musculoskeletal, and neurological disorders consistently ranked among the top contributors to DALYs in many provinces. In the Hong Kong SAR, the top three causes of DALYs were neoplasms, mental disorders, and musculoskeletal disorders, with CVDs ranking fourth. The CRDs were higher in several provinces, including Chongqing, Gansu, Guizhou, Jiangxi, Qinghai, Sichuan, Xinjiang, and Yunnan. In Xinjiang, digestive diseases ranked the third in terms of DALY contribution, a position far higher than that in other provinces [Figure 3B].

Figure 3.

Ranking of age-standardized mortality (A) and DALY (B) rates from NCD Level 2 causes by province in China in 2023. CKDs: Chronic kidney diseases; CRDs: Chronic respiratory diseases; CVDs: Cardiovascular diseases; NCDs: Non-communicable diseases; DALYs: Disability-adjusted life years; NCDs: Non-communicable diseases; SAR: Special administration region.

Discussion

This study provides a comprehensive overview of the burden of NCDs in China in 2023, which will make a significant contribution to the overall disease burden, highlighting their dominant role in national health outcomes. Among the Level 2 NCD categories, the leading causes of mortality were CVDs, neoplasms, and CRDs, whereas the highest contributors to DALYs were CVDs, neoplasms, and musculoskeletal disorders. Although most NCDs demonstrated declining trends in age-standardized mortality and DALY rates, reflecting decreases in premature mortality and demographic transitions toward population aging, their absolute mortality and DALY rates at the population level continued to increase. Moreover, the burden of certain conditions, such as neurological and mental disorders, continued to increase over time, suggesting emerging challenges for healthcare systems. Notably, considerable variation was observed across regions and provinces, indicating that subnational differences in disease burden merit targeted and context-specific health policy responses.

CVDs represented the largest contributor to the NCD burden in China in 2023. Although age-standardized mortality and DALY rates for CVDs have declined by nearly 60% since 1990, the absolute number of deaths and DALYs have continued to rise. This overall increase in disease burden is likely driven by rapid population aging, as most of the CVD-related burden was concentrated in individuals aged 70 years and older. National efforts, such as the China-HEART project and the development of specialized care infrastructure, such as chest pain and stroke centers, may have contributed to improvements in early detection and acute management, thereby reducing premature mortality.^[8–10] Nevertheless, several modifiable risk factors remain prevalent in the population, including tobacco use, unhealthy dietary patterns, insufficient physical activity, hypertension, being overweight, and obesity. These factors continue to drive the overall burden of CVDs, despite advancements in clinical care and disease surveillance.^[11] Among Level 3 causes, stroke and ischemic heart disease have consistently been ranked as the top two contributors to NCD-related deaths and DALYs since 1990. Stroke showed a marked decline in age-standardized mortality and DALY rates, whereas crude mortality remained relatively stable, indicating a persistent burden among older adults. In contrast, ischemic heart disease exhibited a substantial increase in crude mortality, with limited improvement in age-standardized rates, suggesting insufficient progress in controlling age-specific risk. These findings highlight the ongoing need to prioritize stroke and ischemic heart disease within national CVD prevention and control strategies.

Neoplasms were the second leading cause of NCD-related deaths and DALYs in China in 2023. Compared to 1990, the age-standardized mortality and DALY rates for cancers declined by more than 40%. However, crude mortality rates continued to rise, and the overall burden remained substantial, particularly among older adults. Notably, the cancer burden in men was nearly twice that in women. Over the past few decades, China has steadily expanded its cancer registration system, and by 2019, registries had been established in over half of all urban and rural areas, providing strong support for nationwide cancer surveillance.^[12] Benefiting from several national cancer screening programs implemented since 2005,^[13] the rankings and burdens of stomach, esophageal, and cervical cancer among the top 25 causes of cancer mortality declined in 2023. In contrast, lung, colorectal, liver, and pancreatic cancers showed significant upward trends. Lung and colorectal cancers remained among the top contributors to the overall cancer burden, highlighting the limited effectiveness of current prevention and control strategies for these high-impact cancers. The rising burden of lung and colorectal cancers may be associated with changes in behavioral and environmental risk factors. Tobacco use remains highly prevalent in China, particularly among men, and is a major contributor to lung cancer mortality.^[14] Unhealthy dietary patterns have also been linked to an increasing burden of colorectal cancer.^[15] In addition to screening and early diagnosis, strengthening primary prevention strategies that target modifiable lifestyle and environmental risk factors should be emphasized.

CRDs were the third leading cause of NCD-related mortality in China in 2023, although their contribution to DALYs was comparatively lower. Since 1990, the age-standardized mortality and DALY rates for CRDs have declined by more than 50%, suggesting notable progress in reducing the burdens of these conditions. This downward trend may be partially attributable to improvements in air quality resulting from national efforts to reduce ambient air pollution.^[16] Among CRD-related Level 3 causes, COPD has remained the dominant contributor, with age-standardized mortality and DALY rates declining by approximately 60% since 1990. Despite these overall improvements, geographic disparities remain significant. Provinces in Southwest (Xizang, Yunnan, Sichuan, and Chongqing) and Northwest China (Xinjiang, Qinghai, and Gansu) continued to report relatively high age-standardized DALY rates for CRDs. These elevated burdens may be linked to regional geographic features, such as basin topography that exacerbates air stagnation, as well as household use of solid fuels, which remains common in some rural areas.^[17,18] These findings underscore the importance of region-specific interventions that target environmental exposure and indoor air quality.

Musculoskeletal disorders contributed relatively little to mortality but are ranked as the third leading cause of NCD-related DALYs in China in 2023, reflecting their high disability burden despite low fatality. Compared with 1990, the DALY rate for musculoskeletal disorders increased by nearly 50%, while the age-standardized DALY rate declined only modestly by 6.62% (95% UI: 3.41–9.78%), indicating limited progress in reducing disability from these conditions. Among the top 25 Level 3 causes of DALYs, low back pain, other musculoskeletal disorders, osteoarthritis, and neck pain were key contributors to musculoskeletal disorders. Notably, age-standardized DALY rates for other musculoskeletal disorders and osteoarthritis increased by over 10% compared to 1990. The rising burden of musculoskeletal disorders is likely driven by rapid population aging, and with this demographic trend expected to continue, their overall impact is projected to increase further.^[19] Unlike many other NCDs that primarily affect those aged 70 years and older, musculoskeletal disorders related DALYs were high among both the 50–69 and 70+ age groups. This younger affected population may impose a more profound and prolonged socioeconomic burden caused by lost productivity and long-term disability. Additionally, female DALY rates for musculoskeletal disorders were higher than male rates, possibly because of women’s longer life expectancy and higher survival into advanced age with disability.^[20]

Several NCDs with relatively low mortality but high disability burden have notably increased since 1990. Among them, mortality from neurological disorders has increased by 239.14% and that from mental disorders by 382.34%. Alzheimer’s disease has also increased rapidly in the rankings of disease burden. Its crude mortality and DALY rates have increased substantially, whereas the age‑standardized rates have improved little, indicating that the burden in the ageing population remains largely unmitigated. In addition to population aging, modifiable risk factors such as smoking and a high body mass index are important contributors to Alzheimer’s disease, underscoring the need for early-life prevention alongside improvements in long-term care.^[21] Mental disorders also contribute significantly to overall DALYs. Although they are often overlooked owing to low fatality rates, conditions such as depression and anxiety have risen in the DALY rankings, and their burden is relatively evenly distributed across age groups, highlighting that mental health interventions should target not only older adults but also middle-aged and younger populations.^[22,23] These rapid increases in disease burden may also reflect improvements in diagnostic capacity, public awareness and ICD coding and death-certification practices. For example, a multi‑cause analysis from Australia and the United States found that the rise in dementia mortality was largely caused by physicians becoming more inclined to list dementia as the cause of death rather than a genuine increase in mortality.^[24] Similarly, a global study of depressive disorders noted that the increase in mental‑disorder DALYs among adolescents in countries with a high- or high‑middle scio-demographic Index is likely linked to improvements in diagnosis and awareness.^[25] In China, the establishment of memory clinics and public‑health programs has markedly increased early diagnosis and awareness of Alzheimer’s disease. More than 80% of patients and families can recognize early symptoms, and one‑ and two‑year consultation rates have reached 32.6% and 71.6%, respectively. These advances in monitoring and reporting may inflate observed increases in mortality and DALY rates.^[26] In addition, the burden of diabetes and kidney diseases has increased and is likely driven by widespread changes in lifestyle and diet, including sedentary behavior, high calorie intake, and rising obesity rates. Obesity is a well-established risk factor for diabetes, and recent projections suggest that its prevalence in China will continue to increase over the coming decades. Therefore, the implementation of effective obesity prevention and control strategies may play a critical role in reducing the future burden of diabetes.^[27] In addition, sensory organ diseases have emerged as a significant cause of disability, particularly among older adults. Age-related hearing loss has become the fifth leading Level 3 cause of NCD-related DALYs, with both crude and age-standardized DALY rates increasing since 1990. Other major contributors include blindness and vision loss. These conditions not only impair functioning but may also contribute to cognitive decline and mental health deterioration in older adults. The growing burden of these functional disorders underscores the need to integrate chronic disease management with aging-friendly multi-dimensional support systems.^[28]

The burden of NCDs in China is disproportionately concentrated among older adults, with most NCD-related deaths and DALYs occurring in individuals aged 70 years and above. This pattern underscores the profound impact of population aging on the national disease burden. Currently, the healthcare needs of older adults are not being adequately met, particularly in terms of access to medical care and long-term support. The growing burden of NCDs among older adults not only tests the clinical capacity of hospitals and primary care facilities but also increases demand for long-term care and daily support, exerting significant pressure on families and the broader socioeconomic system.^[29] In many cases, family members become older adults’ primary caregivers, which may lead to financial hardship, emotional stress, and reduced workforce participation. Looking forward, a health and social care system better suited to China’s rapidly aging population is urgently needed.^[30] This includes expanding access to affordable geriatric care, developing integrated long-term care systems that coordinate medical services with functional support, and promoting age-friendly health services that are accessible, inclusive, and responsive to older adults’ needs. Strengthening community-based care infrastructure and workforce training are also essential for ensuring continuity of care across settings and life stages.

This study found that for most NCDs, the disease burden was significantly higher among the male population, likely because of greater exposure to risk factors such as smoking, alcohol consumption, hypertension, being overweight, and obesity.^[31–33] However, in the case of musculoskeletal disorders, neurological conditions, and mental disorders, female DALY rates were higher than male rates. Possible explanations include women’s longer life expectancy, prolonged illness duration, greater exposure to psychosocial stressors, and the influence of hormonal changes on both physical and mental health.^[34,35] In the future, sex-specific interventions, particularly those that enhance support for women’s mental health and chronic disease management, will be essential for achieving targeted NCD prevention and control.

The NCD burden in China shows regional differences. East and South China, which are characterized by higher economic development levels and relatively warm and humid climates, have lower age-standardized mortality and DALY rates. In contrast, Northeast and Northwest China experienced higher NCD burdens. These differences may be attributable to the greater availability of healthcare resources and higher health literacy in developed areas, whereas less-developed regions often face shortages in health services, more harmful environmental exposures, and less favorable lifestyle patterns.^[36,37] Future NCD prevention and control strategies should be tailored to the local context. In regions with a higher burden, such as Northeast and Northwest China, strengthening primary public health and medical capacity will be crucial. This can be integrated with the development of NCD prevention and control demonstration zones to promote cost-effective technological tools. Examples include utilizing portable spirometry for community-based CRD screening and point-of-care testing for cardiovascular risk assessment.^[38,39] For the western provinces disproportionately burdened by CRDs, such as Xizang, Yunnan, Sichuan, Qinghai, and Gansu, targeted interventions should include programs to improve indoor air quality, promote clean energy for heating and cooking, enforce strict tobacco control, and reduce exposure to biomass fuel.^[40,41]

This study used the most recent data from the GBD 2023 to comprehensively analyze the NCD burden in China and its provinces. These findings offer valuable evidence to inform targeted NCD prevention strategies, guide health resource allocation, and address the challenges associated with population aging. Nevertheless, this study had several limitations. First, the GBD estimates are primarily model-based rather than derived from direct observational data, which inevitably introduces some uncertainty. Second, although the GBD 2023 framework is methodologically robust and integrates multiple data sources, the lack of locally calibrated decomposition analyses may limit its ability to fully capture subnational heterogeneity, such as within-province urban–rural gradients or differences across socioeconomic groups, potentially leading to an underestimation of the burden among vulnerable populations. Third, the data were analyzed at the national and provincial levels, whereas finer-scale variations could not be assessed. Future research integrating local surveillance data and small-area analyses could enhance the transparency and precision of these estimates.

This study demonstrated that NCDs remain the primary source of disease burden in China, with CVDs, cancers, and CRDs remaining the leading causes of mortality. However, the burden of DALYs exhibited notable heterogeneity across multiple chronic conditions. Marked disparities in sex, age, and region underscore the complex and uneven distribution of the NCD burden, indicating an urgent need for more targeted and differentiated prevention strategies. Moving forward, strengthening primary prevention and early screening, improving the efficiency of high-risk population management, and advancing a more equitable, effective, and sustainable NCDs prevention and care system will be critical. Furthermore, continued efforts to enhance the accuracy and accessibility of health data will be essential for supporting evidence-based policymaking and precision public health interventions.

Funding

This study was supported by grants from the Sci-Tech Innovation 2030 Agenda (Nos. 2023ZD0503900 and 2023ZD0503901).

Conflicts of interest

None.

Supplementary Material

cm9-139-048-s001.docx ^{(309.9KB, docx)}